Iowa is one of just 14 states that does not address Certified Professional Midwives (CPM’s) or traditional midwives in their laws. 34 states currently offer licensure to CPM’s, while 2 allow CPM’s to practice without any form of licensure. Iowa midwives have been fighting for decades for the state to add a statute to Iowa law that specifically states that we can practice, but Iowa has continued to ignore the families that are choosing home birth.
CPM’s are the only credentialed provider in the U.S. that are trained specifically in out-of-hospital birth. We have significant clinical requirements and sit for an 8-hour board exam before we’re issued our credential. CPM’s train for an average of 3-5 years.
For several years, Iowa midwives hoped that we could get a law on the books that’s similar to Minnesota’s law. Minnesota allows midwives to practice without a license, if they so choose (they also offer licensure for those who want to become a licensed midwife). Here in Iowa, we’ve tried that route, commonly called ‘decrim’, and have been told over and over that because midwives deliver babies, they cannot possibly simply allow us to practice without regulation.
With that information told to us time and again, and proposed bills going nowhere, midwives worked with some legislators to propose a licensure bill…but now we’re told, primarily by Republicans, they they have no interest in adding new licensure laws, as one of their main focuses right now is to eliminate red tape that restricts practice. And thus began the loop that Iowa midwives are perpetually stuck in. A quick side note here, the last time a legislator told me he was opposed to new licensure, he was backing and advocating a bill to regulate dog racing. Dog racing was a priority that year, moms and babies were not.
In the late 1990’s, a traditional midwife in Iowa was charged with practicing medicine without a license. She took a plea deal and quit practicing in order to avoid future prosecution. In 2008, another Iowa midwife, a CPM, was charged with practicing medicine without a license, and accepted a plea deal so she didn’t risk jail time should she go to trial and lose her case. In 2013, a Nebraska midwife who attended a birth in Iowa, was charged with practicing medicine without an Iowa license. This time, this midwife took her case to the judge. The judge ultimately dismissed the charges, and did so with a 20 page statement outlining his opinion. This judge (State of Iowa v. Judy Jones) decided that based on laws in other states in the U.S., and the history of midwifery, midwifery is NOT the practice of medicine nor is it the practice of nursing, but is a profession in its own right. The judge said that since midwifery is not the practice of medicine or nursing, and there is no Iowa law addressing midwifery, midwives are not breaking any Iowa laws by practicing. The judge also pointed out that the Iowa legislature itself had appointed a committee over a decade ago to look at the issue of licensing a midwife, and that the legislature had ignored its own committee’s recommendation to offer a licensure path to midwives.
After that ruling, midwives have felt a little safer practicing, but it’s not enough. Without an Iowa license or law simply stating we can practice, Iowa midwives cannot obtain anti-hemorrhagic medications that are within our scope and training to use. We cannot obtain Rhogam on the merits of our own certification, an important medication for a specific set of birthing women. Medical supply companies require that we show proof in our state law that we’re allowed to carry, and therefore purchase, these medications but because Iowa law does not address this, we can’t order them on our own.
Without an Iowa law that addresses CPM’s or traditional midwives, our clients, and others investigating home birth as an option, are often told that home birth is illegal. There are even some hospital OB practices that are still telling clients when they call to set up concurrent care that home birth is illegal. Because of the lack of recognition in Iowa law, many hospital based care providers decline to talk to home birth midwives or consult with us, meaning that when a concern comes up that does warrant consultation with a higher-level provider, our clients often have to make that initial contact and share information with us, instead of the midwives being able to call and give report directly to the care provider. There’s a practice in the state whose management told its hospital-based midwives that they aren’t allowed to even talk to home birth midwives.
This is bad practice. In no other healthcare setting would care providers actually be discouraged, or prohibited, from talking to a mutual patient’s care provider. In fact, it’s the opposite in every other situation. For the best continuity of care and safe outcomes, providers should be sharing information and talking to one another, but when it comes to Iowa women, we act as if it’s better, with the United States’s incredibly poor record on maternal healthcare, that we shouldn’t be allowed to talk to each other.
The fact of the matter is that because Iowa has not addressed CPM’s and made it clear that we’re welcome to practice in the state, hospital-based practices are reticent to consult with us. This puts our clients at risk. When necessary consults and treatment is delayed because of a lack of willingness to work with the midwives, we risk poor outcomes and treat women as if they aren’t important enough to come together and find solutions.
This year, Representative Kaufmann is once again presenting a proposed licensure bill. The language in the bill is modeled off of the most recent bills that have been passed in other states in the United States, and allows CPM’s to obtain a state license. Midwifery licensure bills have always been bipartisan in Iowa, so the hold-up to these bill comes primarily from the Iowa Medical Society, and on some level, the Iowa Nursing Association. These groups spend a lot of money to lobby against our bill, while claiming that the midwives just don’t want to come together to agree on what they think the bill should contain. In fact, one lobbyist group asked us to make 7 or so wording changes to the bill last year, and we agreed to 6 of those changes…and then that lobbyist group told a key legislator that we had refused to work with them! The lobbyist also told the legislator we had refused to discuss something they wanted in the bill-but that they had NEVER shared with us. The medical lobby claims that offering a license to midwives will result in moms and babies dying. They’re completely ignoring the fact that home birth is already happening in Iowa and it will continue to happen with or without their approval. The medical lobby should be focused on increasing access to midwives, something that has been proven time and again to increase outcomes for women, but instead they’re focusing on blocking bills by making baseless claims that cannot be backed by evidence.
The latest thing I’ve been told about the medical lobbyists (again, something they told a legislator we refused to work with them on but never spoke with us about) is that if midwives would agree to be licensed under the nursing board, they could support the bill. However, CPM’s are NOT nurses and agreeing to licensure under the nursing board means the medical lobby writes the rules. If the medical lobby writes the rules, we know that the scope of practice we’re trained for and allowed to practice under per our certification will be restricted, not by our own governing organization, but by the state. If the medical lobby wants midwives to be licensed under the nursing board, THEY need to be willing to work with US as well, and modify their existing board to include CPM’s or they need to allow our scope to be unhindered (with that statement clearly spelled out in the proposed legislation).
One major role midwives play in maternal health care is consistently lower cesarean rates than the national average, and increased VBAC (vaginal birth after cesarean) success rates. The national average for cesareans is 30%, twice the WHO recommendation that says cesarean rates should be no more than 10-15%. In some Iowa hospitals, the cesarean rate is over 50% because some hospitals will not allow women the option of a VBAC (vaginal birth after cesarean). Home birth midwives boast a cesarean rate nationally of just 5.2%! Given that midwives in the home birth setting work with low-risk women, we can compare that 5.2% with the national hospital numbers that show that 25% of low-risk pregnancies in low-risk women will still end in cesarean. Midwives cannot and will not ignore these women who are not given the option of VBAC in many of Iowa’s hospitals, despite the American College of Obstetricians and Gynecologists (ACOG) stating that VBAC should absolutely be made available to women. Midwives cannot capitulate to the medical lobby who wishes to take away a woman’s right to choose to have a planned VBAC at home, especially not when many Iowa hospitals refuse to offer women that choice.
Midwives are not hard to get along with. We want the freedom to practice within scope, which allows us to make our care as safe as possible. We want hospital-based providers to be able to look at Iowa law and know that we’re not illegal care providers and know they won’t face liability if they consult with us when we have clients who need care. We do not want our client’s rights restricted, and that’s why we will not agree to language that prohibits midwives from attending VBAC, breech, or twin births. Women have the right to full informed consent, and there are Iowa women who have and will continue to choose home birth because they’re stripped of options in the hospital setting. Some of these women, had they not found a home birth midwife, would have chosen to give birth at home without a trained midwife in attendance. By attempting to limit the scope of midwives who have the skills and training to attend these births, Iowa is driving women to choose unassisted birth instead of a birth with a trained midwife.
Shared decision making and true informed consent are important components to medical care, and Iowa women should be free to choose to give birth at home with the provider of their choosing, and Iowa should be increasing access to midwives who are proven to improve maternal and neonatal outcomes.