In all 50 states, CNMs, midwives who deliver in hospitals, can get a license to work. But laws regarding CPMs, who are trained for nonhospital births, vary from state to state. In some states, CPMs are required to be licensed. In others, they are regulated but not required to be licensed. In still others, they are banned outright. The Midwives Alliance of North America keeps an updated list of state-by-state rules on CPMs.
Though about half of states allow at-home birth, it remains uncommon in the United States—just 1 percent of births occur in nonhospital settings including home births and birthing centers. Washington was one of the first states to license CPMs, and they now have double the national average of mothers who elect for nonhospital births. For a point of reference, in the Netherlands, about 34 percent of women give birth at home.
In many states that do not license CPMs, an underground, extralegal system of home births exists. This black market leaves CPMs open to the threat of prosecution for practicing medicine without a license. An organization called The Big Push for Midwives is engaged in fights in states to change legislation to legalize CPMs.
According to the American College of Nurse-Midwives, a midwife actually can lead to better birthing outcomes. The organization cites an independent 1998 study that shows reduced infant and newborn deaths associated with midwife-assisted births in the United States.
There aren't requirements about who can and cannot see a midwife in a hospital, but most CPMs will only attend to an out-of-hospital birth if the mother is not in an at-risk category. This usually means mothers cannot be very young or old or have conditions like high blood pressure, autoimmune diseases, cancer, obesity and diabetes. However, "at risk" is not a definite term. "There's a lot of debate in the birth world about what things should be ['at risk']," Perez says. "The only reason you couldn't have a midwife at all, even in a hospital, is if you had to have a Caesarean section, because midwives are not surgeons. That's what obstetricians are—they're trained as surgeons. You're not going to have a midwife doing C-section, but pretty much anything else can be done by midwives."