A Labor of Love – The Licensure of Direct-Entry Midwives




After almost five years of intense labor, the General Assembly has finally delivered access to home birth care in Maryland.  The 2015 legislative session saw the passage of House Bill 9, Maryland Licensure of Direct-Entry Midwives Act, legalizing the attendance of Certified Professional Midwives (CPMs) at home births in this state. The new law, the result of years of legislation, studies, and stakeholder workgroups, includes licensing, regulation, and safety measures to make home birth a realistic option for more women seeking this type of care in Maryland.

The measures in House Bill 9 will license and regulate the practice of non-nurse, direct-entry midwives in Maryland.  It lays out very specific guidelines for scope of practice, educational requirements, transfer procedures, newborn care and other regulatory areas and creates a Direct-Entry Midwifery Advisory Committee, under the State Board of Nursing.   Current law permits physicians and certified nurse midwives (CNMs) to perform home births in Maryland, but, for a variety of reasons, too few of them choose to practice in out-of-hospital settings to meet the demand of expectant mothers across the state.

The prohibition on CPMs in Maryland was seen by many as a restriction on women’s rights and frustrated many mothers-to-be who, after evaluating their care options, wished to pursue home births.   By moving forward with this legislation, Maryland becomes the29th state to license CPMs. It is an important step as many women find themselves looking for alternatives to the labor and delivery wing of their local hospital, turned off by the one-sized-fits-all procedures and protocols and high caesarean section (“C-section”) rates in Maryland hospitals.  In contrast, a midwife works with a woman and her family from pre-natal care up through delivery to provide education and one-on-one support in each step of the process.  This relationship and the CPMs training, which is specifically geared toward out-of-hospital care, allows the CPM to ensure the pregnancy is low-risk, and thus appropriate for a home birth, as well as monitor for any changes that would warrant medical intervention.  Risks, of course, are present in even the healthiest deliveries, but that is all the more reason to have a licensing and regulation scheme in place to standardize the proper response in those situations.

One yet-to-be settled issue is vaginal births after caesarean section (“VBACs”).  Although those in the field of midwifery and proponents of home births sought to allow direct-entry Midwives to attend VBACs, the bill, as passed, still prohibits it.  The new law, however, does require  the Department of Legislative Services to research outcomes of VBAC’s attended by similarly licensed midwives in other states and countries and present that data to the health policy committees. It also requires the Board of Nursing to make annual recommendations of the inclusion of VBACs in the scope of practice for direct-entry Midwives in the future.  This is an important step because many women look to home birth as an option to avoid C-sections for subsequent births, but are unable to access VBAC care at their local hospitals.  Currently, Maryland has only an 11% VBAC rate, which much lower than the national average, especially compared to the high C-section rate for initial births.  In 2012, 50% of Maryland counties had no VBACs performed at all.

There is still more work to be done to provide the full range of services, such as VBACs, and access for all women, including those on Medicaid who cannot afford a CPMs services out-of-pocket, but House Bill 9 was a substantial win for both CPMs and for the women and families of Maryland! House Bill 9 is the product of significant input and back and forth from dozens of stakeholders, including CPMs, nurses, doctors, hospitals, insurers, consumers, trial attorneys, advocates, and more.  It is a bipartisan issue, championed by legislators from the far left and right of the spectrum, and is an important policy change that is more than a professional interest for CPMs.  This legislation represents an expansion of choice for Maryland women and reemphasis on the autonomy of women in the birth process.

Successful passage of a licensure bill is always a long, tough road.  The establishment of a new profession, or this case the reestablishment of a very old one, is an exercise in compromise, commitment and thoughtful creativity.  On May 12, 2015, Governor Hogan signed House Bill 9 into law, and, as with most labors, the finished product was worth the hard work.