Midwifery in Michigan: A Consumer’s Guide
- Certified Nurse Midwives
- Direct-Entry Midwives
- Safety of Homebirth
- Choosing a Midwife
- How to Find a Midwife in Michigan
In the U.S., midwifery is regulated state by state. Direct-entry (or homebirth) midwifery may be legal or illegal by judicial ruling. There may be some certified nurse midwives (CNMs) attending out-of-hospital births, regardless of the status of regulation in the state. For clarity, think of states as “regulated” or “unregulated” and then consider CNMs as a separate option/group (see more below). To learn more about the status of direct-entry midwifery in your state, check out Push for Midwives, particularly their state-by-state map page.
Certified Nurse Midwives (CNMs)
CNMs are credentialed through the American College of Nurse Midwives (ACNM). They are RNs with additional Masters-level training in midwifery. Nurse midwives attend births in hospitals, free-standing birth centers, and homes, though they are primarily found working in hospitals. You may find nurse midwives in solo practice, small group practices of two or three midwives, or large practices of ten or more who rotate being “on call.” Large practices may assign one midwife whom you see for prenatal care, but it is potluck at your birth. Private insurance and Medicaid are typically accepted.
CNMs work with doctor back-up and abide by medical protocols that may mandate consultation with, or transfer of care to, the back-up doctor in certain circumstances. CNMs, for example, cannot be the primary care provider for women expecting breech or twin deliveries. When working in hospital settings, CNMs will likely be practicing under protocols stipulating induction of labor for post-dates pregnancies and so on, similar to OB/GYNs. TIP: Ask prospective nurse midwifery service providers about factors that could cause you to be “risked out” of their care.
Though practicing within the medical model, hospital-based nurse midwives are nevertheless more likely to support normal birth than most OB/GYNs who, after all, are surgical specialists best suited to providing care to high-risk mothers. All midwives tend to believe strongly in the normalcy of birth, woman-centered birth, non-separation of mom and baby, the benefits of water immersion for pain relief, use of the upright position to support normal physiology, freedom of movement in labor, and breastfeeding. The dictates of the CNMs’ individual practice settings (in combination with each client’s unique needs) will influence their ability to actualize these beliefs when providing care to each mom and baby.
Direct-entry midwives are an eclectic group. They primarily attend home births, but may also be found in out-of-hospital birth centers. Typically direct-entry midwives work with low-risk, healthy women who desire a normal, non-medicated birth. A complete home birth or birth center service package typically includes prenatal care, attendance at your labor and birth, and postpartum care, with phone consultations as needed.
A widely recognized credential for direct-entry midwives is the Certified Professional Midwife (CPM), offered through the North American Registry of Midwives. A midwife who has completed and documented experiential skills training (typically within an apprenticeship training model), and passed the NARM exam, earns the CPM credential. Twenty-six states in the U.S. have passed laws regulating direct-entry midwives based on the CPM credential. In unregulated states (like Michigan), some direct-entry midwives may, nevertheless, voluntarily choose to become a CPM. While more and more midwives entering practice in the past ten years are choosing the CPM pathway, direct-entry midwives who lack credentials may nevertheless be highly experienced and well qualified to provide quality care. Most direct-entry midwives are apprenticeship trained and self taught. Some have attended midwifery schools or undertaken a home study course or have been trained abroad.
Theoretically, there are no complications that a birth center midwife can handle without medical backup (meaning transfer of care) that could not also be handled at home. While a birth center may convey a greater sense of safety, this, in and of itself, is an illusion. However, if the birth center attendant is more skilled, that is not an illusion. When emergencies happen at a home birth or in an out-of-hospital birth center, 911 is called and the mother and/or baby are transported to the nearest hospital. As a rule, physicians do not currently “back up” unlicensed midwives in the same sense that they do nurse midwives as members of the team. However, ERs cannot refuse care and many direct-entry midwives have friendly doctor “back up” to the extent that a physician may order necessary prenatal tests for the midwife or be willing to consult with her if needed. When care is transferred to a hospital from a home birth, the midwife generally will accompany her client to the hospital and continue to provide support, however her role becomes more akin to the role of the doula in that setting (providing informational, emotional, and physical support, but not calling the shots or giving medical advice). Once her client has birthed and all is well, the midwife may continue in her midwife role to complete postpartum care services.
Cost of Homebirth / Will Insurance Cover the Cost?
Some insurance companies are providing reimbursement or partial reimbursement for out-of-hospital birth attended by direct-entry midwives. Women on Medicaid or those covered under HMOs are currently unlikely to obtain reimbursement for direct-entry midwifery services in unregulated states (e.g., Michigan). It is the consumer’s responsibility to advocate with her insurance provider and make the case for covering out-of-hospital midwifery services. Start the conversation with your provider! Midwives should also be able to tell you which providers have reimbursed (or partially reimbursed) past clients. Consumers should expect to pay the midwife’s fee up front, out of pocket, and then gain her help in generating a proper receipt to submit to the insurance company for reimbursement. The receipt should include the midwife’s provider number and standard insurance billing codes for services rendered in order to increase the chances of a claim being paid. TIP: When interviewing prospective midwives, ask about their clients’ success with obtaining third party reimbursement for their services.
Midwifery fees vary widely across the country. Fees may range from $1,500 (very low-end for midwives providing care in rural or depressed areas) up to $4,000 or more (in metropolitan areas), with most landing somewhere in the middle. Some midwives may offer a sliding-fee-scale. Consider that, if you have a high-deductible insurance plan, it is quite possible the midwife’s fee could equal the amount of your co-pay for a hospital birth. Therefore, the home birth option may be more affordable than you think! Pre-tax healthcare spending accounts, health reimbursement accounts, or “flex” accounts can be used as well.
If you are interested in out-of-hospital birth and have time to engage in some pre-pregnancy planning, then consider which potential insurance options (if you have choices) will allow for the greatest flexibility in your future choices and best meet your family’s needs.
Safety of Home Birth
Midwives have safely delivered babies at home since the earliest days of our history. Current studies and reports find out-of-hospital birth with a trained midwife to be as safe as or safer than hospital birth for healthy women experiencing a normal pregnancy.
- The British Medical Journal: “Planned home birth for low risk women in North America using Certified Professional Midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.” —Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America. BMJ 2005;330:1416.
- Canadian Research: “Women who planned a home birth had a significantly lower risk of obstetric interventions and adverse outcomes…” —Canadian Medical Association Journal, August 2009.
Note: It can be difficult to study homebirth versus hospital birth outcomes because a randomized controlled trial is impossible; women would have to be randomly assigned where they are going to birth.
Choosing a Midwife
Prevention is the hallmark of good midwifery care. Supporting rather than interfering with normal processes may prevent complications. Expect to find variety in how midwives practice. For example, some midwives may be skilled in working with herbs, homeopathic remedies, and nutritional supplements, while educating women in a variety of proactive strategies. Others may practice in a more reactive manner, recommend routine medical tests, or prefer to address emerging issues with drugs. It’s a continuum and the letters after the name (or lack thereof) do not necessarily dictate where the midwife stands on the continuum of natural approaches versus medicalized care. The simple fact that a midwife attends births in an out-of-hospital birth center or home does not guarantee that her practice of midwifery is holistic or non-interventive.
Consumers should interview midwives carefully to find the approach to care that is the best match for their needs. Following are some questions to get the conversation started and a few things to look out for.
- How many births has she attended as the primary midwife? This should be distinguished from “years in practice” which is essentially meaningless, as someone could claim 25 years’ experience, but have very limited actual experience as a primary midwife. (TIP: Most midwives worth their salt will have a ready and precise answer to this question.)
- Which potential complications can the midwife handle? How is she prepared to handle them? What percentage of her clients give birth with their perineums intact? What are her protocols for pre- or post-term babies?
- Under what circumstances will she transfer care for medical backup? What percentage of her clients end up with a hospital transport?
- Is water birth an option?
The answer to these questions will vary, depending upon the individual midwife and the practice setting. Create your own list of questions prior to interviewing midwives, a list that reflects your values and priorities, and then hire the midwife or midwives who are most closely in alignment with you. Ask around. Good word of mouth about a birth center or home birth practice is important. Trust your instincts AND check the midwives’ references/credentials.
How to Find a Midwife in Michigan
Some midwives in southeastern Michigan advertise their services in our Directory (look under both Midwifery Care and Hospital-Based Birthing Centers). This list is not comprehensive, nor is it an endorsement by the Center, since the midwives must pay to be there. Another directory can be found at the Michigan Midwives Association website. Please keep in mind that no directory is complete. There are midwives out there, with up to thirty years’ experience, who prefer to rely on their good reputations for referrals rather than advertise their services. To find these folks, you may need to do some digging. Ask your local moms’ groups or childbirth educator for the names of two or three midwives.