The time has come to license midwives in Iowa

Rachel Bruns is a volunteer advocate for quality maternal health care in Iowa.

The 2022 Iowa legislative session saw the most significant momentum in more than forty years of advocacy for the creation of a licensure of direct-entry midwives in Iowa. With the 2023 legislative session underway, I will review the pivotal moments in the 2022 legislative session and explain why the Iowa legislature and Governor Kim Reynolds should prioritize enacting a midwifery licensure bill.

While I have addressed the need to provide a licensure for Certified Professional Midwives (CPMs) in previous pieces, I will go more in-depth in providing background on why all Iowans should want and support CPMs practicing in our state.

Note: I would not benefit directly in any way if this bill passed, as I am not a birthworker (doula, midwife, physician), and I do not plan on having any more children. Through my volunteer work with the International Cesarean Awareness Network, I have learned a lot about the different types of midwives and believe Iowans have been “dealt a bad hand” by not having knowledge or access to community birth options that are more readily available in other states and other high-income countries. Iowa families deserve to have all options available for safe and quality maternal health care.

History of midwives

To understand the state of play with Iowa’s midwifery licensure bill, it is helpful and important to understand the history of midwifery in the United States. In 2018, ProPublica released a comprehensive report titled “A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies.” One section highlights the history of how the United States went from having half of births attended by midwives in the early 1900s to most births being attended by physicians in the 1950s. 

While widely accepted in Europe, midwives in the U.S. have been at the center of a long-running culture war that encompasses gender, race, class, economic competition, professional and personal autonomy, risk versus safety, and philosophical differences about birth itself.

Midwives were valued members of their communities until the late 19th century, when medicine became professionalized and doctors’ groups began pushing for a monopoly over obstetric care. Physicians argued that birth was a “pathologic” process that required scientific knowledge and hospital equipment, and they vilified midwives — who were mostly immigrants or, in the South, blacks commonly known as “grannies”— as dangerously uneducated for insisting that birth was a natural (“physiological”) function. In 1915, Joseph DeLee of Chicago, the most influential OB-GYN of his day, called midwives “relics of barbarism” and “a drag upon the science and the art of obstetrics,” while one North Carolina doctor dismissed black midwives as having “fingers full of dirt” and “brains full of arrogance and superstition.” By the 1950s, the vast majority of women gave birth in hospitals, attended by doctors.

Midwifery began to make a comeback in the 1970s and 80s, embraced by middle-class white women who wanted more of a voice in their maternity care, including the possibility of delivering at home.

Shafia Monroe is a midwife who has made a tremendous impact in growing and uplifting the midwifery field in the United States. She has a comprehensive timeline of Black midwives in this country. If you are looking for a quick rundown of the history of midwifery, check out this five minute video titled “The Culture War Between Doctors and Midwives Explained” produced by Vox.

For more in-depth information, I highly recommend the books The Women Who Caught the Babies: A Story of African American Midwives by Eloise Greenfield and Birthing a Movement: Midwives, Law, and the Politics of Reproductive Care by Drake University Professor Renée Ann Cramer.

Interestingly, Iowa played a role in shifting birth away from midwives across the country. The federal “Shepperd-Towner Act” was a landmark piece of legislation which shifted birth to doctors even though “it was an acknowledged fact maternal mortality rate was higher amongst doctors than among practicing midwives even among the midwifery detractors,” as cited in this 2014 research paper. Representative Horace Mann Towner of Iowa, was a main sponsor of the bill.

Shifting care from midwives to physicians also moved birth from the home to the hospital, and from being seen as a normal physiological process to a medical process that required intervention. 

Home birth safety

According to the National Center for Health Statistics, as reported by TIME, home births increased by 22 percent during the COVID-19 pandemic from 2019 to 2020 and increased by another 12 percent from 2020 to 2021. Anecdotally, I have heard home birth midwives in Iowa are busier than ever, often being completely booked for an entire year out.

During the early days of the pandemic, home birth midwives were overwhelmed with calls from pregnant people seeking an alternative to the hospital. Here in the Des Moines area, since I was last pregnant four years ago, we have gone from having a couple of home birth midwives to now having several options of both certified nurse midwives (CNMs) and a certified professional midwife (CPM) providing home birth services in the metro.

The pandemic provided a reality check to pregnant people when considering the question of safety in birth settings. In May 2020, I wrote about how hospitals were exacerbating the already existing maternal mortality crisis by eliminating evidence-based continuous labor support by restricting doulas, family members or even partners from attending births.

Pregnant people in the United States also had to worry about hospitals separating their newborn (which went against WHO recommendations) in the event they were COVID-19 positive. If you had a healthy low-risk pregnancy, why risk getting COVID-19 and deal with the potential staff shortages in a hospital? The article “Fearing Coronavirus, Many Rural Black Women Avoid Hospitals to Give Birth at Home” from Pew Trust highlights these concerns with the added realities of medical racial discrimination faced by Black women in the United States.

To be clear, home birth is not the best setting for everyone, but it is safe with similar or better outcomes for low-risk pregnancies. This study on midwife-attended planned home birth or birth center birth concluded that “Integration of midwifery (licensure, medication, collaboration, Medicaid, liability insurance, training) is important for outcomes.” 

A 2018 study found that states integrating midwives into their health care systems have the best outcomes for mothers and babies. States with some of the most restrictive midwife laws and practices tend to do significantly worse on key indicators of maternal and neonatal well-being. According to that study, Iowa ranks 42nd in midwifery integration, among the worst in the country.

A Florida-based and British-trained midwife, Jennie Joseph, created a direct-entry (CPM) midwifery school. Joseph was named a TIME 2022 Woman of the Year for her work in eliminating disparities in birth outcomes in Florida. Research shows how Joseph’s model of care, which is the midwifery model, reduces disparities for women of color. Jennie Joseph, a CPM, would not be able to get a license to practice in Iowa today, despite being featured as the model for improving maternal health in the country.   

The Iowa 2020 Maternal Mortality Review states that maternal mortality is worsening in Iowa and across the country and that a Black woman in Iowa is six times more likely to die from a pregnancy related cause than a white birthing person. The Iowa 2021 Maternal Mortality Review stated that for all pregnancy associated deaths, “Structural racism and/or discrimination were determined to be a contributing factor in 40% of the cases.” 

Hospital and medical lobbyists arguing against licensing certified professional midwives often claim home birth is unsafe. But that talking point is misleading. Lobbyists representing medical groups who testified during the 2022 Iowa Senate State Government subcommittee on the midwifery licensing bill made a lot of vague statements about safety and “concern for women’s lives,” without providing any evidence or examples from other states that license CPMs.

I would also note that the bill Iowa House members approved in 2022 removes any liability from hospitals due to a transfer from a CPM. Nationwide data on planned home births transfers indicates that only 3 percent are for emergent reasons

I’ve heard an overwhelming number of stories from pregnant people in Iowa of all races, about how poorly they are treated by Iowa’s medical institutions during pregnancy and birth. Too many of us have accepted this as normal. Based on the state’s maternal mortality review reports, one could argue that Iowa hospitals are unsafe. In speaking with a local birth trauma therapist, 97 percent of their clients experienced their trauma in a hospital setting. From Every Mother Counts:

In the U.S., women have reported a range of disrespectful, coercive, and abusive behaviors. Women relate that they have been ignored, shouted at, or threatened (including with coerced or withheld treatment or with calling child protective services), having their physical privacy violated, and, more rarely, experiencing physical abuse. A disturbing number of cases have been documented where women with a life-threatening complication know something is wrong, but their requests for help went unheeded.

Pregnant people should be able to choose where they give birth and with what provider. Furthermore, if physicians and hospitals want to claim home birth is unsafe, they are going to need to demonstrate how they are actually safer in Iowa for low-risk women and birthing people. I am struggling to find that information.

Home births are already happening, and studies continue to show the practice is safe for mother and baby, with similar or better outcomes for low-risk pregnancies. Physician groups will often cite misleading statistics about newborn death rates being higher for home births, but those studies are based on birth certificates, which have unreliable data and include data on home births that were unplanned. From one peer-reviewed article:

Despite limited institutional support for credentialed midwives in the United States attending births in private homes and freestanding birth centers, the weight of evidence in US cohort studies indicates that births in these settings have good outcomes when the studies: 1) are based on charts rather than birth certificates, because the latter often lack accurate outcome and care details; 2) identified low-risk women; 3) are able to discern the planned place of birth, thereby avoiding counting accidental, unplanned out-of-hospital births; and 4) are conducted on a defined group of midwives with training standards. Where comparisons are possible, these US cohort studies (Murphy and Fullerton, 1998; Schlenzka, 1999; Johnson and Daviss 2005a; Stapleton et al., 2013), produced similar results for low-risk births at home, in birth centers or in hospitals, just as the international meta-analyses have found. Even where the defined group of practitioners had questionable homogeneity of education and a varying degree of integration into the US maternity care system, outcomes were similar to those in the other studies cited for low-risk birthing people (Cheyney et al., 2014).

Midwives in Iowa

There are more than 15,000 midwives in the United States according to the Midwives Alliances of North America (MANA). Of those 15,000 there are four distinct types, which I’ve adapted from the definitions from MANA and put them within the context of Iowa:

Traditional midwives (sometimes referred to as “lay midwives”) for religious or philosophical reasons are uncertified or unlicensed and view themselves as accountable to the community they serve. Some states do offer a license for Traditional Midwives. While I don’t have data on the numbers, I assume we have Traditional Midwives in Iowa serving in Amish and potentially Native Nation communities. The midwifery licensure bill that has been proposed would not impact traditional midwives.

Certified Midwives (CM) have a background in a health related field that is not nursing and graduate from a masters level midwifery education program. They have similar training to Certified Nurse Midwives (CNM) and conform to the same CNM standards, but are not required to have a nursing degree. I am not aware of any CMs currently practicing in Iowa. 

Certified Nurse-Midwives (CNMs) are nurses who go to graduate school for midwifery. Training is hospital-based, and most CNMs practice in clinics and hospitals. A CNM scope of practice allows them to provide care in any birth setting (hospital, home, freestanding birth center). CNMs are already licensed by the Iowa Nursing Board. Iowa has more than 130 CNMs, practicing in the state primarily in hospitals and clinical settings. Several CNMs have home birth practices.

A CNM is one of several speciality options for an Advanced Registered Nurse Practitioner (ARNP) and can practice independently in Iowa. A new CNM master’s program will start at the University of Iowa this fall, which may increase the number of CNMs in our state. Previously, those interested in becoming a CNM had to attend a nurse midwifery graduate school out of state.

Certified Professional Midwives (CPMs) are certified by the North American Registry of Midwives (NARM) and are the only midwifery credential requiring knowledge and experience in out-of-hospital birth. CPM training focuses on providing the midwifery model of care in homes and freestanding birth centers (of which there are currently none operating due to barriers from the Certificate of Need law which I address in this previous article). 

In some states CPMs may also practice in clinics and doctors offices. CPMs are currently regulated to practice in 37 states and Washington, DC, most via a licensure. Iowa is one of only thirteen states without some form of regulation. Even without a license, Iowa has a small number (around ten) CPMs currently practicing in the state. There are several pathways to certification which can be found here. According to the National Association of Certified Professional Midwives (NACPM), as of 2021 approximately one in five midwives in the United States is a CPM.

Data from other states show us that when licensure becomes available, more midwives follow. When licensure passed in Florida in 1992 there were only 27 CPM midwives. Today more than 430 licenses have been issued. Florida has 31 birth centers, most owned by licensed midwives. When Missouri approved their bill in 2007, they had twelve CPMs; now around 45 work in that state, along with several student-midwives.

When licensure is available, the supply of providers increases, something Iowa desperately needs, especially in rural areas.

Sarah Sorvillo, a CPM in Des Moines, told legislators last year about getting calls from people in western Iowa, more than two hours away, seeking her care. 

Nurses and midwives

I have frequently heard people question why we need CPMs in Iowa, when we already have CNMs. I believe the misunderstanding stems from a cultural perspective ingrained in many Americans: the medical model of care is superior and somehow safer. But the research simply does not support that idea for healthy pregnancies. 

It is important to recognize that many people do not want to go through nursing school and graduate school to become a midwife, which can be cost-prohibitive and time intensive. If you do not want to be a nurse and only a midwife practicing in the out-of-hospital setting, it is reasonable to pursue the CPM credential.

Most people in the United States may not know that in other countries with significantly better maternal and infant outcomes, midwives are often not nurses. In Canada, the United Kingdom, and Australia (which all have better outcomes than the U.S.), many midwives are similar to CPMs (not nurses) yet they can practice in hospital or out-of-hospital settings. You can be a nurse and a midwife, or you can “just” be a midwife.

You can read more about the differences between the U.S. and Australia in this article. It is also worth noting that the International Confederation of Midwives does not mention the word nurse on its website, where you can read more about their professional framework and essential competencies for midwives, which again, does not include having a nursing degree.

The ICM supports appropriate legislation relating to the regulation of the practice of midwives in all countries, as outlined in this statement on midwifery regulation. The World Health Organization recommends midwives as an evidence-based approach to reducing maternal mortality as stated in the report Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries by Commonwealth Fund: “high-income countries with the lowest intervention rates, best outcomes, and lowest costs have integrated midwifery-led care.”

In this context, “integrated” refers to collaboration and coordination with midwives in out-of-hospital settings, like CPMs, as well as incorporating midwives in hospital-based settings.

Let’s not confuse the issue. We need nurses and specifically Certified Nurse Midwives who are able to provide the midwifery model of care (or as close to it as possible) within the hospital medical setting, as well as those who provide care in birth centers and home birth settings. We also need family physicians with training in obstetrics (without limitations to their scope like they face at some hospitals here in Iowa including Des Moines), and OBGYNs and Maternal Fetal Medicine physicians to provide care to high risk patients.

This is not an either or scenario. We need both midwives and medical professionals. The two are not always the same.

A sticking point that came up during the 2022 legislative subcommittees was related to the makeup of the new board that would oversee the CPM license. Some from the nursing community want to see the CPM licensure come under the purview of the Iowa Nursing Board. That does not make sense because, as explained above, CPMs are not nurses.

Additionally, some suggest fewer CPMs should be represented on the proposed board. However, when you look at the proposed makeup of the CPM board in the House-approved bill, compared to other state licensing boards, it is clear that the CPM board would not have more people from the profession than any other state licensing board (see comparison document here).

Iowa needs more maternal health providers, including CPMs

Iowa ranks 49th among states for the number of OBGYNs per capita, and we are projected to have a shortage of 150 OBGYNs by 2030. While we need to ensure we have enough physicians with speciality training to meet the health care needs of Iowans, we must not assume physicians alone are the solution.

Most other high-income countries with better maternal health outcomes than the U.S. have more midwives than physicians. Across the U.S. and Iowa, the opposite is true. From an issue brief by The Commonwealth Fund:

The U.S. has the highest maternal mortality rate among developed countries. Obstetrician-gynecologists (ob-gyns) are overrepresented in its maternity care workforce relative to midwives, and there is an overall shortage of maternity care providers (both ob-gyns and midwives) relative to births. In most other countries, midwives outnumber ob-gyns by severalfold, and primary care plays a central role in the health system. Although a large share of its maternal deaths occur postbirth, the U.S. is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period.

Conclusion: The U.S. has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports.

It is worth noting that CPMs do home visits with their clients after birth, providing both postpartum and newborn care. CPMs typically see their clients within the first few days of birth at their home, and another two or three times through six weeks postpartum in the home or at an office.

CPMs are trained to identify when higher level care may be necessary and refer to physicians accordingly. For families living in more rural communities, this is critical to ensure mothers and newborns have access to care. Even in more urban environments, getting to a doctor’s appointment with a newborn is no easy feat. The American College of Obstetricians and Gynecologists now recommends seeing patients within three weeks after giving birth. In Iowa, physicians still see patients at six weeks postpartum, often at a point when it may be too late to address concerns. According to ACOG, 40 percent of women who have given birth do not attend a postpartum visit

Recruiting physicians to rural and mid-size cities like many Iowa communities is challenging and costly. Training midwives from within the community is much more cost-effective and sustainable.

At one time, a community college in Iowa expressed interest in offering a CPM (direct-entry midwifery) associate degree program. They did not proceed because the state does not offer a CPM license. The closest midwifery associate degree program is available in Wisconsin at Southwest Wisconsin Technical College.

Megan Day, a doula and longtime advocate for CPM licensing, testified before the Iowa House State Government subcommittee last February:

The aforementioned ProPublica report and study on midwives quotes Neel Shah, an renowned OBGYN and assistant professor at Harvard Medical School, as an advocate for increasing access to midwives and licensure.

He said licensed midwives could be used to solve shortages of maternity care that disproportionately affect rural and low-income mothers, many of them women of color. “Growing our workforce, including both midwives and obstetricians, and then ensuring we have a regulatory environment that facilitates integrated, team-based care are key parts of the solution,” he said.

Unfortunately, the medical lobby including hospitals and physicians groups have been hostile to CPMs and continue to oppose the proposed bill House File 2547, which passed the Iowa House by 93 votes to two in 2022. The following organizations in the medical lobby registered opposed to the bill at some point last year:

  • Iowa Medical Society
    • Iowa Chapter-American Academy of Pediatrics
      • Genesis Health Systems
        • Blank Children’s Hospital
          • UnityPoint Health
            • Iowa Osteopathic Medical Association
              • Iowa Academy of Family Physicians
                • Iowa Hospital Association
                  • MercyOne
                    • The Iowa Clinic, P.C.
                      • Medical Associates Clinic and Health Plan
                        • Iowa Independent Physician Group
                          • Wellmark, Inc.
                            • Des Moines University

          Last year, Bleeding Heartland covered one medical lobbyist’s admission as to why they didn’t speak against the CPM licensing bill during the House subcommittees in 2022, and waited to do so until the bill reached the Iowa Senate.

          Lobbyists registered in support of the bill in 2022 included Common Good Iowa, Iowa ACES 360, and the Kirkwood Institute. These groups recognize the value CPMs already provide to families, the tremendous opportunity to improve maternal and newborn health, and the unfairness of not providing a licensure that is wanted and needed to fully practice. 

          Not all physicians in Iowa oppose CPM licensure. A maternal-fetal medicine physician, Dr. Stephen Pedron, has been an outspoken supporter of midwives. He wrote a letter to Iowa legislators expressing his support of the CPM licensure bill in advance of the 2021 legislative session and provided testimony at two separate House subcommittee meetings in 2022. For those unfamiliar with maternal-fetal medicine, they care for the highest risk pregnancies.

          Watch Dr. Pedron’s testimony to the Iowa House State Government subcommittee in February 2022:

          Watch Dr. Pedron’s testimony to the Iowa House Ways and Means subcommittee in February 2022:

          In addition, Sarah Costello, a medical student at the University of Iowa, wrote an op-ed addressing her desire to collaborate with CPMs when she becomes a family physician. Watch her testimony to the Iowa House State Government subcommittee last February:

          As I have shared in other articles, the American College of Obstetricians and Gynecologists supports CPM licensure that aligns with International Confederation of Midwives educational standards. You can read their 2015 statement here.

          ACOG also issued a 2016 statement on the U.S. MERA Bridge certificate, which was created to “bridge” education and training for direct entry midwives that had yet to be licensed by states or had yet to complete accreditation. Excerpt:

          The US MERA bridge certificate at present is only intended to address the training and educational needs of CPMs in states that do not currently license these providers. ACOG strongly encourages all apprentice (PEP) trained CPMs to utilize this bridge certificate opportunity. Every CPM, no matter when they were credentialed or where they practice, should at least meet the educational and training standards required of midwives in other nations.

          ACOG looks forward to working with ACNM and the other US MERA organizations. It is essential that we send a unified message to legislators, regulators, the public, and our patients that we support nothing less than high quality maternity care.

          ACOG has reaffirmed its support for midwifery that conforms to high standards as recently as 2020.

          To be clear: the CPM licensure bill the Iowa House approved last year aligns with ACOG’s policy statement, as it requires the US MERA Bridge certificate and aligns with ICM Global Standards for education and licensure. 

          During last year’s contentious Iowa Senate State Government subcommittee meeting in 2022, Dennis Tibbens, a former lobbyist for the Iowa Medical Society and now Director of the Iowa Medical Board, asserted incorrectly that ACOG does not support the bill. A representative from Iowa’s ACOG was conveniently not present. I find it hard to believe Mr. Tibbens didn’t know that for at least the past seven years ACOG has supported CPM licensure as written in the bill. I would welcome someone from ACOG or the Iowa Medical Society pointing me to language stating otherwise. 

          During the same Iowa Senate subcommittee, “equal time” was given to hospital and physician lobbyists who interact with legislators daily, while CPMs, consumers, and advocates who drove hours from across the state to show their support for the bill were not given the opportunity to speak. Senator Chris Cournoyer chaired the subcommittee and later went on to completely gut the bill in its amended version presented at the full committee meeting, effectively killing the bill, as Bethany Gates reported in this Bleeding Heartland article.

          You can watch some of the compelling comments from consumers, midwives, and advocates from last year’s House and Senate subcommittees here.

          Why licensure?

          If CPMs are already practicing in Iowa, why do they need a license? That’s a fair question. There are two primary reasons. First, recent history shows there is a real threat of prosecution. Second, CPMs cannot access medications within their scope of practice without a license. 

          Three different CPMs have been prosecuted in Iowa over three decades (1990s, 2000, 2010s) for “practicing medicine” without a license. Those midwives were not charged due to any poor outcome, but because a hospital-based provider did not like that the midwife was practicing.

          Since no state law addresses the practice of direct-entry midwifery, prosecutors brought charges. Unfortunately the risk of prosecution is still there, but in 2013 the environment improved after a judge dismissed charges against a midwife who attended an Iowa birth. The judge said since midwifery is not the practice of medicine or nursing, and there is no law in Iowa addressing it, midwives are not breaking any Iowa laws by practicing. 

          The judge also took note that the Iowa legislature has had several opportunities to license midwives with committees analyzing it and conducting scope of reviews in 1995, 1999, and in 2009, with a report to the General Assembly in 2010. That report recommended licensing. 

          At one time, the state allocated annual funding of $140,000 for the training of community-based midwives, recognizing their value to public health. But that funding was eliminated in 1995.

          One of the midwives previously prosecuted, Melanie, has been practicing for 30 years in Cedar County where she has attended hundreds of births. During the 2022 Senate State Government subcommittee, she shared her experience of being prosecuted by the state in 2006 simply for providing maternity care to her clients, in a county that has no other OB services.

          Melanie’s ordeal demonstrates why few people would want to take the risk of practicing as a CPM in Iowa without a license.

          The challenge of not being able to readily access life saving medications that are within the training and scope of CPMs is the most significant day-to-day barrier. Without a license, a pharmacy will not dispense medications like Pitocin and Cytotec, which are basic front-line medications used to manage postpartum hemorrhage.

          They also cannot purchase Rhogam, an injection given to women who are Rh- to prevent their body from developing harmful antibodies that can harm their future unborn babies. CPMs can purchase those medications in 37 other states and Washington, DC. 

          Lack of licensure means that CPMs cannot send their clients to most radiology facilities or labs for prenatal lab work and ultrasound, because most require a state license in order to refer clients for those testing options. In 2021, Bethany Gates, a CPM in Vinton (Benton County), had a client who lived two hours away from the radiology place that would accept her ultrasound orders. The client opted to instead have the lab and ultrasound order sent to her local hospital. Upon receiving the order, the local hospital refused to perform the testing because Bethany did not have a state license.

          This delayed the client’s routine prenatal testing by several weeks, as they scrambled to find a provider who would order the labs and ultrasound for them.

          If you watch any of the videos I’ve included in this post, I hope one of them is this video featuring Bethany. She explains in detail about the challenges of being a CPM in Iowa, how it impacts her clients, and how her family has considered moving to another state that is more supportive of CPMs.

          Most people agree we want people to move to Iowa—not leave it. Improving access to quality maternity care is a factor that people consider whether they move somewhere. The issue also affects whether current midwives will stay here and whether new midwives move here. It would be a tremendous loss for our state to lose an established and well-respected maternity care provider like Bethany.

          Some may feel that to create a new license, the legislature should hear a more compelling case beyond improving care access and outcomes. The good news is that even without a CPM license available, home births are saving Iowa taxpayers money. In 2021 alone, an estimated $5 million has been saved, thanks to planned home births and fewer cesareans because of the services provided by home birth midwives.

          Whereas Iowa has prosecuted a midwife about once a decade, the state of Washington provides a contrast:

          The differences between state laws can be stark. In Washington, which has some of the highest rankings on measures such as C-sections, premature births, infant mortality and breastfeeding, midwives don’t need nursing degrees to be licensed. They often collaborate closely with OB-GYNs, and can generally transfer care to hospitals smoothly when risks to the mother or baby emerge. They sit on the state’s perinatal advisory committee, are actively involved in shaping health policy and receive Medicaid reimbursement even for home births.

          One problem with the 2022 bill was the fiscal note put the licensing fee at more than $1,500, which would have been the highest in the country. The average CPM licensing fee across the U.S. is $400. South Dakota, which licensed in 2017, is at $750 and Wisconsin, which licensed in 2006, is at $54. 

          Ideally, Iowa would allocate state funding to bring the licensing fee down to an affordable level. The ARNP fee, which includes certified nurse midwives, is $81 every three years. My husband, who is a licensed pharmacist in several states, says $1,500 is almost three times more than his highest average annual state licensing fee. Here are comparisons to other Iowa license fees: 

          • Nursing: $99/every 3 years
            • Chiropractors: $270 initial license fee, then $120/every 2 years
              • Massage Therapy: $120 initial license fee, then $60 every 2 years
                • Occupational Therapy: $120 initial license fee, then $60 every 2 years
              • Optometrists: $300 initial license fee, then $144 every 2 years
                • Physical Therapist: $120 initial license fee, then $60 every 2 years
                  • Physician: $450 initial fee, then $450 every 2 years
                    • Physician’s Assistant: $120 initial license fee, then $120 every 2 years
                      • Psychology: $120 initial license fee, then $170 every 2 years

          A high fee won’t dissuade Iowa CPMs from supporting the bill, even if it is inequitable compared to other professions working in health related fields. Iowans should be demanding the state provide CPM licensure at an affordable rate, since that would save the state money overall.

          Since licensing midwives, Washington state have seen a cost savings from CPM delivered care of ten times the cost of administering the state licensing program, as well as improved maternal outcomes. Iowa should be able to find a way to offer the licensure at a reasonable fee knowing it will get a significant return on investment.

          There are more than 3.6 million births every year in the United States. With the cost of birth spread across public assistance programs, employer-funded insurers, family-funded insurers, and families paying out-of-pocket, the 65.7% lower cost of home births relative to hospital births represents an opportunity for substantial savings for governments, employers, insurance providers, and households.

          At the end of the day, every pregnant person needs to decide what birth setting is best for them. There is no “right” answer, and every pregnancy and birth is different. Iowa should ensure the safest environment for all birth settings and increase access to maternity care providers, especially in rural areas.

          CPMs will increase access to evidence-based and quality providers, while saving the state money. I encourage Iowans to reach out to their elected officials to ask them to support the midwifery licensure bill that will hopefully be reintroduced in the 2023 legislative session in the coming weeks. 

          If you have made it this far, I encourage you to watch a video from the Iowa House bill passage (starting around 4:28) last year with remarks from Republican State Representative Bobby Kaufmann, who sponsored the bill, Democratic State Reprepresentative Mary Mascher (now retired), who has been a longstanding champion of the bill, and Democratic State Representative Ras Smith (now retired).

          Kaufman noted that day, “As Rep. Smith alluded to, this bill does serve as the single most diverse bill in terms of the levels of support from the far left to the far right that I have personally worked on. Representative Mascher, you have been working on this for 20 years, we have been working on it for ten years, we are finally here as far as the House. I have every intention of pushing that this gets signed into law.”

          Top image: Advocates for midwifery licensure pose following last year’s Iowa House State Government subcommittee meeting on the bill. Photo provided by Rachel Bruns, published with permission.

          About the Author(s)

          Rachel Bruns