Thursday, March 25, 2010

Midwifery in Illinois

I lived in Illinois for three years after completing my PhD coursework at the University of Iowa. Direct-entry midwifery in both Iowa and Illinios was (and still is) illegal. Citizens' groups in both states are currently trying to pass legislation to license Certified Professional Midwives (CPMs). A lot of people have told me that Illinois will probably be the toughest state for legalizing and licensing direct-entry midwifery, since it is the home state of the American Medical Association. I went down to the Illinois state capitol when Zari was a baby to lobby and testify in favor of licensing CPMs. There was a large group of Amish people present on that particular day to support the proposed midwifery bill. At that particular meeting, the home birth supporters got portrayed as religious nut-jobs. None of us were particularly happy about that, the Amish included.

Certified nurse-midwives can attend home births in both states, but Illinois is particularly difficult for home birth CNMs. They have to have a signed collaborative agreement with an OB in order to practice. As you might imagine, this proves incredibly difficult to obtain. One home birth CNM I know approached something like 100 physicians before she found one willing to take her on. And the supervising OB can dictate what the CNM can and cannot do.

Iowa is more friendly to home birth CNMs than Illinois. In Iowa, nurse-midwives are considered independent health care practitioners and do not need any kind of physician supervision or collaborative agreement to attend births. Still, in both states, there are very few home birth CNMs. Only 5 of Illinois' 102 counties have legal home birth attendants. The situation isn't much different in Iowa. This means that most women wanting home births in Iowa or Illinois will have to hire "underground" midwives.

For two fascinating, in-depth looks at contemporary direct-entry midwifery in Illinois, I suggest you read these two articles that just came out this week:

19 comments:

  1. If the problem is the lack of CNMs able to do homebirth due to regulation, why is the proposed solution not freeing them from this regulation rather than trying to get a whole different set of people licensed? It seems ridiculous that CNMs would be under greater practice regulations than a CPM.

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  2. I assume the Nurse Practice Act would have to be changed shortly after CPMs were legalized. But I do think (even as a nurse) that establishing the CPM license is important, because there's really no sense in forcing all would-be midwives to get a degree in general medical nursing (which deals more with geriatrics and chronic disease management). It has to be discouraging to many aspiring midwives. It's really a distinct discipline from nursing.

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  3. Christie,

    I don't think the restrictions on CNMs is the only problem. CNMs will never totally fill the demand for home births--most choose to practice in a hospital setting. Even in states like Iowa where CNMs can practice autonomously, most home births are still attended by non-nurse midwives. A CNM education is incredibly expensive and a home birth midwife rarely makes much money at all--another reason why most CNMs don't go into home birth practice. I agree that the IL restriction should be changed, but there would still be shortage of legal midwives.

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  4. Being just across the "pond," so to speak, this concerns me... Missouri only recently licensed CPMs to practice, and though it seems as though we are making great strides (a birthing center, the first center local to STL, is soon opening!), there are still only a handful of practicing midwives and, to my knowledge, only one other birth center in the state. So change does not come quickly enough, it seems. Thanks, as always, for the information!

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  5. The McClain article is a great read; thanks for the link!

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  6. In Illinois currently my state senator sponsored a bill that would eliminate the cooperative agreements for CNMs. So far the bill is dead in the water. I don't think they have support in the Illinois State Senate to put the bill to a vote. I should follow up with Senator Steans to see where this bill stands.

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  7. I've had 4 homebirths in IL with unlicenced midwives. I almost considered having an in-hospital birthing center suite birth for my 4th (the first one I was insured for, and therefore the first it would have been cheaper not to birth at home) but changed my mind when I was around 4 months pregnant, when a friend who'd been planning a birth center birth (in another state) was risked out for having a breech baby. She ended up with a much-unwanted c-section; I, in the same situation, would have been searching frantically at the last minute for a home birth midwife! I decided to go to one from the start, just in case. I ended up going past 42 weeks (another reason women get risked out of birth centers, and legally-attended home births) and am glad I still had the option to have the birth I wanted.

    Long story short: legalizing lay midwifery would mean more regulations imposed on the midwives. More safe and healthy pregnancies being risked out... I personally feel most comfortable with unlicenced midwives. I hope they continue to practice, even if lay midwifery becomes legal and regulated.

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  8. Illinois residents, please contact your state representative and ask for support for HB 226, the Home Birth Safety Act. You can look up your representative at ILGA.gov (legislator lookup).

    I agree 100%. The written collaborative agreement is not the only reason CNMs are not meeting the entire demand for home birth providers. A lot of it is economic. And also desire and passion to be a home birth provider. The job requires quite a bit of time sacrifice, the economic reimbursement is much less than an advanced practice nurse can make in a hospital practice. Sadly as mentioned by M, there is not a lot of Springfield support for removing the written practice agreement.

    Thanks for the discussion. Rixa.

    Michelle Breen, MHS
    Coalition for Illinois Midwifery

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  9. "Long story short: legalizing lay midwifery would mean more regulations imposed on the midwives. More safe and healthy pregnancies being risked out... I personally feel most comfortable with unlicenced midwives. I hope they continue to practice, even if lay midwifery becomes legal and regulated."

    I totally agree! Carla Harley has a great post on her Facebook page about licensing that you may wish to read, Rixa.

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  10. I've talked with Harla about licensing. I used to be a lot more wary of licensing, and I totally understand the worries about regulating authentic midwifery out of existence. I love Oregon's system of voluntary licensure and wish that all states would have that.

    That said--I feel more and more strongly that midwives need to be able to practice openly. When they are illegal, they cannot collaborate, consult, or even communicated with hospital-based providers when their clients might need it. They have to dump their clients at the hospital doors or pretend to be the woman's "friend" or "doula"--thus making it harder for the hospital staff to take care of the woman. And in many of the states I've lived in, where midwives are illegal, their numbers have been shrinking due to C&D orders, arrests, etc. As much as I have hesitations about licensure, I feel that it's better than being illegal; if the choice came between the two, I'd choose being licensed over being illegal (and being arrested for a felony, going to jail, paying fines, etc).

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  11. (This is the same "anonymous" who posted at 6:59 above.)

    Don't get me wrong: I am not opposed to licensing midwives in IL. I suppose I didn't point this out very well. I just hope that there are still midwives working under the table for those cases where a normal, healthy pregnancy may be risked out with legal midwives (breech births, going past 42 weeks, etc. though there are legal midwives who will rearrange your due date for you so you appear to still be within "normal" term.)

    I know there are many women out there who would love to home birth but refuse to do so with illegal attendants, and not having legal ones to use, hope for a natural hospital birth instead. For these women, legalizing midwifery everywhere would be great--it would get more births out of the hospital!

    The midwife who attended my 4th birth said she will probably not become licensed if lay midwives become legalized. So I have hope that I won't be stuck choosing between a hospital birth (hahahahahahahah no) or an unassisted birth if I find myself at 43 weeks again.

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  12. Anon, I do agree with you. I just wish there weren't this hard choice between licensure (and possibly a very narrow restriction on who the midwife can attend) and autonomy (with the possibility of arrest).

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  13. I want to point out that the Chicago Reader article was published in 2003.

    I recognized "Cassandra;" she needs more than a pseudonym for anonymity!

    As an example of how the tide is turning, "Cassandra" is currently a very vocal advocate for licensure. She's working with two state consumer groups and a national group (The Big Push,) to bring legislation to our state.

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  14. I guess that article isn't that recent! It just came into my google reader a few days ago so I assumed it was new.

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  15. Not google reader--I meant to write google alerts.

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  16. One of the national nursing magazines recently featured an Illinois CNM who headed the midwifery practice at one of the larger downtown Chicago hospitals, and one of the first things she clarified was that "midwives [by which she meant CNMs] almost never do home births!"

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  17. This awesome. I have some friends that are looking for a midwife in Mchenry IL, and never knew that kind of role that a midwife plays.

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  18. unfortunately, it is very much the same, three long years later. Congratulations, however, on CPM licensure in Indiana!

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  19. It's interesting to hear about the legal status of midwives in some states, considering the historical role of them. I hope things have or will improve in the future, because some women might want a midwife and that should be an option. http://stankevychobgyn.net/Obstetrics/

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