A midwife cares for a pregnant woman before, during, and after they give birth. By developing relationships with their clients, midwives say they can help each women determine how and where they want to give birth, whether in a hospital, a birthing center or in their own home.

Valerie Runes once worked as a midwife in Chicago. Today, Runes is an attorney who specializes in family law. She says she often receives calls from midwives worried they might be in trouble with the law because they don’t know if what they’re doing is legal, or not.

Some of the questions Runes says she hears from midwives range from, “They want my records. What should I do?” to “What’s the law in my state? I don’t know,” to “What do I do next? Should I hide all of my equipment and my records?”

According to Certified Professional Midwives Now, a national organization advocating for more licensing of midwives, there are twenty-six states in the US that license and regulate midwives. Many other states don’t have licensing programs for midwives, and without licensing and the regulations overseeing the licensing, midwifery can be illegal.

In some states, a midwife can be licensed to work as a nurse. But midwifery advocates see this gap in the licensing and regulation of midwives as a problem. Many midwives, they say, want to focus their practice solely on pregnancy and birth, and a requirement that all midwives become licensed nurses would require education and training irrelevant to their practice.

In states where the work of midwives is prohibited, some midwives work “underground,” risking prosecution if they are reported to the authorities.

For more 20 years, Runes says she worked as a midwife in Illinois where midwifery was and still is not allowed, “I attended around eleven hundred births during that time,” she says. “I was also aware all of the time that it was illegal.”

When she began her work as a midwife, Runes says she was apprenticing under Karen McDonald, another midwife in Chicago. Then one day, Runes says, she got a call from McDonald, “She called and told me, ‘You know I just got a visit from the Huffman State Police and I was arrested for practicing medicine without a license. You probably should not come today for pre-natal appointments.’”

Runes says McDonald agreed to a plea bargain and to avoid going to trial and possibly to jail, she said she would never practice midwifery again. Runes took over her practice and says she wasn’t afraid. She thought if she and the other midwives who were practicing undercover were cautious enough, the state wouldn’t bother to come after them, “That’s not going to happen to me. That’s never going to happen to you. That’s never going to happen to this other midwife because we are all very careful.”

But fourteen years later, Runes discovered that even with her cautiousness, the state of Illinois did in fact care about non-nurse midwifery practices. So much the state hired a private investigator to pose as a pregnant woman who was interested in homebirth. The woman called herself Susy Smith. “We (the midwives) got a lot of phone calls,” Runes says. “I got a phone call. Other midwives got a phone call. Hi, I’m Susy Smith. I’m looking for a midwife. Can you help me?”

The woman representing herself as Susy Smith was working undercover for the State of Illinois. She contacted midwives throughout the state and asked them questions about the types of equipment they were using and made inquiries about their work. Smith also asked the midwives she contacted to send her pamphlets about their midwifery practices.

“A couple of months later I did get a cease and desist order,” Runes says, “and it didn’t come as a huge surprise.  I looked at it and responded to it and sent a letter back to the department of regulations telling them I’m going to keep doing what I’m doing.”

For midwives like Runes who’ve committed to practicing midwifery in states like Illinois where there is no regulation or licensing program, it’s a bit of a catch 22. The state can prosecute midwives for practicing without a license, but doesn’t provide an avenue for midwives to successfully secure a license.

Runes continued to practice even though she says, “there’s still no law that prohibits direct entry midwifery.” Direct Entry Midwives may be educated through self study, apprenticeship or at an independent school or college, not at a nursing school, and they practice midwifery exclusively in non-hospital settings such as at home or birth center.

Throughout the US there are many who are advocating for midwives to be licensed and regulated in an additional twenty-two states. Renee Cramer is an Associate Professor of Law, Politics, and Society at Drake University.  Cramer says part of the problem of regulating midwifery is there isn’t just one type of midwifery. There are nurse midwives, direct-entry midwives, and certified professional midwives, and each designation has a different training and certification. While that can be confusing for lawmakers to negotiate, Cramer says the bigger problem is that in most states, midwife regulation just isn’t a top priority, “These are very small scale politics. There’s not a huge population of midwives and midwife-seeking families. So, state legislators are fighting battles over school funding and technology and redistricting. Those things seem much more immediate. They have dollar signs attached. “

And Cramer adds, midwives aren’t only fighting legislators. They may also be fighting controversy among themselves. “In any instance where there are small scale politics, of course we are going to see a personality conflict.”

Midwives are not only divided over what type of regulation they want. Cramer says they are also in disagreement about whether or not regulation is necessary in the first place. “There are midwives and there are midwifery advocates,” Cramer says, “who believe that we don’t need government regulation of their profession because their professional credential and/or the professional community can do that for them.”

Runes says it would be too difficult for the community of midwives to regulate their own profession and says its important a third party regulate midwives. “Midwifes are afraid of being seen as being judgmental,” Runes says. “ f I tell her that she shouldn’t be inducing labor with Pitocin at home, well then I’m being judgmental. Maybe that’s okay with her. Maybe that’s okay with her client. There’s more to accountability than just being accountable to the client.”

Runes says it can also be tough to  know what to do when things go wrong. “What do families do who have an issue with a midwife?” asks Runes. “We don’t do anything at this point. And there is no way to discipline a midwife in a state where she is not licensed.”

If a woman using a midwife for her birth experience has a bad outcome in a state without licensing or regulation of midwives, the state also doesn’t have a mechanism or system for assessing what happened, and there is no way for holding the midwife accountable.

Bambi Chapman lives in Massillon, Ohio. She has six children. Her first four children were born in a hospital. When she was going to give birth to her fifth and sixth children, she decided to use a midwife, “I thought it sounded absolutely amazing” Chapman says. “I was enamored with it. So by the time I had number 5, I had the guts to say, okay I’m going to go ahead and do this.”

That birth went well and Chapman assumed that the sixth birth, with her daughter Mary Beth, would go just as seamlessly. When Chapman started going into labor, she says she called her midwife and kept her updated, throughout the day. “You know, I knew I was in labor, it wasn’t a huge deal.  And I stayed up all night, laboring as well. Still kept her (the midwife) posted.”

Finally, it was time for the midwife to deliver Mary Beth. Chapman recalls, “At 4:10 in the morning, I had called her and said this baby is coming. You need to get over here.” But the midwife didn’t arrive right away. Chapman started to push so her husband called the paramedics.

“He (Chapman’s husband) called an ambulance,” Chapman says recalling the early morning birth of her daughter, “hung up the phone, delivered our baby and in walks the medics.” The medics didn’t have any training in births, so Chapman says they sat and waited for the midwife. Chapman recalls she, “just sat in the tub and made small talk with the guys.”

Chapman says the midwife came a little later and did a newborn exam. Chapman says she brought up a few concerns she had about Mary Beth such as floppiness, jaundice, and a lack of a rooting (breast feeding) reflex. But, she sayas, her midwife said everything looked normal and there wasn’t any need for a hospital transfer. Chapman didn’t argue. Everyone left and she lay down for a nap.

“Then an hour later,” Chapman says, “my husband woke me up. He had her in his arms and said I think she stopped breathing and I took her from him. And she was lifeless. There was no heartbeat, no breath, no anything.”

Chapman rushed Mary Beth to the hospital but it was too late. “I don’t remember a whole lot of the things that were said to me besides that they had given her the second shot of Epinephrine,” she says, “but she wasn’t responding. And I knew there wasn’t much more they could do. Shortly after is whenever they pronounced her.”

Chapman says she tried to bring a wrongful death suit against her midwife but no lawyer would touch her case and now firmly believes that had she been in a hospital Mary Beth would have lived.

Rene Cramer says things are much more likely to go wrong when birth professionals don’t get along with each other. Doctors may refuse to look at the patient records. In some cases, hospital staff may ask security to escort the midwife out of the hospital. Doctors may also threaten to report the midwife to the state.

Valerie Runes says this breakdown between birth professionals can have terrible consequences, “There are certainly midwives who drop off their clients at the ER and wish them good luck. You can’t do that. But there are people who do that because they are afraid. They are afraid of prosecution.”

There are states where hospitals and midwives co-exist and even work together. The state of Florida has been licensing midwives since 1992, and has clear rules and expectations for all midwives. It requires midwives and hospitals to consult with one another before a birth and requires each midwife to submit a back-up plan.

Jennie Joseph is a Certified Professional Midwife in Winter Garden, Florida, and she says, “I was one of the first midwives in Florida to become licensed in 1994.”  Joseph runs a birthing center for low-income women called The Birth Place.recent scientific study found that women with limited or low income are at higher risk for pre-maturity and poor pregnancy outcomes. Joseph says, by taking every patient who comes to her for prenatal care and enabling them to make their own decisions about their births, she’s been able to turn statistics around. Ninety-five percent of babies born at her birth center have been born at full term.

“We feel part of something productive, something positive,” Joseph says.  “We don’t go home all frustrated and angst ridden because we had a bad day. We love this work. We are happy. The patients and the clients—they are happy.  The community knows what we are doing and supports us. We have this overall bubble of joy over here.”

Joseph isn’t a traditional midwife in the sense that she prioritizes homebirths or natural care. Instead, she says she has created a model of midwifery that empowers her patients. If a patient wants prenatal care at the center and then wants to give birth at the hospital, she arranges for that to happen.

“They (the hospitals) were very happy,” Joseph says, “and were able to take those women and deliver them and then duly return them to me after they were done.”

The women who have limited income who come to the center usually wouldn’t be able to afford the options of care they provide. But since midwifery is legal in Florida, it is mostly covered under Medicaid.

So while midwives in Florida have their work covered by the state, midwives in many other states are unable to get insurance coverage while midwives in their state are still working on becoming licensed and regulated.

In some states, midwives may be gaining some ground. Midwifery legislation is pending in fourteen states, but even if these states pass the legislation, the battle for midwives may not be over.

“You can have legal status for midwives,” Cramer says, “but no one will access them unless they are considered at least a tiny bit mainstream.”

Legalizing midwifery is a step toward legitimizing and mainstreaming midwifery, but it may not be enough. Midwives may have to do more to change our cultural perceptions of what midwifery is. They have to prove that home birth is indeed a legitimate, safe, and empowering option for women to take.  That’s a challenge for all midwives no matter what state they’re in and regardless of whether their practice is legal or not.

(Photo credit: Suzanne Gipson/offset.com)

Special thanks to Ann Heppermann for editing this story and to Pat Walters for his senior editing. Kaitlin Prest designed the sound and produced the story.

Simone Seiver is Post Production Editor. Phillip Wilt is our Web Manager.