Malpractice Insurance

When looking for a safe care provider for your birth, it is very important to find one that carries malpractice insurance.

Many home birth midwives do not carry malpractice insurance, reassuring their clients that they don't need it because "malpractice insurance only protects doctors so that they can keep practicing when they do something wrong."

In truth, malpractice insurance does not protect health care providers who make mistakes. It protects the families who the health care provider injures. Birth injuries in particular can be very costly and require expensive life-long care. If a family chooses a health care provider who carries malpractice insurance, and something goes wrong because of the health care provider, malpractice insurance will allow the family to be able to get the money they need to take care of the injury. If it's a hospital-based doctor or midwife who made the mistake, malpractice insurance will not protect them from the professional repercussions of their actions. Hospital-based care providers are overseen by boards of professionals who thoroughly review their actions; malpractice insurance doesn't protect them in any way from losing their hospital privileges or their license.

On the other hand, if a family chooses a birth center or home birth midwife who does not carry malpractice insurance, and something goes wrong that the midwife should have prevented, the family will have no venues for financial compensation. They will have to pay for the (potentially life-long) costs of the injury themselves. And the home birth midwife will have no professional repercussions, as she has nothing to stop her from taking on new clients without telling them of her past negative outcomes.

Many home birth midwives without malpractice insurance cannot be sued if they have a negative outcome, because very few lawyers will take on a lawsuit against them if they don't carry malpractice insurance. There just isn't enough money in the midwife's bank account to make the lawsuit worth it to the lawyer. And if a lawsuit is successfully brought and won against them, they can just declare bankruptcy, use a new name and continue practicing. One birth center in Michigan did just that.

In a report comparing different state midwifery laws, "Do State Midwifery Laws Matter?", the data shows that requiring midwives to carry malpractice insurance cut the rate of newborn deaths in half. Women and children benefit from midwives carrying malpractice insurance - and they benefit a lot.

If your midwife does not carry insurance because the cost will cut into her profits, she has weighed the pros and cons of not carrying malpractice insurance, and decided that the benefits to her outweigh the risks to you.

The Qualifications of US Home Birth Midwives

In trying to understand why the risks of home birth are so elevated compared to hospital birth, it's important to understand the "qualifications" of home birth midwives.

There are several different types of midwives in the United States and if you're not familiar with all of them their titles can sound similar and confusing. CNM, CPM, CM, DEM, LM...what's the difference? As Danielle Repp explains in her series "American Midwives": 

"There are two midwifery certifying bodies in the USA: American Midwifery Certification Board (AMCB) and North American Registry of Midwives (NARM). The AMCB is considered the Gold Standard for midwifery certification and is the certifying body for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs); NARM is the certifying body for Certified Professional Midwives (CPMs). Licensed Midwives (LMs) also fall under NARM as it is the NARM entrance exam they take. Specific requirements for LMs may vary by state in order to take the exam."

"So in short, midwives in the USA basically fall into one of these three categories:
1. AMCB certified
2. NARM certified
3. Uncertified"

She continues:
 
"1. Certified Nurse Midwife (CNM)"

"Certified Nurse Midwives (CNMs) are some of the most highly skilled and educated midwives in the world. The Certified Nurse Midwife is one of the only types of midwives in the world that requires a nursing degree. The CNM also holds a master’s degree as the minimum level of educational requirement (some have doctoral degrees). CNMs must complete their education through an ACME-accredited midwifery program (ACME = Accreditation Commission for Midwifery Education). Once completed, they can apply to take the AMCB certification exam."

"Certified Nurse Midwives are licensed and have prescriptive authority in all 50 states (and other territories of the USA). The educational and clinical skills training of the CNM not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, andent of sexually transmitted diseases."

"2. Certified Midwife (CM)"

"The Certified Midwife (CM) credential has existed since 1994. The CM is the direct-entry version of the CNM. While CMs do not need to have a nursing degree, they must take all of the nursing school pre-requisites (such as anatomy, physiology, microbiology, etc) and must receive a bachelor’s degree and master’s degree. The CM’s educational and clinical skills training is similar to the CNMs, as it again not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, and management of sexually transmitted diseases."

"3. Certified Professional Midwife (CPM)"

"The Certified Professional Midwife credential ... was developed as a direct-entry route to become an out-of-hospital midwife. CPMs are not authorized to work in a hospital setting."

"Certified Professional Midwives do not have any degree requirements. The only educational requirement is to have a high school diploma, which was not a requirement until September 1, 2012."

"The Portfolio Evaluation Process (PEP) is a popular route to become a CPM. It is an apprenticeship where the student midwife follows and learns from a preceptor midwife. After attending 40 births (and the prenatal exams leading up to it), the student midwife can qualify to take the NARM exam. Anyone with a desire to become a midwife can seek out a preceptor. Half of CPMs have earned their credential through the PEP route."

"Another route to become a CPM is to graduate from a Midwifery Education Accreditation Council (MEAC) school. There are nine MEAC schools in the USA, some of which award certifications, some diplomas and some degrees."

"CPMs ...do not have prescriptive authority in any states (in certain states, CPMs are able to obtain certain medications, such as Pitocin, Cytotec, antibiotics, etc but CPMs cannot write prescriptions). CPMs also would not qualify to practice midwifery in other developed countries due to the lack of formal education requirements; the CPM requirements also do not meet the International Confederation of Midwives (ICM) standards."

The above was all from Danielle Repp's series American Midwives, part 1, part 2, and part 3; emphasis mine.

Due to the variation in types of training accepted to become a CPM, some CPMs might have enough education to meet the ICM minimum standards. However, the CPM credential itself does not require it, and ACOG estimates that "possibly as many as two-thirds of CPMs do not meet the ICM standards."

I want to repeat - Certified Professional Midwives - the kind of midwives that attend the majority of the home births in the United States - do not have any educational requirements other than a high school degree. And if they became a CPM before 2012, they don't even need that. They don't need to take anatomy, or physiology, or immunology, or even basic college biology.

And do you know what's even worse? In some states, midwives do not have to have any qualifications at all to practice. None. The state where I spent my college years - Utah - has voluntary licensure, which means that if a midwife simply decides that she'd rather not be licensed by the state, she has no educational requirements, no limits on her scope of practice, and no accountability for her actions. This satirical website points out the weaknesses in such a system.

Here are a couple charts that explain the difference between the midwives who work at doctors offices and in hospitals (CNMs) and the majority of home birth midwives (CPMs, LMs, lay midwives, etc.):

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Now, if you think you'll be safe at home birth if you choose a CNM instead of a CPM, think again. Researchers in 2009 found that home birth with a CNM had twice as many babies die than hospital birth with a CNM. An even more recent study published in 2016 found that babies born to CNMs and CPMs at home birth died three to four times more often than babies born at the hospital, with no statistically significant difference between home births with CNMs or CPMs. Even if your midwife is a CNM instead of a CPM, you still won't be able to tell at home if your baby is being deprived of oxygen, you won't have an operating room if it becomes urgently needed, and you won't have a neonatal resuscitation team with all of the equipment that might be needed to save your baby.

More excellent articles that explain the disparity between US home birth midwives and US hospital midwives and the home birth midwives in other countries can be found here:

• Safer Home Birth Requires Educated, Regulated Midwives
• Why I Can't Support CPMs - Not a Single One
• Honest Midwife

The hypothetical situations you can imagine when you think about home birth midwives' lack of education and regulation - like, "If I have an emergency during labor at home, will my midwife know what to do? Will she have the skills and training to save my baby?" - clearly actually happen at home, as we can see from the numbers. With home birth midwives, three times as many babies die. With home birth midwives, seventeen times as many babies have brain injuries. These are the numbers that result from the faulty regulation and extremely low educational requirements required of US home birth midwives.

The Coalition for Safer Home Birth

In response to the increased death rates at home birth and the lack of regulation and accountability of home birth midwives, an citizen-led organization called the Coalition for Safer Home Birth has formed. The Coalition is made up of home birth families, doctors, midwives, and advocates who wish to make home birth safer in America.

To draw our lawmakers' attention to the laws that would most improve the safety of home birth in the United States, the Coalition for Home Birth has started a petition on Change.org.

The petition endorses the following regulations for midwives:

1. Require a License
2. AMCB Certification
3. Malpractice Insurance
4. Low-risk Scope of Practice
5. Report Outcomes to the Public
6. Integrated System of Care

You can sign it here: Change.org: Protect Mothers & Babies - Make Home Birth Safer

We need to improve our home birth system! Please read and sign the petition, and use it as a guide for pushing for a better system in your state.

Hurt By Homebirth

When I was first learning about home birth, I found the site "Hurt By Homebirth." The stories that I read profoundly affected me.

A picture of Shridam, used with permission from his mother

Shridam's Story, as told by his mother Dhanya
Magnus's Story, as told by his mother Sara
Sheppard's Story, as told by his mother Marlo
Angela's Story, as told by her mother Nicole
Grant's Story, as told by his mother Rachel
Zen's Story, as told by his mother Elizabeth
Thomas's Story, as told by his mother Erin
Sam's Story, as told by his parents and his aunt
An update to Sam's story, after he passed away just before his third birthday
Wren's Story, as told by his father Josh
Mary Beth's Story, as told by her mother Bambi
Aquila's Story, as told by her mother Liz

These deaths and injuries were preventable, and these parents have to live with the sorrow of missing their beautiful children.
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Why international studies do not show American home birth is safe

Home birth in the United States is very different from home birth in other developed countries.

Different Midwives

In countries like Canada, the UK, and the Netherlands, the midwives have much higher educational standards than US homebirth midwives. They must have a university degree, they meet the standards set forth by the International Confederation of Midwives, they are integrated into the health care system, and they have hospital privileges.

Most home births in the United States are attended by Certified Professional Midwives (CPMs) or Licensed Midwives (LMs). Neither CPMs nor LMs would be able to practice in any other developed country; their educational standards are just too low. They do not have to have a university degree (if a midwife became a CPM before 2012, she doesn't even need to have a high school degree), their credential does not meet the standards set forth by the International Confederation of Midwives, they are not integrated into the health care system, and they do not have hospital privileges.

Certified Nurse Midwives (CNMs), which do attend some home births in the United States, are much more similar to midwives found in other developed countries. Like the midwives found in the UK, Canada, and the Netherlands, they must have a university degree, they meet the standards set forth by the International Confederation of Midwives, they are integrated into the health care system, and they are (usually) able to obtain hospital privileges.

This helpful chart from "American Home Birth" illustrates the differences between the types of midwives:

Different Systems 

In addition to the differences between American midwives and the midwives found in Canada, the UK, and the Netherlands, the home birth systems are completely different.

In Canada, the UK, the Netherlands, and other developed countries home birth is integrated into the main medical system. Midwives are highly regulated and have accountability for their actions and outcomes.

If a woman wants to have home birth, she is assessed by a care provider to make sure that she is "low risk." "Low risk" means she does not have risk factors such as a previous cesarean, twin (or other multiple) pregnancy, breech baby, previous postpartum hemorrhage, and much, much more. These things are not just "variations of normal" - they are complications that increase the risk to woman and baby during pregnancy and labor. The risking out criteria is quite extensive, to make sure that only the lowest-risk women are attempting home birth.

If a woman develops risk factors any time during her pregnancy or labor, her care is transferred to an OB and she delivers in the hospital. The transfer rate is quite high - about 40% in the Netherlands. A high transfer rate is the sign of a good home birth system - it means the midwives are recognizing risk factors and taking them seriously. Transferring is to keep the woman and her baby safe, as they are no longer safe attempting a home birth with their risk factors.

In the US, home birth is not integrated into the main medical system. There are almost two systems - the hospital system, and the home birth system. Home birth midwifery laws are determined on a state level, and there is an incredible amount of variation between the states. In general, accountability of out-of-hospital midwives is very low.

In the United States there are no national risking out criteria for women attempting home birth, and the states that do have legally required risking out factors have very few of them. Here is a chart that compares the Dutch risking out criteria to Oregon's risking out criteria: Dutch Homebirth Standards vs. Oregon Homebirth Standards. And most states have even less risking out criteria than Oregon.

In most states where midwives can legally attend out of hospital births, they are free to take on women of any risk, and pride themselves on their low transfer rates - even though a low transfer rate is a sign that a midwife is either missing risk factors or ignoring them.

For all of these reasons - poor education, training, regulation, and accountability of US midwives, and the large differences in the US homebirth system compared to the homebirth systems in other developed countries - one cannot use studies from other countries to prove that home birth in the United States is safe. One must use home birth data from, and only from, the US to determine safety of home birth in the United States. 
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