"The Key to Keeping Midwifery Alive in the 1990s"
	Allan Solares published his article "The Key to Keeping Midwifery Alive in the 1990s" in Midwifery Today in 1990. Six years later his points are still incredibly relevant, and help to further explain Citizens for Midwifery's position regarding licensing of midwives. We appreciate permission from Midwifery Today to reprint Solares' article in full.

Editor's note: Allan Solares is best known for his booklet, A Birthing Renaissance, and variously published articles which argue for the replacement of licensure by alternative systems to protect midwifery's identity and integrity. This article represents a major break from his previously published opposition to licensure.

Imagine a world in which midwives cared for most women and their newborns -- at home. Unfortunately, such a world is farther away from reality than it was 10 years ago. Midwifery is in the midst of a quiet crisis. The number of home births has declined. Most importantly, midwives are serving only a tiny percentage of pregnant women and their families. Midwifery is failing to achieve its immense and extraordinary potential. Ten years ago I wrote a booklet titled A Birthing Renaissance which received widespread distribution and was later included in a book published by NAPSAC, and in articles in Mothering and The Practicing Midwife. I actively opposed licensure in the belief that it would corrupt the practice of midwifery.

While many of the arguments against licensure are still valid, today I have reached a different conclusion -- licensure is "essential" for midwifery to prosper and survive. Midwives in most states have attempted to practice without licensure for at least the last 15 years. And it is not working. Mothers are returning to the hospitals. Midwifery as a whole is not growing. The signs that midwifery and home birth are in decline are recognizable in many forms.

In its heyday in the '70s and early '80s, midwifery and home birth were having a dramatic effect on birthing practices by other health care practitioners, and significantly affecting hospital procedures. Consumer interest was high. There were many articles in national magazines and local papers. Today, if we are honest about it, midwifery is not reaching many people. Hospitals and physicians are not being substantially affected. There is virtually no media coverage. There is no longer a large and vocal consumer movement behind it.

This is largely because unlicensed midwives cannot fairly compete in a health care system that does not legally recognize them. Private and public health insurers, by and large, will not reimburse them for their services. Most midwives cannot support themselves. Many midwives are abandoning practice or changing professions. And worse yet, fewer and fewer young women are attracted to midwifery. So, it seems that midwifery doesn't have to be legally suppressed to kill it. Midwifery could simply fade away from lack of financial sustenance.

It is time to try a new strategy. A strategy that can succeed in bringing midwifery to its full potential, while preserving its integrity and unique identity. A strategy that allows diverse and innovative methods of practice. For the challenge of the '90s will be to determine how to bring childbirth out of the hospitals and surgical suites, and midwife-attended births back into the homes of millions of families. Licensure will enable midwives to meet this goal. But, talk of licensure raises deep-seated fears that have become entrenched over the last decade. Concerns about harming the integrity of midwifery dominate many discussions about licensure.

Yet such debates almost always fail to probe beyond the surface arguments. Essentially, they ignore the fact that a licensing law can be either harmful or helpful depending on "how" it is structured. There are key legal principles that can enhance rather than endanger midwifery. Independence and apprenticeship are among them. But, before discussing how to make licensure an ally, it is first necessary to further explore why licensure is needed today. In spite of its drawbacks, there are at least six compelling reasons for pursuing licensure at this stage of the midwifery movement. The first two reasons are the most familiar, while the last four are less well recognized.

1. Midwives need a secure legal status with a full and independent scope of practice. The most commonly stated reason for licensure is to eliminate the constant threat of legal prosecution or to pre-empt legislation to outlaw midwifery. Most movements tend to respond to crises. Midwives are no exception. But, midwives cannot stay in a quasi-legal status forever. Midwifery is threatened, not by licensure, but by the absence of licensure. Regulation or prohibition are inevitable. And if midwives don't do it, then someone else will. It is time for midwives to stand up, time for birthing families to stand alongside them -- time to demand that midwives and home birth be recognized. Midwives need licensure to obtain an independent scope of practice, particularly to legitimize the use of emergency medications and equipment, and to perform procedures that are essential to safe home birth.

2. Midwifery needs greater consumer awareness and credibility. The number of home births are decreasing. The rapid growth of home birth and midwifery in the seventies was due in part to the cultural values of the baby boom generation, which is now moving beyond its prime childbearing years. In response to the childbirth movement, hospitals have successfully adapted and competed for clients. Consequently, not as many younger women are choosing home birth and midwives. In spite of lots of good press in the early days -- almost 20 years ago -- home birth receives virtually no notice in the media anymore. Midwifery is still considered a fringe practice by most people. Many consumers know little about midwife-attended home births, or they believe it is not safe. Licensure would provide acknowledgment that midwifery is a safe option. Licensure would provide credibility and increase consumer interest.

3. Midwifery must reach out to a new and larger population. The most significant reason for licensure is that midwives must work to make midwifery and home birth an integral part of the health care system. Midwifery must be able to succeed as a viable option accessible to thousands of women. Midwifery must grow from serving a small population to serving thousands of women and their babies. Without licensure, a few midwives will continue to practice and a minimal number of home births will occur. But midwifery can be so much more. There is an historic opportunity in the nineties to enter and reform the maternity care system. There is a crisis in maternal health care throughout the United States. Physicians and obstetricians are abandoning birth practices in droves. It is becoming increasingly difficult for pregnant women in many poor and rural areas to find a doctor who still delivers babies, let alone be able to afford one. This is precisely the niche where many midwives are already practicing and where the potential demand for more midwives is enormous. In fact, midwives have the potential to provide prenatal care to thousands of pregnant women who are eligible for Medicaid. Many of these women receive little or no prenatal care. Many of these women could be candidates for a midwife-attended home birth if they had proper prenatal care. But, once again, midwifery services are generally not eligible for third party payment (reimbursement by private and public insurers) unless they are licensed.

4. The decline in home births and the midwifery profession is largely due to the absence of third party payment. Since most private and public insurers do not pay midwives for home births, most consumers are not inclined to choose an unpaid home birth in favor of a paid hospital birth. So fewer home births are done and fewer midwives are needed. In response, fewer midwives are practicing. The unfortunate fact is that in spite of the deep personal dedication of most midwives, the income from midwifery does not adequately or fairly compensate them for the extreme effort and unique hardships associated with being a midwife -- extensive training, being on call, late hours, and other impositions on family, professional, and personal life. Many midwives have entered school to become nurses, nurse midwives, and physicians. Many have simply abandoned their practices. While some individual midwives may do well, the profession can't flourish without plenty of practitioners able to maintain a career-long commitment. Midwifery is losing too many of its career practitioners and not enough new ones are entering the profession.

5. Health care costs could be reduced dramatically. Private and state health insurers could save millions of dollars through the utilization of midwife-attended home births. The cost for a midwife attending a home birth is only a fraction, probably about one third, of a physician managing an uncomplicated hospital birth. A lower cesarean section rate would reduce costs even more dramatically. But midwifery cannot grow and prosper without third party payment, and licensure is an absolute prerequisite to third party payment.

6. It is feasible to win "Licensure You Can Live With." All of the above arguments would be pointless if it were not possible to win licensure that would enhance rather than endanger midwifery. After fifteen years of studying the licensure of health professions and concluding post-graduate study of the issue, my focus has evolved from seeing only the pitfalls of licensure to recognizing and seizing the tremendous benefits it can achieve for midwifery. Indeed, licensure can provide midwives with independence, a secure legal status, a full scope of practice, autonomy, consumer awareness and credibility, third party payment, and most critically, access to millions of families, especially poor and rural women. Licensure and third party payment would make midwifery and home birth affordable for everyone. Consumers would be free to make a real choice about the type of birth experience they want. More families would experience the unique benefits of having babies in their own homes without medication and with support and love from their own family and midwife. Midwives would be able to earn a reasonable living and stay in practice rather than turning to other pursuits. It would be an incentive for more people to become midwives. Midwives would see new opportunities open up to work with other health professionals and in other health care settings.

Midwifery is in danger of becoming irrelevant. Irrelevant to everyone but the few midwives who manage to hang on. And that's not enough. The midwives of today are only passing through. You are the torchbearers of a long tradition. That torch cannot be allowed to be extinguished during your tenure. It may burn more brightly than ever before, if its extraordinary potential is realized.

{SIDEBAR}: The proposed Oregon Midwifery Practice Act has been developed to provide safeguards. It is based on seven key principles:

1. The midwife is an independent professional; i.e., midwives are not controlled or supervised by another health profession.

2. A variety of educational routes are available, including apprenticeship.

3. The licensing board is controlled by midwives.

4. The statute does not establish specific protocols of practice, but rather preserves the midwife's autonomy.

5. The midwife is authorized to use specified drugs and minor surgical techniques or other devices for prenatal, perinatal and postnatal care, and emergency situations.

6. Midwives will provide an Informed Choice form to each client describing background, services and other information useful to consumers in making an informed choice and assuming personal responsibility.

7. Midwives certified by their professional association will be "grandmothered;" i.e., will automatically meet the requirements for licensure when the law takes effect. --

About the author: Allan Solares helped found the Oregon Midwifery Council in 1977. In previous articles he argued for the use of systems other than licensure to protect midwifery, and promoted the system of Informed Choice, now used throughout the country. He devoted postgraduate study at the University of California Graduate School of Public Policy to the history and practice of licensure of health care professionals in the United States.

Reprinted with permission from: Midwifery Today, PO Box 2672, Eugene OR 97402 541-344-7438, e-mail , http://www.efn.org/~djz/birth/MT/Mtindex.html