Homebirth Midwifery Licensing: Working for Families or a Piece of Paper?

From Wikipedia: “In particular a licence may be issued by authorities, to allow an activity that would otherwise be forbidden. It may require paying a fee and/or proving a capability. The requirement may also serve to keep the authorities informed on a type of activity, and to give them the opportunity to set conditions and limitations.”

Which begs the question: why would helping a woman have a baby at home be forbidden in the first place? Hasn’t this practice been going on for centuries before the authorities decided to butt in? It is ultimately the responsibility of the family to choose the person (or no person at all) that they deem competent enough to assist them with the birth of their child. This is true whether they choose a homebirth midwife or an OB. So why is everyone ‘pushing’ for licensure and the demise of the lay-midwife?

Let’s remember: A license doesn’t guarantee competency or flawless performance of said task. It simply means that minimum requirements have been met and dues have been paid to the satisfaction of the licensor. We need only look at the slew of bad drivers currently plaguing our roadways to understand that licensing guarantees nothing. When I discussed the licensed driver parallel on Twitter, someone responded that they’d rather have a licensed driver drive their car than an unlicensed driver. Personally, I’d rather have an experienced driver, one who’s been around the block a few times, doesn’t immediately panic if the situation gets a little hairy; a confident driver, rather than a freshly licensed 16-year-old whose experience consists of book-learning and a driver’s education class. I don’t give a shit about a license, I want ability. Nor do I want a driver who’s been conditioned to believe disaster lies around every corner; someone who’s nervous and jumpy, checking mirrors and dashboard dials every few seconds regardless of the current road conditions or driving situation. That’s just looking for trouble. I want someone who’s calm, reassuring, who isn’t going to jump the gun and possibly make matters worse.

Do you understand my point? Had enough of the driving analogy? Me too. In other words, why isn’t a seasoned midwife, one who has apprenticed for years, learned from experience, chooses not to have a piece of paper proclaiming her accomplishments, as good as a licensed one? There’s something wrong with this way of thinking. Education is education, whether you get it through life-learning and experience or through an institution. They’re simply different paths to a similar goal. It makes me wonder if those who are against lay-midwifery are also against homeschooling. Same idea, yes?.

Now we move on to regulations. Regulations go hand-in-hand with licensing. ‘In order to do what that paper says we’re allowing you to do, you have to work within our predetermined scope of practice, regardless of what you’re capable of handling.’ In some states midwifery regulations are so tight that only the most textbook-perfect of pregnancies and births will be ‘allowed’ to happen at home. Overweight/obese? That’s too risky. VBAC? Forget it. Postdates? Out of the question. All three? You’re fucked. Say bye-bye to your planned homebirth, you’ve been determined to be a ticking time bomb that only an OB and his scalpel can manage. To this I say bullshit. One person’s ‘complication’ is another person’s ‘variation on normal’. But if you want to keep that license, you better work within those guidelines, no matter how many women you end up having to risk out to the hospital, no matter what you’re capable of handling or what you think about those ‘risky’ situations. All for a license that says you can and, by law, you have to.

Which brings me to this: What about that license is worth turning women away? Does it have magical powers that save you from litigation? No, you can still be sued. Will it rally a bunch of fellow midwives or medical professionals to your defense? No, only your reputation and relationships within the community can do that. It may make it easier to accept insurance coverage, but this is not universal and shouldn't be a primary goal. So, then, what do you really lose if you lose your license? Being kicked out of the club?

Some say licensing works to protect the consumer by regulating how a professional can practice. If that’s so, why bother with second opinions? Why interview doctors until you find the one that jives with your lifestyle and preferences? Because some doctors have different experiences that formed the way they practice, different methods of treatment, different ways of seeing a problem and solutions to that problem. So why do doctors have such a wide range in which they can move around with regards to their practice, but licensed midwives do not? Is it because the medical community, even after all these years of working with licensed midwives, still has no respect for the practice, believes that birth is still inherently dangerous and best left to the ‘professionals’ to handle? Hammer, meet the head of the nail. Licensing has not improved the face of midwifery. Instead, it has created a new breed of midwife, one who is more medically-minded, whose practices are based more on a medical model of care because they need to work within a highly regulated scope of practice or risk losing a license.

I have a secret. If you’re good at what you do, honest with the families you serve, know your personal limitations and work within them, are not afraid to seek help when you need it, and develop good personal and professional relationships within the birth community, a license becomes nothing but a piece of paper that tells the world you paid your dues and met ‘continuing education’ requirements for that year. It doesn’t open more doors, it doesn’t bring respect, it doesn’t make you a better or more competent midwife, it doesn’t guarantee you a certain income, it doesn’t make you bulletproof. It doesn’t protect women from ‘bad midwives’. It doesn’t improve outcomes. If you didn’t have that license dictating your abilities you would be able to expand your practice to include those women who aren’t covered by the regulations but whose desires for a peaceful homebirth are no less important. You could do so much more for women and their families if you just served women to the best of your abilities and stopped letting a license hold you hostage.

Whatever your alliance, whatever your motives or goals or opinions with regards to homebirth midwifery licensing, one thing is certain: if you let a regulatory body have control you become part of that machine. Many join up with ideas of change, bringing healing and reason to a broken and irrational maternity system that fails women left and right. But so many get held back by that paper, allowing it to determine their path, and eventually molding them into part of the system where they find themselves arguing in favor of more management and medicalization and against the change they were fighting for. They lose sight of what’s at the heart of being a midwife: serving families, helping them achieve the birth they want, educating and supporting them in their decision-making and honoring their choices.

Which leads me to another topic: doulas and their scope of practice, the vilification of choice, hypocrisy, and political alliances. Stay tuned, that post is forthcoming…