Nevada, Currently The Wild West Of Birthing, Is Considering Licensing Midwifery

By April Corbin Girnus, Nevada Current

April 19, 2023

Nevada is something of a wild west of midwifery.

It is the only state in the western United States that does not regulate the profession, and one of only a quarter nationwide that does not. For many midwives, that status is a point of pride — Nevada is a safe haven of medical autonomy while giving birth. Other midwives believe state licensure is an important step toward expanding the profession so that more women and babies can benefit from non-hospital birth.

Those two factions are clashing over Assembly Bill 386, which would establish optional state licensure for certified professional midwives, or CPMs.

Tiffany Hoffman, one of two Reno-based CPMs who helped draft the bill, told lawmakers the bill seeks to “maintain and expand” Nevada’s history of reproductive freedom.

But, she acknowledged, “middleground is really hard to find.”

Democratic Assemblywoman Daniele Monroe Moreno, the bill sponsor, said that during the 2021 legislative session she received a death threat after introducing a similar bill. She recalled her husband calling her to let her know the police had just shown up at their home.

“They’re here because there’s been a hit put on you,” she remembered him saying. “And I said, yeah, I know. It’s a midwife bill.”

She added, “This bill did that.”

The 2021 bill, which needed to pass by a two-thirds majority because it would establish licensing fees, failed in the Senate by just one vote. Votes did not fall strictly on party lines, with two Republicans (Heidi Seevers Gansert and Ben Kieckhefer) voting with 11 Democrats in support and Democrat Mo Denis voting with seven Republicans in opposition.

Like its 2021 counterpart, AB 386 will require two-thirds approval from the Legislature to pass. It will also need to clear the desk of Gov. Joe Lombardo, who has expressed a desire for fewer regulations statewide and called for a review of business licensure requirements.

‘People might say Nevada is standing alone’

Certified professional midwives are training in birthing babies in out-of-hospital settings, typically at the client’s homes. These midwife-attended home births make up just a fraction of overall deliveries — close to 2% in Nevada as of 2021.

But the number is rising.

Proponents of AB 386 believe it will provide patients with more transparency and better protections, and strengthen relationships between CPMs and medical professionals who are often wary of midwifery. The bill would open CPMs for inclusion in Medicaid, which currently covers at least half of all births in Nevada.

Monroe Moreno during an Assembly Committee on Commerce and Labor hearing earlier this month emphasized that licensure would be optional — “for those who want to be held to a higher standard.” She said she had no intent to criminalize unlicensed midwives, unless they were not disclosing that status and misrepresenting themselves as being licensed.

“I made a promise to community midwives that I would not ask for a mandate for every midwife to be licensed,” she said. “There are a group of people who don’t agree with that. … (But) I did not want to take that away because that is a profession.”

Monroe Moreno vowed to keep that promise.

The National Association of CPMs supports the bill.

The Nevada Midwives Association is opposed. In a letter signed by its nearly 30 members, about half of which are CPMs, they raised concerns that the bill does not clearly state that licensure is voluntary. They fear certain provisions will be interpreted as applying to all midwives, not just those engaging in the licensure process.

Others in opposition said they believed optional licensure is the first step toward mandatory licensure.

Out-of-state midwives and their patients travel to Nevada specifically to give birth because Nevada does not require licensure, says Lenny Sue Tinseth, a CPM who is opposed to the bill.

“(People) might say Nevada is standing alone with no regulation,” she added. “Or it stands alone for health freedom and a woman’s autonomy over her body. … Many people would call that a gem.”

‘…a plumber on the electrician board’

Opponents also have a problem with the makeup of a midwifery board the bill would create. One obstetrician, one pediatrician or certified nurse midwife, and three or four certified professional midwives would be voting members. And one social worker or public health community organizer would be a non-voting member.

Tinseth argues an obstetrician and a pediatrician should have no place on a board designed to regulate and oversee certified professional midwives.

“You wouldn’t put a plumber on the electrician board,” she adds. “Even if they work together sometimes.”

The Nevada State Board of Nursing, for example, is made up of four registered nurses, one practical nurse, one certified nursing assistant, and one consumer member. Similarly, the State Board of Pharmacy has on it six registered pharmacists and one representative of the general public.

AB 386 would require all midwives to have their clients sign a standardized disclosure form that explains the different classifications of midwives.

Monroe Moreno, Hoffman, and Macdonald see it as consumer protection, since lay people may not understand the different types of midwives and what levels of education and experience are associated with them.

Certified nurse midwives, CNMs, are advanced practice registered nurses who have attended an accredited masters-level midwifery program. They are certified by the American Midwifery Certification Board, and in Nevada licensed by the State Board of Nursing.

There were only nine CNMs registered in Nevada in 2021, according to a report by the nursing board. Those numbers may rise as UNLV’s School of Nursing builds out its new midwifery program, which director Kate Woeber told the committee has begun the pre-accreditation process.

Certified professional midwives, CPMs, are certified through the North American Registry of Midwives, which has requirements pertaining to education and the number of home births attended under the supervision of qualified certified practitioners. Currently, 36 states license CPMs. Almost all of the other states have formal efforts to establish a licensure option.

Then there are midwives who are not CNMs or CPMs. These midwives are sometimes called traditional midwives or direct-entry midwives (DEM). There is no standard for their education and no required level of experience someone must have before calling themselves a midwife.

The number of CPMs and traditional midwives practicing in Nevada is unknown.

AB 386 passed out of Assembly Committee on Commerce and Labor on April 14.

[Editor’s Note: This article has been updated to correct which committee the bill was heard in.]

Nevada Current, a nonprofit, online source of political news and commentary, documents the policies, institutions and systems that affect Nevadans’ daily lives. The Current is part of States Newsroom, a national 501(c)(3) nonprofit supported by grants and a coalition of donors and readers.