The Current State of Midwifery in Minnesota
In Minnesota, there are three main birth attendants: Obstetricians/Gynecologists, Certified Nurse Midwives (CNM), and Certified Professional Midwives (CPM). Minnesota is one of 31 states where it is legal for all three attendants to practice. These three professionals have a complicated relationship that has changed throughout the last century, but traditional midwifery (state law refers to midwifery practiced by CPMs as traditional midwifery or direct entry midwifery) has been legal in Minnesota since 2000.
Finding data on homebirths in Minnesota is difficult. Some data is available through the State of Minnesota and the CDC, but the data only lists births by the attendant and birth place. I could not find data on information such as the number of homebirths that result in transfers and homebirths that end in c-sections.
A BRIEF HISTORY OF MIDWIFERY IN MINNESOTA
Minnesota was founded in 1858, and up until the medicalization of birth, like most states, Minnesota depended on midwives to deliver expecting birthing persons. In fact, in 1891, there were 254 midwives registered with the State of Minnesota. In 1909 a law was passed licensing Midwives and 208 midwives were licensed. Midwives remained an important part of birth in Minnesota until 1940 when the state stopped granting and renewing licenses. Around this time Nurse Midwives were introduced as a part of the medical institution and the increasing medicalization of birth.
The 1909 Minnesota law was never changed, so while no new licenses were being accepted, midwifery was not explicitly illegal, creating a sort of a-legal bubble where midwives could practice but did not have the institutional support of the state. This a-legal bubble is described in Mary Lay’s 2000 book titled, “The Rhetoric of Midwifery: Gender, Knowledge, and Power.”
In 1984 the last licensed midwife in Minnesota died. At this point, a large group of midwives and midwifery organizations had formed, including the Minnesota Midwives Guild which had defined a scope of practice adopted by most midwives in Minnesota based on the guidelines of national organizations and peer reviewed by its members. Around 1990, the midwives and their organizations pushed for licensure under Minnesota law. They pushed for this for several reasons, including wanting a clearly defined scope of practice that could be used to standardize midwifery in Minnesota. But there were quite a few different groups, and not all midwives supported licensure. For further reading, check out Lay’s book.
The conversation about licensure took almost 10 years, up to 1999 when Minnesota adopted a law with language very similar to that of the 1909 law defining the scope of practice of direct-entry midwives. When the bill took effect in early 2000, eight midwives were given licenses. Since then, midwifery has grown in Minnesota. In 2008, there were 21 CPMs and approximately 200 CNMs. In 2011, Minnesota started licensing Birth Centers, and currently, there are 44 licensed CPMs, 355 CNMs, and 6 licensed birth centers operating in Minnesota.
CURRENT STATISTICS
According to CDC and Minnesota data, Minnesota has approximately 69,000 births each year with a cesarean rate around 27%. The fertility rate is 1.97 children per birthing person’s lifetime, the infant mortality rate is 5 per 1,000 live births, and the maternal mortality rate is 14.7 per 100,000 live births. All three of these figures are lower than the national average.
THE CERTIFIED PROFESSIONAL MIDWIFE (CPM)
According to the Minnesota Board of Medical Practice, as of November 2018, there are currently 44 licensed midwives in Minnesota. Minnesota has a very clear, narrow definition of who midwives are and what they can do. According to the law, midwives are allowed to deliver the birthing person (including twins and breach births) and provide prenatal and postpartum care of persons who are expected to have “a normal pregnancy, labor, and delivery.” The law also gives a specific list of medical services and tests they are expected to perform on the birthing person and requires a plan for transfer of care and transport of the birthing person to a hospital. Under the law, Midwives are also allowed to administer several prescribed substances to ensure the safety of the birthing person, such as Vitamin K and postpartum antihemorrhagic drugs.
To become a licensed midwife in Minnesota, you must be a Certified Professional Midwife (CPM) as accredited by the North American Registry of Midwives (NARM). Then you must apply to the state showing that you have completed a number of tasks, such as having participated in 40 homebirths (having been the primary attendant at 20) and completed at least 75 prenatal examinations and 40 postpartum examinations.
THE CERTIFIED NURSE MIDWIFE (CNM)
According to the Minnesota Board of Nursing, as of December 2018, there are 355 licensed CNMs in Minnesota. According to the Minnesota law, Nurse Midwives have a wide scope of practice. Thanks to a law passed in 2014, CNMs are no longer restricted by physicians and collaborative agreements. Basically, this means that CNMs can function as the primary care provider for mothers without the supervision of a medical doctor. This allows for CNMs to deliver children at home, in birth centers, and in hospitals in conjunction with physicians.
In general, CNMs and CPMs have very similar jobs, except CNMs have a lot more institutional power. For example, CNMs have the ability to admit, manage, and discharge patients as well as prescribe medications including contraceptives, and even treat the partners of birthing persons for STIs. These powers allow CNMs who work for birth centers or deliver home births the ability for the continuation of care if a patient needs to be transferred. Depending on the transfer agreement with the local hospital, a CNM may be able to be the primary care provider after hospital transfer, while many CPMs are often barred or shunned from the delivery room.
To become a nurse midwife in Minnesota, you must take the steps to become an Advanced Practice Registered Nurse and earn a master’s degree in nurse midwifery. Then you must pass a national exam from the American Midwifery Certification Board. At this point, you must apply to the State of Minnesota for a license in order to begin to practice.
CENTER FOR DISEASE CONTROL DATA
Table 1A shows CDC data on the total number of births (vaginal and cesarean) in Minnesota in 2017 by the location of the birth and birth attendant, while Table 1B shows the data as a percentage of all live births. Table 1C shows the percentage of live births by attendant. Unsurprisingly, 96% of all births took place in hospitals, while only 1.36% took place at home and 0.78% took place at a birth center.
I was surprised to find that 12% of all births were delivered by CNMs, while only 0.66% of all births were delivered by CPMs. When we divide the number of births delivered by these two attendants by the number of licensees, we see that CNMs disproportionately deliver more births per licensee than CPMs: each licensed CNM in Minnesota delivered an average of 23.3 births in 2017, while each licensed CPM delivered only 10.4 births.
This data also shows that CNMs were the only birth attendant to practice in all three locations specified by the CDC — the hospital, at Birth Centers, and at home — and preform both vaginal and cesarean births. CNMs also delivered more births at birth centers than CPMs did, while CPMs delivered more births than CNMS at home.
BIRTH CENTERS IN MINNESOTA
Currently there are six Freestanding Birth Centers licensed in Minnesota. According to Minnesota law, which first licensed birth centers in 2011, a Freestanding Birth Center (FBC) is…
Four FBCs serve the Twin Cities, Minnesota’s largest population center, while the other two are in rural Minnesota. According to CDC data, Birth Centers in Minnesota delivered 543, 527, and 437 births in 2017, 2016, and 2015 respectively. As we can see in Table 1D, birth centers delivered only 0.78% of live births in 2017.
The law states that to be licensed, an FBC needs to be accredited by the Commission for the Accreditation of Birth Centers (CABC). The scope of practice of an FBC in Minnesota was adopted from CABC and the American Association of Birth Centers (AABC) with the following exceptions: the FBC cannot perform abortions, provide general or regional anesthetic, or preform surgeries except for episiotomies and repair. AABC has a very clear scope of practice and requirements for accreditation, including clear outlines for prenatal and postpartum care, transfer and continuation of care, and facility and equipment needs.
Minnesota law also clearly dictates that births occurring at FBCs must be low risk. Minnesota Birth Center, one of the FBCs serving the Twin Cities, has a PDF that shows some of the pre-existing conditions that disqualify a birthing person from using their birth center, which gives us a glimpse at this process.
One thing I noticed about Minnesota law that I did not see for CPMs or CNMs is specific language about insurance and reimbursement. The state breaks down the billing into prenatal, birth, and postpartum care. Birth Centers can charge 100 percent the average rate a physician will charge for the actual birth, but for prenatal and postpartum care, they can only charge “70 percent of the statewide average payment rate.” If the birth results in a transfer, the birth center can only charge “15 percent of the statewide average.”
I was not able to ascertain the reason for this particular language. Perhaps, this is to try to keep what is supposed to be a low-cost option when compared to hospital birth low cost, but this has issues. For example, this law may make birth centers want to keep patients at the birth center when they need to be transferred so they can bill insurance for a higher rate, possibly compromising the health of the birthing person.
MIDWIVES OPERATING A-LEGALLY IN MINNESOTA
According to NARM, there are 57 CPMs in Minnesota with active certification. That’s 11 more than are licensed according to the Board of Medical Practice. Interestingly, the law never states that midwives must be licensed by the state, creating a legal loophole where practicing without a license is not technically illegal.
If we look at the data for homebirths in Table 1C, we see more than half of the births are listed as attended by “other.” This category catches births that happened at home on accident or the parents decided to have no attendant. However, because the number of births in this category is so high and NARM shows there are more certified midwives than licensed midwives in Minnesota, I think this shows that there are likely unlicensed midwives operating in the state with a certification.
LOOKING FORWARD
Minnesota has come along way in the last 20 years: they have re-licensed traditional midwives, incorporated CNMs into the hospital, and licensed FBCs. However, the state can do better. First, the state needs to pass a law explicitly explaining the ability of CPMs delivering in patients’ homes to be reimbursed by insurance. Second, they should require CPMs to submit more information about their births to either the state or NARM to help build a better database. Finally, the state should pass a law allowing for the continuation of care by CPMs as they enter the hospital. This last recommendation is maybe easier said than done and will require a lot of reform and cultural adjustment but will help keep care of the mother and child at the center of focus.
