For Health Care providers

Below, we have provided a general overview of out-of-hospital (community) birth containing information that is highly relevant for healthcare providers to know. It is not a comprehensive literature review, but serves as an introduction to midwifery care and the evidence supporting it. 

Definitions

Doula: A trained advocate who provides information as well as emotional and physical support during pregnancy, labor, childbirth, and postpartum, and in situations including pregnancy loss, induced abortion, and delivery after known fetal demise.

Midwife: Per the International Confederation of Midwives (ICM) definition a midwife is an autonomous healthcare provider who optimizes the normal biological, psychological, social and cultural processes of the female reproductive processes, childbirth, and early life of the newborn; promotes people’s personal capabilities to care for themselves and their families; and provides holistic care that meets each client’s individual needs. (1)

Certified Nurse Midwife (CNM): Advanced practice nurses who complete specialty training in midwifery following general nursing education. CNMs are licensed as autonomous, primary providers in Massachusetts. The majority attend births in hospitals, but may also have received training to provide care in homes and birth centers.

Certified Professional Midwife (CPM): Credentialed primary maternity care providers who deliver a broad spectrum of services in community birth settings (e.g., home and birth centers). CPMs gained the right to a pathway to licensure in Massachusetts in August 2024 and state licenses will begin to be issued in June 2025.

Community Birth / Out-of-Hospital Birth: Terms that encompass both birth centers and planned home birth.

Birth Centers: Centers that provide a holistic birthing experience with minimal medical intervention, most commonly led by midwives.

Planned Home Birth: A planned labor, delivery, and immediate postpartum transition managed in the birthing person’s home. Planned home births are safest when attended by a skilled birth attendant (such as a midwife or physician) who is well integrated with regional health systems.

Frequently Asked Questions

How will MA Bill H.4999 affect maternal healthcare in the state of Massachusetts?

This bill is an omnibus of maternal health legislation that expands access to midwifery care and out-of-hospital birth options as well as perinatal mental health care, postpartum home visiting, lactation services, donor milk, and more. It was signed into law on August 21, 2024. Notably, it creates a pathway to state licensure for Certified Professional Midwives (CPMs) and requires MassHealth to cover CPM care. The legislation also requires MassHealth to reimburse certified nurse midwives (CNMs) equitably for the same services compared to physician reimbursement. The law modernizes state birth center regulations and allows CPMs and CNMs to staff and lead birth centers. Once implemented, the law will make it more feasible to open and operate birth centers in Massachusetts and remove income barriers to accessing midwifery care in all birth settings.

As this legislation transitions into full effect and allows access to CPM licensure beginning in June 2025, the number of midwives practicing in Massachusetts is expected to increase. The certification and licensure of midwives establishes well-defined safety and quality-of-care standards, as well as allows better integration of midwifery care into the U.S. allopathic healthcare system, which benefits all patients who choose to have a community birthing experience. 

Per the Massachusetts statute updated by the 2024 law, an interdisciplinary Board of Registration in Midwifery has been established to oversee CPM licensure. In addition to establishing the requirements for licensure, the board will also:

  • “adopt rules and promulgate regulations governing licensed certified professional midwives and the practice of midwifery to promote the public health, welfare and safety consistent with the essential competencies identified by [North American Registry of Midwives]” (From Section 292 of Massachusetts General Law Chapter 112)

  • “develop practice standards for licensed certified professional midwives that shall include, but not be limited to: (A) the adoption of ethical standards for licensed certified professional midwives; (B) the maintenance of records of care, including client charts; (C) the participation in peer review; (D) the development of standardized informed consent forms; and (E) the development of a standardized written emergency transport plan forms relative to the timely transfer of a newborn or client to a hospital” (From Section 292 of Massachusetts General Law Chapter 112)

Certain individuals are exempt from regulation by Massachusetts certified professional midwife licensure laws and regulations: physicians, nurse midwives, EMTs, anyone performing emergency aid, federally-employed midwives, certain birth attendants who are religious, cultural, or Native American providing traditional midwifery services to their communities without compensation. (See Section 290 of Massachusetts General Law Chapter 112 for details.)

As seen below, Massachusetts is joining 37 other states that regulate CPMs.

 

How are community births relevant to me as a medical provider?

Data over the past few years show that the number of childbearing people who desire a planned home birth has only increased (see graphs below). Among any patient population, there will be some people who choose a birthing experience outside of the hospital. As more states across the United States pass legislation supporting the work of midwives, it is important for healthcare providers to be familiar with all birthing experiences and options. Clinical providers within the U.S. allopathic healthcare system may have prenatal patients who are curious about their options. They may care for a parent who has had their first baby in the hospital but desires a community birth for their second. They may meet patients who have been transferred from their home birth to the hospital to receive medical care beyond the midwifery scope of practice. In any case, planned community births will remain an integral aspect of maternal healthcare in which an increasing number of patients are participating. 

Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Natality on CDC WONDER Online Database. Data are from the Natality Records 2016-2023, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/natality-expanded-current.html on Feb 16, 2025.

Graphs created by Sarah Tran. 

What is the scope of care of a midwife?

The scope of care of a midwife, as defined by the International Confederation of Midwives(1):

The midwife is recognised as a responsible and accountable professional, who works in partnership with [birthing people] to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.  

The midwife has an important task in health counselling and education, not only for the women and gender diverse people they serve, but also within families and communities. This work should involve antenatal education and preparation for parenthood and may extend to sexual and reproductive health care, and care for infants and young children.  

A midwife may practise in any setting including the home, community, hospital, clinic or health unit.

In practice, midwife scope of care varies state-by-state depending on state laws and regulations. In Massachusetts, the new law passed in 2024 establishes statutory parameters and a Board of Registration in Midwifery which will promulgate regulations for the practice of licensed certified professional midwives. As the Board continues to develop regulations, established law provides broad indication of CPM scope of practice in Massachusetts. Relevant excerpts from Massachusetts General Law are included below.

From Massachusetts General Law Chapter 112:

  • (From Section 290) “Low-risk pregnancy”, a pregnancy with no maternal or fetal factors that place the pregnancy at significantly increased risk for complications, as determined through regulation by the board in consultation with the department of public health, including, but not limited to, factors related to maternal or fetal health conditions likely to affect the pregnancy and the gestational age and presentation of the fetus at the time of labor and delivery. 

  • (From Section 291) The practice of midwifery by a licensed certified professional midwife shall include, but shall not be limited to:

    • (i) the practice of providing maternity care to a client during the preconception period and the antepartum, intrapartum and postpartum periods of a low-risk pregnancy;

    • (ii) the practice of providing newborn care; and

    • (iii) prescribing, dispensing or administering pharmaceutical agents consistent with section 295.

  • (From Section 292) Nothing in this section shall be construed to authorize the board to promulgate regulations that require a licensed certified professional midwife to practice under the supervision of or in collaboration with another health care provider.

  • (From Section 295) A licensed certified professional midwife duly registered to issue written prescriptions in accordance with [specified provisions] may order, possess, purchase and administer pharmaceutical agents consistent with the scope of midwifery practice, including: (i) antihemorrhagic agents, including, but not limited to, oxytocin, misoprostol and methergine; (ii) intravenous fluids for stabilization; (iii) vitamin K; (iv) eye prophylaxes; (v) oxygen; (vi) antibiotics for Group B Streptococcal; (vii) antibiotic prophylaxes; (viii) Rho(D) immune globulin; (ix) local anesthetic; (x) epinephrine; and (xi) other pharmaceutical agents identified by the board through rules or regulations in consultation with the department of public health.**

** Please note that the formulary will ultimately be set by the Massachusetts Department of Public Health.

Why might a patient choose an out-of-hospital birth?

Common themes from focus group studies on why a pregnant person may choose a community birth include: the empowerment of making a personal choice, avoiding unnecessary interventions and interruptions, previous experiences with disrespect and dismissal within the U.S. allopathic healthcare system, choosing a birthing space where they feel comfortable and safe, and appreciating the continuity of care offered by the midwifery model. (2,3)

Members of communities that feel disenfranchised by their experiences within the U.S. allopathic healthcare system may particularly connect with the midwifery model of care and the option of community birth. In a small focus group study of Black women living in Texas, all participants had positive perceptions of midwifery care and birth centers, but cited lack of awareness, lack of insurance coverage, and high out-of-pocket costs as barriers to choosing community birth as an option. (4) These long-standing access issues have prevented members of marginalized communities from choosing a planned community birth. Data from older studies show that many people who chose planned home birth were white and higher educated. (5,6) However, as states pass legislation that allows for midwifery care to be reimbursed by state health insurance, community births will continue to become more accessible to a wider demographic. Newer data reflects such changes: From 2020 to 2021, home births among non-Hispanic Black birthing people increased 21% (from 0.68 to 0.82% of all births), compared to an increase of 15% (from 0.48 to 0.55% of all births) for non-Black Hispanic birthing people and an increase of 10% (from 1.9 to 2.1% of all births) for non-Hispanic White birthing people. (7)  

Who is a good candidate for a community birth?

Individuals of reasonably good health, absent chronic conditions which increase the risks associated with pregnancy and childbirth, and who desire to play an active role in their own care make excellent candidates for community birth. Additionally, candidates for community birth should be interested in and willing to experience childbirth in the absence of epidural and/or spinal analgesia. Most medical guidance groups and professional bodies use the term “low risk” to describe individuals clinically optimal for community birth; however, this term does not have a specific clinical definition and is defined differently by various U.S. medical associations. The American College of Obstetricians and Gynecologists (ACOG) describes a low risk birth as “a clinical scenario lacking clear demonstrable benefit for medical intervention.”(8) In 2015, the Society for Maternal-Fetal Medicine developed a definition for births that are low risk for cesarean delivery, which identified “all term, singleton, vertex, live birth deliveries without previous cesarean delivery or high-risk diagnoses.”(9) Ultimately, the determination of risk factors, suitability for community birth, and probability of transfer of care from the community to hospital environment is an ongoing process throughout the perinatal period and includes review of the patient’s specific health history and medical risks, socio-emotional history and risk factors, access to supportive services including nutritional and mental health services, and availability of a functional transfer system in the event that advanced obstetrical or pediatric intervention becomes necessary. 

Are home births safe?

There have been numerous studies showing that planned community births, attended by a skilled provider, are not only safe but may confer better outcomes compared to hospital births for the sub-population suited to birthing at home. Birthing at home or in any community setting (e.g., a freestanding birth center) will pose increased risk of adverse outcomes for certain individuals if risk factors or emerging complications are ignored. Critical elements of care that promote optimal outcomes for people planning community births include:

  • Ongoing risk assessment by a skilled provider

  • Trust and open communication between the birthing person and their primary maternity care provider

  • Open and timely access to expanded networks of care, including emergency transportation options

Several large scale studies in the United States demonstrate the safety of planned home birth with a skilled birth attendant:

  • A retrospective cohort study of 2006 birth certificate data in the United States analyzed 745,690 births and found that while out-of-hospital births had more frequent prolonged/precipitous labors and a significantly larger number of neonates with 5 min APGAR scores <7, out-of-hospital births also resulted in less frequent chorioamnionitis, less fetal intolerance of labor, less meconium staining, less assisted ventilation of newborns, fewer neonatal intensive care unit admissions, and fewer birthweights <2500 g. (5) 

  • A retrospective cohort study of 16,924 midwife-led, planned home births in the United States between 2004 to 2009 found that “the majority of women and newborns experienced excellent outcomes and very low rates of intervention relative to other national datasets of U.S. women.” (6) This included an 87% rate of successful vaginal birth after cesarean section (VBAC), lower rates of operative vaginal and cesarean births compared to reported data for hospital-based U.S. births, and 4.5% reliance on oxytocin augmentation and/or epidural analgesia. The intrapartum fetal death rate among planned home births in this sample was 1.3 per 1000 (96% CI, 0.75-1.84), and researchers hypothesized that the lack of integration across different birth settings likely contributed via delayed transfers to hospital.

  • A 2016 meta-analysis of birth outcomes by planned delivery location found that for low risk pregnancies, planned home births are as safe as planned birth center births. (10)  

  • Furthermore, in an integrative literature review that included more than 84,300 birthing people, those who began care in a birth center had higher spontaneous vaginal birth rates and perineal integrity compared to people who received hospital care, as well as lower rates of cesarean birth. There were few severe maternal outcomes and no maternal deaths. (11) 

Additionally, there is a plethora of data on community births from countries where midwife-led care has been well integrated for decades. 

  • A 2018 systematic review of studies across Canada, New Zealand, Japan, and the Netherlands concluded that home births were associated with significantly higher spontaneous delivery, less likelihood of receiving medical intervention, lower risk of fetal dystocia, and lower risk of postpartum hemorrhage when compared to low risk hospital births, with similar neonatal morbidity and mortality across the two groups. (10) 

  • In Ontario, Canada, where midwives have been regulated since 1994 and are integrated into the healthcare system, data show that when compared to low risk hospital births, those who chose planned home births were less likely to undergo labor augmentation or receive pharmacologic pain relief, had fewer assisted vaginal and cesarean deliveries, and were less likely to experience severe perineal trauma or postpartum hemorrhage. From this analysis of birth data between 2006 to 2009, there were no maternal deaths reported in either group and neonatal data (including APGAR <4, need for ventilation, and stillbirth or death) was comparable across the two groups. (12)

What are the benefits of midwife integration into the U.S. healthcare system?

A 2024 World Health Organization (WHO) position paper succinctly summarizes the benefits of and needs for midwifery integration [emphases are added]: 

“The majority of maternal and neonatal deaths and stillbirths can be prevented with timely access to high-quality care … Worldwide, many women and newborns experience mistreatment during pregnancy, childbirth and postnatal care. Overmedicalization of pregnancy and childbirth has escalated in recent decades contributing to further poor quality of care and unfavourable outcomes for women and newborns, and posing a barrier to achieving universal health coverage (UHC). Under international human rights law, governments are obligated to promote, respect, protect, ensure and uphold the rights of women, newborns, children and adolescents to receive high-quality health care and enjoy the highest standards of health. As a foundational step on the pathway towards UHC, the World Health Organization (WHO) endorses the reorientation of health systems towards primary health care (PHC). This includes the development of models of care that … advance the principles of promoting comprehensive integrated health services. In the pursuit of providing high-quality health services to improve health and well-being for all in the context of UHC, transitioning to midwifery models of care represents a cost-effective strategy to optimize outcomes for women and newborns with minimal use of unnecessary interventions. 

‘Transitioning to midwifery models of care’ refers to the process of reorientation of health systems away from the currently prevalent fragmented and risk-oriented model of care to a midwifery model of care in which women and newborns, starting from pre-pregnancy and continuing all the way through the postnatal period, receive equitable, person-centered, respectful, integrated and high-quality care, provided and coordinated by midwives working within collaborative interdisciplinary teams.” (13)

Evolution of our maternity and perinatal care systems here in the United States is particularly needed. Our country must confront having the highest maternal mortality rate among developed countries. (14) We also spend the most per live birth of any country in the world. (15) Furthermore, the U.S. experiences stark racial disparities in maternal and fetal health. For instance, in 2020, maternal mortality rates were 40.8 out of 100,000 live births for non-Hispanic Black and African Americans, compared to 12.7 out of 100,000 for White Americans. (16) Continuity of care, a client-centered approach to risk counseling, and expanded postpartum care are tenets that improve outcomes while also being keystone aspects of the midwifery model of care. The evidence also shows the critical importance of networks of care and system integration such that birthing people can receive complementary, non-midwifery care in a timely manner when the need arises. 

The Access and Integration Maternity Care (AIMM) Study (published in 2018) analyzed the relationship between integration of midwives into the U.S. healthcare system and key birth outcomes. Researchers developed a Midwife Integration Scoring System (MISS) and used it to assess degree of midwife integration in states across the US. The MISS took into account factors such as the regulation of midwives (CPMs, CNMs, and CMs), Medicaid reimbursement for midwives, and whether there are statutory limitations or restrictions to site of practice for licensed midwives. The study found that states with the highest integration of midwives had significantly lower rates of C-sections, higher rates of vaginal births after C-section (VBACs), higher rates of spontaneous vaginal deliveries (SVDs), lower rates of preterm birth, and lower rates of low birthweight babies. Meanwhile, states with low integration and fewer midwives, as well as lower access to midwives across birth settings, had the highest rates of neonatal mortality. (17) 

 

How can I be supportive of plans for community birth?

As a provider, familiarizing yourself with the evidence on what clinical factors make someone a good candidate for home birth, taking time to discuss the full range of planned birth locations in a non-judgemental fashion, and reminding families that hospital-based care remains available to them should their risk profile change, are all important steps to maximize patient choice in their reproductive care while optimizing the safety of community birth. As research on midwifery care, planned home births, and birth centers continues to expand, it is imperative to remain up to date on the latest evidence and clinical guidelines. We have compiled below a selection of resources oriented towards a medical audience for more information and best practice guidelines. 

What are some other helpful resources I can reference?

Credit: This content was prepared by Sarah Tran, final year MD/MPH student, with contributions from Rebecca Herman, CPM and Zev Colsen, CPM. 

References

1. Definition of Midwifery. International Confederation of Midwives. June 9, 2017. Accessed March 6, 2025. https://internationalmidwives.org/resources/definition-of-midwifery/

2. Bernhard C, Zielinski R, Ackerson K, English J. Home Birth After Hospital Birth: Women’s Choices and Reflections. Journal of Midwifery & Women’s Health. 2014;59(2):160-166. doi:10.1111/jmwh.12113

3. Hadjigeorgiou E, Kouta C, Papastavrou E, Papadopoulos I, Mårtensson LB. Women’s perceptions of their right to choose the place of childbirth: an integrative review. Midwifery. 2012;28(3):380-390. doi:10.1016/j.midw.2011.05.006

4. Anyiam S, Woo J, Spencer B. Listening to Black Women’s Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment. J Midwifery Womens Health. 2024;69(5):653-662. doi:10.1111/jmwh.13635

5. Wax JR, Pinette MG, Cartin A, Blackstone J. Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births. American Journal of Obstetrics and Gynecology. 2010;202(2):152.e1-152.e5. doi:10.1016/j.ajog.2009.09.037

6. Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health. 2014;59(1):17-27. doi:10.1111/jmwh.12172

7. Gregory ECW, Osterman MJK, Valenzuela CP. Changes in Home Births by Race and Hispanic Origin and State of Residence of Mother: United States, 2019-2020 and 2020-2021. CDC National Vital Statistics Reports. 2022;71(8). https://www.cdc.gov/nchs/data/nvsr/nvsr70/NVSR70-15.pdf

8. ACOG Committee Opinion on Planned Home Birth. The American COllege of Obstetricians and Gynecologists. April 2017. Accessed February 16, 2025. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/planned-home-birth

9. Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. American Journal of Obstetrics & Gynecology. 2016;214(2):153-163. doi:10.1016/j.ajog.2015.10.935

10. Rossi AC, Prefumo F. Planned home versus planned hospital births in women at low-risk pregnancy: A systematic review with meta-analysis. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2018;222:102-108. doi:10.1016/j.ejogrb.2018.01.016

11. Alliman J, Phillippi JC. Maternal Outcomes in Birth Centers: An Integrative Review of the Literature. J Midwifery Womens Health. 2016;61(1):21-51. doi:10.1111/jmwh.12356

12. Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ. 2016;188(5):E80-E90. doi:10.1503/cmaj.150564

13. Transitioning to midwifery models of care: global position paper. World Health Organization. Published online 2024. Accessed March 5, 2025. https://www.who.int/publications/i/item/9789240098268

14. Tikkanen R, Gunja MZ, FitzGerald M, Zephyrin LC. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund. doi:10.26099/411v-9255

15. International Health Cost Comparison Report. Health Care Cost Institute, International Federation of Health Plans. Published online July 2022. Accessed March 6, 2025. https://healthcostinstitute.org/images/pdfs/international_health_cost_comparison_report_2022.pdf

16. Sutton MY, Anachebe NF, Lee R, Skanes H. Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020. Obstetrics & Gynecology. 2021;137(2):225. doi:10.1097/AOG.0000000000004224

17. Vedam S, Stoll K, MacDorman M, et al. Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLOS ONE. 2018;13(2):e0192523. doi:10.1371/journal.pone.0192523