I couldn’t agree with you more! I live in IL now where there are no home birth or birth center options, as noted in your post. We’re headed to a hospital, with a midwife, but I fear a struggle to ensure that we have the non-medicated birth for which we are striving. My midwife assures me that she won’t do anything without my permission first. I hope the nursing staff are on board with that, too.

Great post and thanks for sharing this important information with your readers.

I live in Illinois and have had 2 home births with a CNM. My 3rd HB w/ CNM ended in a hospital birth because of premature labor at 35w.
There ARE home birth CNMs in Illinois but they are hard to find and swiftly decreasing in number because of rampant persecution from the AMA, which is housed in IL, and ever decreasing payouts from insurers.
Truly, the best protection for a natural hospital birth is education. We went in knowing that we could opt out of anything. I had to sign a stack of waivers and explain exhaustively to every nurse why we were doing things the way we were. It was not ideal but in the end I got most of what I wanted for my baby’s and my health and safety.
Intermittent monitoring, upright without stirrups (but still on the table, which was uncomfortable), few internal exams no eye goo, no vit K, no Hep B, delayed cord clamping, immediate kangaroo care and I took my placenta home.
I really believe that this last experience was a collection of fortuitous circumstances.

I feel so lucky to live 45 minutes away from the only birth center in Georgia – in Savannah. I’m shocked that there aren’t more, especially in the Atlanta area. So sad for all of the woman in the US who don’t have a birth center available to them.

@Geigerin – I guess it shouldn’t technically be “states” but it includes Washington D.C. as a separate area from Virginia.

Thank you for this post. When I was planning my HBAC (home birth after Cesarean) I got a lot of feedback from folks who were pretty ignorant about my actual options. People would say, “Well, you can have a VBAC in the hospital you know!” and I would have to say, “But at least 85% of women in my state DON’T, and I don’t want to be a weird anomaly, or pushed into things I don’t want.” My aunt said, “There’s a birth center in Danbury, you know!” and I had to reply, “But they won’t TAKE me as a VBAC patient.” And even though we have an in-hospital birth center in CT which is supposed to be pretty good, THAT was not even an option for me. I was fortunate to have several options for professional and capable homebirth midwives in CT- and also fortunate enough to have the cash to pay up front for the birth because their legal status makes it harder to get insurance reimbursement.

Regarding the “why didn’t they have a birth center/home birth?” thing? It bothers me for another reason. I had a couple of high-risk factors working against me to be a candidate for a home birth. I still had a natural birth. Sure, I had to fight for it, but for all the people who tell me “why didn’t you have a homebirth,” I kind of wince because I don’t want to have to explain those high-risk factors. Women should be able to have as close to a natural experience as possible regardless of the setting. I know you agree, Danielle, but it bears underlining in the scrutiny this mom faced: even *if* a mom’s best option is the hospital, that doesn’t mean her pregnancy is a pathology.

An update…In Nebraska (where I live) it is legal to birth unassisted in your home it is however it is illegal for any trained professional to attend, CNM or CPM. We are currently working on this and would love for this to change in the future. It is unfortunate that we are forced to make the decision to either birth at the hospital, go unattended (which some women are not comfortable with), travel to a surrounding state, or work with a midwife underground. I think that is why so many woman just “give up” and give birth at the hospital.

Please correct this information:

I am a CNM in South Dakota. I provide home birth care for South Dakotans and Wyomingites… I am licensed in both states and “yes, I am legal”. Currently in South Dakota, there are 4 CNMS who will provide home birth care and by the end of this summer there will be 2, possibly 3 more. In Wyoming, there are 4 CNMs who provide home birth care.

As far as birth centers go, South Dakota currently has a bill in the House that wil license and regulate birth centers. CNMs are working very hard to provide options here but it takes time once a bill has passed for all of this to come to fruition. Jeanne Prentice, CNM (Spearfish, SD)

CNMs CANNOT legally attend homebirth in Nebraska. It is a felony.
CPMs are not recognized in Nebraska, but CPMs and DEMs have received orders to cease and desist. There are no birth centers in the entire state. Women here either birth in a hospital, birth unassisted at home, or use the services of an underground CPM or DEM.

Nice article! It’s difficult to keep up with all of the changes happening in each state. I am constantly looking at the midwifery websites to see which state outlaw things. I know that both Nebraska and Alabama have outlawed CNM attended home births.

I’m assuming what Jeanne is pointing out is the section where you said “Well lets take a look at how many states do not offer home birth with available midwives” and then South Dakota is listed. However, with four home birth midwives (CNMs) legally practicing across the state and three more added by this summer, that’s a very nice start for a state with such a small population (800K). I wish my much larger state had the same availability of autonomous midwives. :o(

In Illinois CNM’s can attend home births if they have a physician to back their practice. In central Illinois (the Peoria, LaSalle/Peru areas) there are two CNM’s who practice under the supervision of an OB/GYN. Of course, this isn’t enough coverage, but it is available to a fortunate few.

Having not seen the episode, I can’t speak to the exacts of the couples situation, but I think it’s ridiculous that any woman should feel that in order to have a natural birth, she needs to be someplace other than a hospital. I had planned to have a natural childbirth but needed to be induced due to preclampsia. I was very glad that I had planned to birth at the hospital and was familiar with the facility and nurses. Even with being induced, I wanted to avoid any pain killers or meds that I could and the hospital was EXTREMELY supportive of this. I was so glad to be someplace that not only had the practitioners to care for me but also the facilities in case of an emergency. Everyone should have the right to birth where they are comfortable and feel safe. For me, I was only going to feel safe knowing that if something went wrong or was at risk for my baby, I was a a good hospital with everything needed to react quickly. That surely would not have been the case had I been at home. But I did not want to or have to give up the natural process of labor and delivery (besides a kick start).

In addition to safe delivery location options, I hope for more nurses and OB/GYNs like the ones I experienced and more understanding by the community at large to support a woman in her choices for her labor & delivery.

@Natalie – Thank you for pointing that out. I cited the wrong state, which I will change right now. Instead of Alaska, I put Arkansas.

@Natalie – Clearly I am having a day! LOL!
Thank you for pointing that out… I have been using the MANA chart, but alas, I am on about 3 hours of sleep right now!

That is really, really sad to hear. I thought we had it bad here in Texas where we had to pay for more than half of our first birth center birth, but to know that some states don’t even have the option is just wrong. Our birth center has a one-digit c-section transfer rate, while the overall c-section rate for this area is closer to 50% in hospitals. A birth center has been a great option for us in our first birth and in the one we’ll be having in about 12 days!

Agreed, Danielle, it is very hard to find a CNM outside of a large city in IL. Mine moved to Arizona after the birth of our 5th so we had to drive an hour to see one in the city for our 6th (introduced through our previous MW). Fortunately, Gina lives near the city and knows who to ask. I would love for such information and care to be openly available to all without having to dig.

This is a great resource at a glance on how dire things are midwives. Unfortunately, it is about the money. My unplanned, unmedicated, uncomplicated hospital birth cost $13,000 and I left in 24 hours. My MW cost $4000 w/ prenatal, birth and post partum care. Every woman that births at home keeps 10 – 15 thousand dollars from OBs and hospitals. With numbers like that we can be fairly certain that public safety is not the issue.

Another update… there are two freestanding birth centers currently in Maine – The Birth House in Bridgton, and Northern Sun Family Health Care in Topsham.

That’s not true about IL. We have CNMs here that are perfectly legal to do homebirth (mine’s a CNM.) We also have some doctors here that attend homebirth. It’s very much a legal and available option in many parts of the state. It’s just that CPM’s or Direct Entry midwives are not “legal.” But they’re definitely not the only type of provider that covers out-of-hospital birth here.

The comments about how the couple should have been at a birth center, or at home really bothered me too! I live in NE, one of only 2 states where CNMs cannot attend home births (Alabama is the other). I live in the largest city in the state & it’s very hard to have a homebirth here with a DEM or CPM, probably a lot harder in rural areas! If you don’t “know” someone its just about impossible. Like you said, we also have no birth centers. We were so close to one being opened but no doctor would sign on & in NE CNMs must work in a collaborative practice with an MD. We are making some progress so CNMs cannot be denied privileges simply bc they are CNMs. Hopefully it will happen, allowing thousands of NE women more options for their care. Thanks for the article! I dont think a lot of people realize how limited women’s options are all across the country!

Great discussion — and, unfortunately, still too true that women do not have good access to out-of-hospital birth options in most states. I have some updated and useful information, however, about CPMs and birth centers that might help those of you who are looking for options:

CPMs: The MANA chart is outdated and unreliable. A better resource is the PushMap on the website of The Big Push for Midwives Campaign:

http://www.thebigpushformidwives.org/index.cfm/fuseaction/home.stateStatus/index.htm

The Big Push is a coalition of state consumer groups and midwife associations from most of the states that still lack licensure for CPMs (23 states plus DC plus Puerto Rico and Guam). The member groups are listed below the map. If you live in a state without legally-practicing regulated direct-entry midwives, please consider joining the local Friends of Midwives or Safe Birth Options or other consumer group in your state and help us PUSH for greater access to legally-practicing regulated midwives. In states where CPMs practice legally and with licenses, access is MUCH better and easier. Check out Texas, California, Florida, New Mexico, for example. And where there are legal midwives, there will be more freestanding birth centers. BTW, direct-entry midwives are licensed and regulated in both Alaska and Arkansas.

BIRTH CENTERS: Yes, there is a great difference between a freestanding birth center and a section of a hospital that the hospital chooses to call a “birthing center.” Check out the website of the American Association of Birth Centers (AABC) at http://www.birthcenters.org, which provides a directory with contact information of all its member centers. Forty states license and regulate birth centers, but some states (e.g., Missouri, Illinois) impose difficult-to-meet requirements, while a few others (e.g., South Carolina, Florida) limit whether birth centers can provide care for vbacs. Actually, there are at least 3 freestanding birth centers in Utah (although not presently AABC members), and at least one in Connecticut (Danbury), and birth centers are in the planning stages in some of the states on the list in the post: Hawaii, Georgia, Indiana, Kansas, Kentucky, Missouri, and Ohio. Again, if you want to help solve the access problems, you would be welcomed as a member of AABC, which offers individual memberships for consumers, or groups like Friends of Missouri Birth Centers. A group in Kentucky has set up a facebook page for those who are working on bringing Kentucky a birth center. Check around online — every state has a Friends of Midwives group or something similar and would welcome your participation.

3. CNMs: CNM scope of practice include out-of-hospital birth, but only about 3% of CNMs practice in out-of-hospital settings — some in birth centers, some in home birth practices, some in both. Nebraska does prohibit CNMs from providing home birth services. However, in many states, CNMs are required to have a written practice agreement, or collaborative agreement, or joint protocols or such or even be supervised by a physician. Thus, as a practical matter, a CNM in that state can only open a birth center or offer home birth if she can find a doctor who will allow her to do so. Although the CNMs in New York recently got their law changed, but it has been an uphill battle in other states and in some, like Florida, CNMs appear to have just given up trying.
Unfortunately, the national nurse-midwives organization, ACNM, is opposed to licensure of Certified Professional Midwives, so the affiliated state CNM groups are required to oppose attempts by consumers to lobby for licensure laws.

Some good news: CPMs gained regulated status in Idaho only two years ago. There are now at least 3 birth centers in the state.
Bottom line: the key to gaining birth options and better access to home birth and birth centers is consumer activism. Join up with your sisters in your state, find them on facebook, learn how to lobby. If citizen activists could bring down Egypt’s government using the internet, non-violence, and persistence, we can overcome the opposition of organized medicine and get good laws passed for CPMs, birth centers, and CNMs.

Danielle,
Thank YOU for posting about this. The sad truth is that, if 10% of all American women decided overnight to start giving birth at home, that would be 400,000 or so and we simply do NOT have enough midwives (yet) to care for them all. If midwives have to fear being arrested or getting a cease and desist order, if midwives could practice in the open, easily found by consumers who want their services, more women would become midwives and we could grow our birth workforce. The CPM credential was a huge step forward, but ulegal regulated status is the next — VITAL — step to improving access to midwives.
One other piece of good news: In March 2010, the U.S. Congress passed a law that guarantees Medicaid payment to all birth centers and the professionals who own and staff those centers, whether CNMs or LMs/CPMs. This is huge boost for access, since such a high percentage of women who give birth in this country are Medicaid recipients.
LOVE this blog — all you guys are just great!!!

I happen to be one of the fortunate ones who lives in central Illinois and was able to have a home birth with one of the two practicing CNM’s. It is true however that my only options were a hospital birth or a home birth – there are no birthing centers. I did have three natural births in the local hospital, but it is a very small hospital (approx. 40 births a month) and individual attention is the norm, not the exception. As a doula, I have seen many planned natural births take a turn fast at the other local hospitals.

I would point out however, that I might have had an unplanned unassisted birth if not for the relatively “new” CNM doing home births in our area who happens to live 30 minutes away. I know this because the only other CNM who does them was also on her way to my birth but ended up turning around and going home because she is a 2-hour drive away and wasn’t going to make it. While I was comfortable with this situation, it does point to the problem of accessibility even in an area where we are considered covered.

I have no words to express how grateful I am and I feel like I literally won the lottery for my fourth birth. It makes me sad that we don’t have more options here and makes me jealous of those who have them and don’t even realize it.

Hellos!

Just a quick fix to a typo in the original post above:

“Then there are the CPM’s or Certified Practicing Midwives. Their educational background is different than CNM’s and the legality of them practicing drastically varies. In 10 states it is illegal for these kind of midwives to attend births …”

It should read “Certified Professional Midwives.”

Also, an easier link to remember to the PushMap is here:
http://www.thebigpushformidwives.org/pushmap

Thanks very much!

Natalie – I wish for the same thing as my experience was much like yours. A “hey, I can have a natural birth in a hospital” attitude met with a mean L&D nurse who mocked my refusal of an epidural and proceeded to tortured (no, not too strong of a word) me which lead to more intervention than necessary including an epidural and pitocin.

I will inquire as to if a mom has considered a midwife assisted birth (not so much now that I am in IL and they are harder to find although when I could recommend mine in OK I never had anyone contact them). I also strongly suggest that moms that want to have a natural birth in a hospital find a doula to help them with their plan.

Silently, I feel that in most hospitals in America a natural birth is not possible. An unmedicated birth can happen, but most hospitals have policies that make a truly natural birth impossible.

In the Chicago area, there is also the option of birthing at home with doctors. http://homefirst.com/

Also, in Georgia, it is neither legal nor illegal for a midwife to attend a homebirth, if I recall correctly. The law says they must be certified by the State, but the State does not provide for certification.

There is a group trying to start a birth center in Atlanta. If you want more info, and want to be in on the planning, find “Intown Midwifery” on Facebook, as they have the info on their page.