By Barbara Pash
A dramatic rise in home births by unlicensed practitioners, as well as in the number of people requesting United States birth certificates for babies born that way, has led a state agency to issue a statement on health and safety guidelines for women wanting to deliver their children at home.
“We haven’t changed the current law. But there’s been an increase in anecdotal reports of births attended by unlicensed people around the state, and it’s a concern,” said Frances Phillips, deputy secretary for public health services in the Department of Health and Mental Hygiene.
In Maryland, home births have increased from 291 in 2001 to 409 in 2010. This represents less than one percent of all live births in the state, but it is a sharp increase. The figures apply to all home births, both planned and by unlicensed practitioners.
Maryland is not the only state to be experiencing a rise in home births attended by unlicensed practitioners. “It’s happening around the country,” she said. “It’s a very small percentage of births. But it’s an uptick we have noticed.”
Phillips attributes the rise partly to a skepticism about traditional medicine. “There appears to a small subset of families that are choosing to reject traditional approaches to delivery, traditional heath care providers,” licensed midwives have told her.
“There is also a belief in some communities that home birth is a way to avoid unnecessary experiences in a hospital and for the newborn, for infant screenings,” Phillips continued, adding that there may be other factors of which she is unaware. “We don’t know what motivates people to make what I see as a risky decision.”
Along with the state health department, the Maryland Board of Nursing, Maryland Association of County Health Officers and Maryland Affiliate of the American College of Nurse-Midwives endorsed the statement that was issued last month.
Basically, the statement urges women who want to give birth at home to first consult with a licensed doctor or nurse midwife to determine if the circumstances are appropriate. Planned home deliveries need to be attended by a licensed physician or nurse midwife, it states.
Nancy Adams, president of the Maryland Board of Nursing, which licenses and regulates the practice of nurse-midwives, said its concern was to assure the safety and quality of home births.
That, too, was a consideration for the state health department.
“Maryland has stricter licensing regulations that some other states. Licensing is the public’s protection,” Phillips said.
If a home birth is attended by a licensed doctor or nurse midwife, that professional is authorized to issue a birth certificate. In the case of an emergency, emergency technicians from official units can also issue birth certificates.
In the case of a home birth attended by an unlicensed person, getting a birth certificate is more difficult. Parents must request one from the local jurisdiction’s health office.
“Parents come in and they’ve very vague about who attended the birth. They say ‘no one’ or the husband,” said Phillips, noting that the phenomenon is so new that up to now, the state health department has not identified in its records whether a home birth was attended by a licensed practitioner or not.
“We didn’t keep that data separate because we didn’t think we had to,” said Phillips. “Going forward, we will because of the number of anecdotes we were hearing from health officers who were increasingly uneasy over [some home birth] circumstances. Over a year ago, they requested clear state guidelines,” which was another reason for issuing the statement.
In order to issue a birth certificate to a child born without a licensed practitioner present, the local health department must follow a detailed and lengthy procedure that involves interviews, collecting medical records of prenatal testing, and documentation that the mother was living at a local address at the time of the birth.
“It’s a case-by-case situation. The health officers take it very seriously. To create a new identity, a U.S. identity [under false circumstances] is fraud. A birth certificate is a crucial piece of documentation,” she said, although whether people are deliberately lying to get a American birth certificate is not known.
“That’s what the whole investigation is about. That goes to the heart of the procedure. If health officers are not satisfied, they won’t sign the certificate,” she said.
While birth certificates are ultimately issued in most cases, Phillips said she knows of several recent instances where they were not. Looking just at the Washington, D.C. area — Montgomery, Prince George’s and Frederick counties — she knew of one case in which a birth certificate was not issued and other cases that are under investigation.
Deputy Prince George’s County Health Officer Elana Belon-Butler said that last April, a health officer sent a certified letter declining to issue a certificate for a home birth.
“The applicant could not provide enough information to verify the facts of the birth,” said Belon-Butler. She said the parents are in discussion with the health office and are “taking the necessary steps” for the issuance of a birth certificate.
If a health officer declines to issue a birth certificate, the parents can appeal that decision to Circuit Court. Privacy rules shrouding these types of cases make it impossible to find out if and how many have been filed.
Said Phillips, “My sense is that the majority of home births in Maryland are by licensed practitioners. That’s good. We are not anti-home birth. But we are also seeing the consequences of unlicensed home births,” she said, referring to reports of newborns, and sometimes mothers, who are brought to emergency rooms suffering from the adverse effects of the birth experience. “There’s been a worrisome increase in those reports, too.”