Midwives gain a victory in Illinois, but look for more
Illinois prepares to again legalize midwifery 30 years after outlawing practice, but advocates say licensure isn’t enough.
For Star August, the birth of her first son in 2009 was nothing short of traumatic.
“[I woke] up from a drug-induced coma to find my son being resuscitated next to me,” August said.
August said she knew she didn’t want to go through another birth without a Black midwife by her side, advocating for her.
Eventually, August felt a pull to become a midwife herself, founding an organization called the Holistic Birth Collective, which focuses on providing home births for Black mothers. She is currently studying as a student midwife with a midwifery program in Wisconsin and will take her certification exam with the North American Registry of Midwives next month.
August has completed her practical education shadowing home births in Chicago, but Illinois does not recognize certified professional midwives, or CPMs. That will all change in 2022, however, when Illinois will again start licensing CPMs after nearly 30 years of outlawing the practice, only allowing midwifery to be performed by nurses with midwife certification.
A bill heading to Gov. JB Pritzker’s desk would reverse decades of policies on midwifery, once again legalizing the practice and licensing CPMs in Illinois. But advocates say more work still has to be done.
A tool against medical racism
A 1992 law made traditional midwifery illegal in Illinois — a felony punishable with up to $10,000 in fines or three years in prison. Only nurse midwives are able to provide midwifery services, and in most areas of the state, they’re limited to practicing in hospitals.
But even after Illinois stopped licensing CPMs in the mid-1960s — and made the practice illegal a few decades later — midwives have continued to supervise home births underground. Approximately 15 midwives are currently practicing in the shadows in Illinois, and they’re in high demand.
Both national and state data shows Black women are more likely to die during pregnancy and childbirth than white women; an April report from the Illinois Department of Public Health found Black mothers in Illinois are eight times more likely to suffer a fatality during pregnancy or birth.
Black maternal morbidity and mortality is tied to a score of reasons, including lack of access to healthcare or being disproportionately likely to have underlying conditions that can complicate pregnancy.
But another emerging theory is white medical professionals’ implicit bias against people of color.
Proponents of re-legalizing traditional midwifery in Illinois argue that midwives — especially those who are sensitive to the specific cultures their patients come from — could help stem the tide of maternal morbidity and mortality
Last month, lawmakers voted to do just that, approving a framework to again legalize traditional midwifery and license CPMs in Illinois.
State Sen. Cristina Castro (D-Elgin) sponsored the measure with an eye toward correcting racial disparities in maternal health.
“Black and Latino women will have another option when it comes to their health, and especially their maternal health,” Castro said.
Pritzker is expected to sign the measure, making Illinois the 36th state in the nation with legalized midwifery when it fully takes effect next October.
To get a license, midwives who haven’t already been certified for at least three years will need to take a course approved by the Midwife Education and Accreditation Council and be certified with the North American Registry of Midwives. They also need to be trained in neonatal and cardiopulmonary resuscitation.
Barbara Belcore, the treasurer and legislative chair of the Illinois Council of Certified Professional Midwives, said bringing traditional midwifery back out of the shadows will help more families have safe home births.
“There's over a thousand babies that are born in-home in Illinois every year, and the numbers are climbing,” she said. “And there’s not nearly enough licensed home birth providers to provide services for these families.”
There are many reasons families may opt for a home birth. Some may be trying to avoid medical racism while others may be trying to avoid exposure to illness while giving birth in a hospital setting, especially during the pandemic.
Whatever the reason a mother chooses to deliver at home, Belcore says it’s only a good option if they can find a safe provider, which has been challenging in a state where only nurse-midwives are allowed to practice legally.
“If [midwives] chose to work underground, they couldn't advertise their services, and certainly had to find creative ways to get the resources they needed to keep home birth safe,” Belcore said.
Beginning next year, CPMs will be able to bring patients to the hospital and transfer their care to a doctor based in an institution if necessary. In a hospital, they’ll have recognition as birth professionals when discussing patient care with doctors in the facility.
No Medicaid and other barriers to entry
But for proponents of midwifery, legalizing and licensing on their own are not enough. Many advocates are demanding Illinois authorize Medicaid coverage for midwifery services — something not addressed in the legislation heading to Pritzker’s desk
Castro said she’s committed to getting midwifery covered by Medicaid, but said licensing had to come first.
“In order to look at getting it covered through Medicaid, it has to be licensed,” she said. “So this is the first step into those conversations.”
August of the Holistic Birth Collective sees Medicaid coverage for midwifery services as the key to fixing maternal health disparities by race. Two out of every three Black mothers are covered by Medicaid when they give birth.
But she doesn’t trust the promise of trailer legislation to get midwifery services covered by Medicaid. Medicaid coverage for midwifery services is a patchwork; August pointed out that only 11 out of 35 states where traditional midwifery is legal also provide Medicaid coverage for those services.
The Affordable Care Act requires Medicaid to pay for nurse-midwives and birth center services. But some facilities have a hard time getting reimbursed enough to make up what it costs to supervise a birth.
“Based on the experiences we’ve seen play out in other states, we had no reason to trust that access to [CPMs for Medicaid-insured persons would swiftly follow upon licensure,” August said.
August ultimately resigned as president of the Illinois Council of Certified Professional Midwives shortly after speaking to NPR Illinois because “the legislative representatives of ICCPM and the legislators with whom they partnered did not share my sense of urgency regarding Medicaid access,” she said.
August also had concerns about how Black women would get the credentials they needed for a license. She says she is the only Black student midwife who will qualify for a license when they become available due to the licensing law’s requirement that midwives take a course with the Midwifery Education Accreditation Council.
Cost is also an issue.
“Midwifery schools specifically are extremely expensive, anywhere from $10,000 to $60,000,” she said. “And a lot of Black families don't have the funds to be able to pay for this.”
Daphne Kuehl is familiar with the high cost of becoming a midwife. Kuehl originally trained as a registered nurse and worked as a lactation consultant and delivery nurse before deciding to get a midwifery certification. The degree cost her $80,000.
Kuehl said she and her husband were “privileged” because they were both able to work as she was getting her nurse-midwife certification. They lived off of loans while she was doing clinical training, which is uncompensated. Because of the pandemic, she hasn’t yet had to pay back those loans.
Because Kuehl is a nurse-midwife, she’s always been able to practice legally. She’s based at Southern Illinois University Family Medicine in Springfield and estimates that 90% of her patients are on Medicaid.
Kuehl said she supports the legalization of traditional midwifery in Illinois as a way to make home birth a real option in more sparsely populated parts of the state. She’s one of just four midwives in Springfield, which she described as “an island” for many health care services in central Illinois.
“For people who are seeking [CPM] care to do home birth, there are midwives that do home birth here,” she said. “But there are only two or three who would possibly come to Springfield, and it’s really on the edge of where they go.”
Between a year-long lag time for the measure to take effect and the time it takes to get certified, it will take a few years for the legislation’s full impact to be realized. For August and the women she serves, it’s going to be a long wait.
“I come across women every day who want to have a home birth, but are unfortunately not going to be able to, specifically from culturally congruent providers,” August said. “It's just not an option. I feel like this bill is very much the beginning.”