Giving birth at home or in a birthing center has been gaining popularity in the United States. The percentage of out-of-hospital births almost tripled between 2004 and 2014, jumping from 23,000 to 60,000 babies—or from just over half of 1 percent to 1.5 percent of births, according to government data. The overwhelming majority of these births involved midwives, for whom regulation varies greatly from state to state. Washington State requires licensing and at least two years of training, and education that includes obstetrics and neonatal pediatrics. By contrast, Michigan has until recently had no laws regulating midwifery outside of nursing or hospitals—a licensing and regulatory program will go in effect this April.
That development may be positive, as historical evidence suggests that licensing professional midwives improves health and safety.
D. Mark Anderson of Montana State University, Ryan Brown and Daniel I. Rees of the University of Colorado at Denver, and Kerwin Charles of the University of Chicago Harris School of Public Policy looked to the early 20th century, when many states introduced midwifery laws. They analyzed prelicensing and postlicensing maternal mortality trends from 1900 to 1940, focusing on the annual number of women who died per 100,000 females.
In regulated states, maternal mortality fell immediately after licensing requirements were adopted. That wasn’t the case in unregulated states such as Arkansas, Oregon, and Michigan.
The researchers say that the study period helps establish a causal effect between licensing and health. Over the period studied, women typically gave birth at home and a single health-care provider—either a doctor or a midwife—had sole responsibility for the health of mother and infant. Drawing on US Census Bureau data published during the study period, the researchers observe that licensing reduced maternal mortality by 6-7 percent.
The relationship between midwifery laws and maternal deaths was more pronounced in states that required applicants to pass an exam or graduate from a certified school. However, even the most basic licensing requirements led to a reduction in maternal mortality. In Georgia and Mississippi, for example, certification required only being judged of “good moral character” and demonstrated cleanliness—and mortality fell 3.5 percent over the 40 years studied.
The researchers also find occupational licensing is associated with an almost 7 percent reduction in mortality due to puerperal fever, or postpartum bacterial infection. This suggests that antiseptic training and nonintervention, or limiting the use of forceps, helped save lives.
Requiring midwives to be licensed also led to a 5 percent reduction in the nonwhite infant mortality rate, amounting to approximately 12 fewer deaths per year. One possible reason, suggested by the researchers: the more-stringent regulatory environment could have forced incompetent, unlicensed midwives to retire, while those midwives who continued to serve black communities had to obtain additional training.
In developing countries, where traditional birth attendants provide the majority of maternity care around childbirth, the study’s findings are particularly relevant—and move policy debates beyond anecdotal evidence. Experts have long argued that requiring training and licensing for birth attendants would improve health. The research provides data to support the argument.