Certified Professional Midwives (CPMs) are midwives who practice in an out-of-hospital setting. For Iowa CPMs, this means that we attend home births, and in other states CPMs attend home births and births in birth centers. CPMs are nationally credentialed after completing clinical requirements and passing an 8 hour certifying exam. CPM training meets the International Confederation of Midwives training standards, which is the standard globally for midwifery training and is recognized by the American College of Obstetricians and Gynecologists as the appropriate training for midwives providing care.
CPMs, like CNMs and OBs, provide care to pregnant women throughout their pregnancy, birth, and postpartum period. They see their clients regularly during pregnancy, assessing overall health and wellbeing of both mom and baby, and assessing for any risk factors that might preclude a client from planning a home birth. CPMs go to their client’s homes when their clients are in active labor, and monitor the baby and the mother throughout the course of labor and birth. CPMs then provide the follow-up postpartum care, often in their client’s homes, to assure an appropriate recovery is taking place and to assess the baby.
Here in Iowa, CPMs are unregulated. The Iowa Code does not have any law that addresses the practice of CPMs. In theory, this sounds like a great freedom move, but in reality, this means that midwives face many challenges as they strive to provide the quality care they’re known for.
In the mid-1990’s, 2008, and 2013, 3 different CPMs were charged, by the State of Iowa, with practicing medicine without a license. These midwives were not charged due to a poor outcome, but because a hospital-based provider did not believe the midwife should be practicing, and, since there IS no state law that addresses our practice, prosecutors brought charges.
In addition to practicing with the risk of being put in jail, unlicensed midwives cannot purchase antihemorrhagic drugs that they are trained to use, and that are well within their scope to carry and utilize. Unlicensed midwives are very limited in where they can send their clients for prenatal labwork and ultrasounds, due to most facilities requiring the ordering provider to have a state license. When something comes up that requires consultation with a hospital-based provider, many licensed providers are hesitant to consult with an unlicensed midwife due to the liability concerns that come with consulting with someone the state doesn’t recognize as a licensed provider. Most planned home births result in the birth taking place at home, but when a transfer is indicated during labor, many hospitals refuse to consult with the midwife, accept her records, or take report from her during the transfer. Some clients are treated during transfers as if they were a drug addict off the street coming in with a history of no prenatal care, and in some cases women are actually told they have to go to a different hospital or be subjected to an unnecessary cesarean because they are ‘high-risk because you were planning a home birth’. Keep in mind that the vast majority of home birth transfers are NOT emergencies, but are for pain relief.
The history of the pursuit of licensure for CPMs is vast and long. In 1999, the midwives in the state requested the Iowa Legislature authorize a scope of practice review. In 2000, the Iowa Department of Public Health presented their scope of practice review findings, which determined that CPMs should be offered a license, and a midwifery board should be established under the IDPH.
That was 22 years ago. Since that time, midwives and their supporters have lobbied the state legislature almost every year, asking for a license. Of primary concern was the fact that Iowa seems to have no issues with putting midwives in jail for practicing without a license in spite of the fact that Iowa has chosen NOT to offer a license, nor have they chosen to criminalize the practice of midwifery. Over the course of 22 years, a midwife bill was unable to make it to the floor in either chamber for debate.
This year, a midwifery licensure bill, HF 2547 (formerly HSB 123 and HF 2291) advanced through the Iowa House, passing almost unanimously through TWO full committees, and passing the floor vote 93-2. Throughout this process, there were exactly 0 lobbyists or public members who spoke in opposition at the subcommittee meetings, while midwives and midwife supporters filled the rooms both times. This bill’s language was the same language prior year’s bill contained, so this wasn’t a new idea. On the house floor, 0 representatives spoke in opposition of the midwifery bill, and for the first time in over 2 decades of work, a CPM licensure bill advanced out of the House chamber.
The midwife licensure bill went to the Senate, where it was erroneously assigned to the State Government committee. The bill came out of the House as a Ways and Means bill, and that’s where it should have gone in the senate. The chair of the State Government committee, Senator Roby Smith, assigned Senator Cournoyer, who was very new to the topic of midwifery, as chair of the subcommittee in spite of the fact that several members of the State Government who have been working on this bill for years asked to be part of the subcommittee. The subcommittee set a meeting date for 22 hours after the bill was assigned to them, and at the last minute changed the meeting location. This cut the meeting to just 30 minutes in spite of the fact that there were about 15 people in support of the bill in attendance, at least half planning to speak, in addition to several midwives who attended via zoom and were not given the opportunity to speak. The medical lobby ended up taking over half of the allotted time, and the midwives were not given the opportunity to respond to the blatant lies the medical lobby tossed out. The bill passed with amendment, with the amendment to be determined later. You can read the update from that subcommittee and find the link to view the testimonies from that subcommittee here.
Less than 24 hours later, the full state government committee met and discussed the midwife licensure bill. They proposed an amendment that none of the midwife lobbyists had been made privy to prior to the meeting. In fact, that amendment did not become publicly available until about 2 hours after the meeting. The amendment deleted the bill in its entirety, save the 3 lines at the very beginning introducing the bill (which they amended to retitle), and replaced the bill with a paragraph about occupational licensing. At the very end, they included that this newly revised bill would go into effect only upon the enactment of SF487, a senate license bill currently in the senate. You can read the License Iowa Midwives update on that committee meeting here. It is worth noting that the majority of the Republicans on the Senate State Government committee support the midwife licensure bill in its original form, but provided yes votes to keep the bill alive. The Democrat senators on State Government were also all in support, but submitted a ‘no’ vote due to the amendment, citing the fact that this new bill does nothing to help moms and babies. Senator Jochum’s comments were entirely correct, and midwives appreciate the bipartisan support and the reasons both Republican and Democrat supporters voted the way they did in committe.
Based on the comments of the speech given by the subcommittee chair during the full meeting, it’s evident that the CPM licensure bill is now being used as a political pawn by Senator Roby Smith. It is entirely unprecedented to delete a bill that passed almost unanimously out of one chamber, and to replace it with something completely different that only would go into effect if a different bill in the other chamber gets passed.
We heard over and over from the subcommittee chair that ‘maternal healthcare is near and dear to my heart’, but the actions of the State Government Chair shows a complete disconnect from the needs of Iowa women. Iowa ranks 49th in the nation for number of OB providers per capita. The maternal mortality rate has doubled over the last few decades, which means that women my age giving their babies are twice as likely to die today from pregnancy or childbirth-related complications than our own mothers were when they gave birth to us.
Increasing the number of midwives who meet global training standards, as CPMs do, has consistently shown a significant decrease in maternal and neonatal mortality, as well as a decrease in billions of dollars globally in healthcare costs.
For women receiving care from homebirth midwives who meet these standards, they see a 5.2% cesarean rate whereas women cared for in a hospital setting see a 30% cesarean rate. Not only is this significant in the health of women, it represents a massive health savings when women are not subjected to cesareans unnecessarily.
Iowa saw a 20% increase in home births from 2019 to 2020, and another 20% increase again from 2020 to 2021. In 2021 alone, the estimated healthcare cost savings to Iowa and its citizens because of planned home births was $5,000,000. Yes, you’re counting the 0’s correctly. In 2021, $5 million was saved because of the care provided by homebirth midwives. Combine that with the improved health outcomes because of midwife-led care, and it’s evident that refusing to pass the very well vetted midwife bill in favor of advancing an agenda is a foolish decision, and one that Iowa women will not forget when they’re at the polls in November.
Bethany Gates is a Certified Professional Midwife from Vinton, Iowa. Bethany lives in Vinton with her husband, Judah, and their 4 daughters.
Thank you for an explanation about what is going on with this bill. Unfortunately I see a huge pattern here, and even in other news items that happened just this week from the Iowa legislature, that confirms that they do not care about the men women and children that live in the state and what happens in our lives. I pray that people really will pay attention and vote accordingly.