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So it is no surprise that a large 2009 Dutch study showed home birth to be safe. What that means for women elsewhere is less clear, however, and results of various U.S.-based studies tend to conflict. "Research in this area is desperately needed, particularly for women in the United States," says Wax.
The lack of definitive data guarantees that the birth wars won't soon end. But many obstetricians and midwives can at least agree on one thing: easy and immediate access to hospitals can improve birth outcomes and increase home-birth safety overall. Which is precisely why midwives say they are pushing to expand state licensing of CPMs. In states where licensing already exists, home-birth advocates say, there is, on the whole, good cooperation between midwives and hospitals.
A midwife's working relationship with a hospital aside, what really matters is her competence. The reality is that licensed or not, midwives are already practicing in every state, many in the shadows and many lacking any certification whatsoever. Certification is granted on the basis of a candidate's attainment of obstetric knowledge acquired at midwifery school, through distance learning or in an apprenticeship along with her experience attending births. A midwife must assist 20 births and serve as the primary midwife on at least another 20 to become certified, a process that typically takes three to five years.
In states without licensing programs, the danger is that women seeking a home birth will not know whether the women delivering their babies are CPMs. Many don't even think to question whether certified and uncertified midwives have different training. That's why in two states where legislators have recently considered licensing CPMs Wisconsin, where a law was passed, and Massachusetts, where the matter is still pending the bills were championed by unexpected proponents: women whose babies died during home birth. Their babies didn't die because the women chose to give birth at home, they said, but because the midwives who attended their births had not been certified as competent. In the absence of a state licensing system, women can be none the wiser.