The Women Having Babies Underground

The legal landscape for home births varies by state, leaving some moms outside the law.

Credit: Jared Cummings

After two years working in a labor and delivery unit as a surgical tech, Carlie Smith knew she didn’t want to give birth in a hospital. Nearly every night shift she worked was the same: women were wheeled in for cesarean sections following failed 39-week inductions that their bodies and babies weren’t ready for.

But as a North Carolina resident, Smith didn’t have many options for home birth. North Carolina is one of a dozen states that doesn’t license Certified Professional Midwives, who are direct-entry midwives specializing in out-of-hospital birth. CPMs can face arrest just for practicing in the state.

So Smith went underground. She found a midwife based in Charlotte, N.C., to attend the birth of her first daughter in August 2022.

“My first birth was definitely intense. I was in prodromal labor for a week, but my actual labor was three hours,” Smith told TAC. “It was very empowering because I was the one that caught her.”

Smith is one of a growing number of women choosing home birth. The number of home births in the United States jumped nearly 20% from 2019 to 2020, according to Pew Research Center analysis of National Center for Health Statistics data. That statistic is far from a pandemic fluke. Midwives across the country say their busy schedules are evidence that women are returning to home birth.

While many states, including California and Texas, are friendly to home birth, other states are less so, leading some pregnant women to seek care from underground midwives. It’s unclear how many of 2020’s home births were attended by underground midwives, because the families that use them usually mark births as “unattended” on vital records. What is clear is the need for the few remaining states that ban CPMs to consider whether their laws reflect how women in these states are actually giving birth. Women are hungry for home birth, and when some of them face hurdles to a legal home birth, they opt not for a hospital or birth center but for “free birth,” forgoing the midwifery model and giving birth at home unassisted.

The awful statistics surrounding birth and postpartum in the U.S. are one reason that low-risk women are attracted to the midwifery model, in which pharmaceutical and surgical interventions are minimal and postpartum care is emphasized. U.S. maternal mortality more than doubled from 1999 to 2019, from 505 deaths to more than 1,200. Additionally, the U.S. has one of the highest rates of C-sections in the world at 320 procedures per 1,000 live births, according to a Commonwealth Fund survey. C-sections put moms at risk of life-threatening conditions like uterine rupture during future vaginal births.

In contrast, The Farm Midwifery Center in Summertown, Tenn., where midwife and author Ina May Gaskin made a name for herself, reported a C-section rate of less than 2 percent for 2,844 pregnancies between 1970 and 2010.

Skeptics of home birth have plenty of statistics to point to, too. The American College of Obstetricians and Gynecologists warns that planned home births are associated with a more than twofold increased risk of perinatal death and a more than threefold increased risk of “neonatal seizures or serious neurologic dysfunction.”

“Although the American College of Obstetricians and Gynecologists (the College) believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery,” the group said on its website.

There are a variety of reasons why a family might choose an underground midwife, even if it means paying thousands of dollars out of pocket. Some live in states that ban CPMs from attending home births, including Georgia, New York, and North Carolina. Others live in rural areas and have limited options as underfunded hospitals shutter their maternity wards. Still other families want to bypass state regulations that prevent midwives from attending births of women who are pregnant with multiples or who have previously had C-sections.

Daesha Cummings, who moved from Virginia to Arizona before the birth of her third child in 2023, chose an unlicensed “granny midwife” to attend her most recent birth after using licensed providers for her first two. Even though Arizona has more than 80 licensed CPMs, Cummings said she just “jived” with her unlicensed midwife and appreciated that she wouldn’t automatically transfer her to a hospital if her pregnancy went past 42 weeks. Cummings said she was grateful for her choice when she delivered her son at 42 weeks and two days.

“He came out quietly and peacefully. There was zero commotion in the room. There was just worship music playing,” Cummings told TAC. “It was the most peaceful entrance into the world I have ever experienced.”

Her labor was so short that her husband and sister were the only ones at the birth – her midwife arrived shortly after. Cummings, a pre- and postnatal personal trainer and certified doula who goes by @daeshajoyfit online, said a successful home birth isn’t something that just happens. Women have to train themselves mentally, spiritually, and physically for birth and postpartum. She shared the example of one of her clients who began practicing her breathing for labor as soon as she conceived.

“She was so committed to wanting a natural birth, and she worked so diligently through the entire nine months to make sure she was ready,” Cummings said. “I was grateful to be a huge part of that. You really have to go out of your way to prepare your space, to prepare your mind, to train your body to have the stamina in order to navigate birth.”

Having a home birth does include an element of risk, and having an underground home birth can multiply those risks. A midwife practicing illegally may hesitate to transport a mom to a hospital or face a hostile environment when she does. That’s “not a good situation,” said Carol Nelson, a CPM who has been attending births at The Farm Midwifery Center for more than 50 years.

Nelson began her midwifery career in the 1970s, when many women were drugged into a state called “twilight sleep” to give birth—or, rather, have their babies pulled out of them with forceps. Midwifery had all but disappeared after a decades-long smear campaign by the medical community. The CPM credential didn’t exist, so Nelson and other like-minded midwives had to create it. Now, nearly 40 states from California to Virginia license CPMs. Nelson is on the board of the North American Registry of Midwives, which issues the CPM credential. CPM candidates typically apprentice under an experienced midwife, called a preceptor, for three to five years.

“Most of the state laws are reasonable. There are a few of them that are still pretty restrictive, but for the most part they’ve licensed midwives,” Nelson told TAC. “When you look at a state that didn’t have licensing, and then you get licensing, you see how the numbers of midwives grow and grow.”

Both home birth midwives and families faced persecution from authorities during the decades Nelson fought for the CPM credential. But in several states, CPMs still operate in fear of the authorities. A North Carolina mother who spoke to The American Conservative on condition of anonymity said her midwife was initially afraid to take her as a client because she was working in state government at the time (the midwife ended up attending the home births of her three children).

It’s a common misconception that home birth is illegal in the state, said a North Carolina midwife who spoke to TAC on condition of anonymity. North Carolina does permit Certified Nurse-Midwives—who are registered nurses who have graduate-level midwifery training—to attend home births, but since they are trained to work in hospital settings, there are not nearly enough CNM-led home birth practices in North Carolina to meet demand.

The midwife is an administrator of a private Facebook group helping North Carolina moms connect with home birth midwives. The group, created in 2020 when interest in home birth skyrocketed, now has more than 4,000 members.

“In North Carolina, prior to the pandemic, the only way to find a home birth midwife was through old-fashioned word of mouth. You had to go to church with some woman who’d had her babies at home and whisper to her, ‘Who was your midwife?’” the midwife said. “So we created that Facebook group. It’s by no means exhaustive. There are still midwives who prefer to be deep, deep underground, no social media presence… Then there are others, like myself, who don’t mind participating in social media and helping offer suggestions and connections that can lead a woman to the right resource, wherever in the state she might be.”

Who’s having home births in North Carolina? The midwife said home birthers represent a wide spectrum of political, religious, and cultural backgrounds.

“It’s really fascinating how diverse the people are who are drawn to home birth. It’s definitely not… just for hippies and homesteaders,” she said. “Sometimes it’s for religious or cultural preferences. Sometimes it’s a desire for more intimate personalized care. Certainly during the pandemic and after, it was because people wanted to have more medical autonomy or autonomy over their choices, and fear of the control of the hospital system forcing masking during labor, or forcing partners to be separated, or separation of mothers and babies.”

Many of the moms and midwives I spoke to predicted a long road ahead for CPM licensure in the state. Emily Saunders, a mom of five who had her first home birth at 41, hopes that sharing evidence with open-minded physicians can turn the tide. Saunders is the network director for North Carolina Physicians for Freedom but spoke to The American Conservative in a personal capacity.

“Even freedom-minded health care providers have some hesitancy around home birth,” Saunders said. “They hear ‘home birth’ and there’s this fear factor, and it’s just because of the way they’ve been trained.”

Saunders should know. Her husband is a physician practicing integrative medicine who initially had a lot of questions about home birth.

“He had to deliver about 200 babies in his training, and this is the complete opposite of everything he was taught,” Saunders said. “Both of us would agree it was the best decision we ever made… It was so nice to have all our boys there and be able to relax in the space of my own home. It was such an easy birth. And then to move right into my bed and go to sleep? That was the best thing ever.”

A bill to create CPM licensure in North Carolina, called the Accessing Midwives Act, was introduced in 2023, but didn’t get far.

“I’m really surprised by it in a lot of ways because we have a solid conservative legislature right now, but Big Medicine is so powerful in North Carolina. That’s where the pushback is,” Saunders said. “But I am very hopeful that something could happen.”

Meanwhile, consumer group NC for CPMs is working toward a legislative victory. More than 20 percent of North Carolina counties are considered maternity care deserts, and the group says more midwives is the solution.

“In 2025, we will present a bill that will allow Certified Professional Midwives to acquire licenses to practice midwifery care in the state of North Carolina. Over the next year we have many goals, one of which is to educate the masses on the benefits and safety of midwifery care,” NC for CPMs told The American Conservative in a statement. “There are many Certified Professional Midwives poised and ready to fill this care gap once it is legal to practice. Licensing midwives would mean there is a standard of care and accountability which protects moms and the future of the profession.… This is the best scenario, a state in which midwives can autonomously practice to their full abilities while being able to respectfully turn to an OB/GYN, Certified Nurse Midwife, or other specialty when necessary to provide the best care possible for mothers and babies.”

North Carolina home birth advocates can look to another southern state, Alabama, for a playbook for increasing access to midwives. Alabama passed a law in 2017 to legalize midwifery, according to AL.com. Now, Alabama has more than 20 licensed CPMs who attended more than 300 out-of-hospital births in 2022, according to the Alabama Reflector.

Karen Brock, one of the first five CPMs licensed in Alabama in 2019, had been licensed in neighboring Tennessee since 2002. She managed to serve Alabama families for many years before the new law.

“Midwives serving families beginning in the late 1980s risked being charged with a misdemeanor of practicing Certified Midwifery without a license. This was a fine and/or possibly jail time,” Brock told TAC in an email.

What changed?

“A small group of persistent women worked indefatigably for many years, building up political capital and educating the public,” Brock continued. “The value of these women has largely gone unsung, but they are the foundation of midwifery in Alabama.”

The home birth movement is growing, but there are also threats that it might splinter. The high cost of birth and women’s distrust of the medical system are contributing to interest in free birth, also known as unassisted birth.

“Because there’s so little access to legal and safe midwifery [in North Carolina], there’s a huge groundswell of freebirthing, where women are influenced to DIY their home birth without a midwife,” the North Carolina midwife said. “There are large organizations like Free Birth Society that take a really radical, almost anti-midwife stance.”

Free Birth Society has more than 130,000 followers on Instagram and warns against hiring a “medwife” who perpetuates “the system.”

“Some women are only seeing the Instagram highlight reel of people’s twinkle lights and water birth at home, and then they don’t understand that it is this really complex decision involving life and death. It would be wise to have skilled hands and wisdom and presence there to guide the process,” the midwife said.

Nelson said free birth is happening in Tennessee, too, even though the state has been licensing providers for years.

“Who’s watching? Who’s keeping track?” she said. “Is everything really okay or not? People say, ‘I’ll be all right if something happens.’ They’re not all right. They’re just not. You lose a baby—that is super traumatic. You lose a mom—how could you ever be okay with that?”

Nelson warned against any movement that paints all doctors and nurses as the enemy. On a policy level, home birth advocates must get comfortable working with those with differing views, she said. Nelson is co-chair of the Innovations in Maternity Care committee of the American Public Health Association and has co-authored several APHA policies about CPMs and out-of-hospital birth.

“When we first started working, there were 11 states that regulated midwives, and the CPM evolved into a real thing,” she said. “Very quickly, the majority of those states took the CPM process as well as the exam. Now, we have 38. Part of the reason is things like those policies because legislation would come up in a state, and we’d have those policies from the APHA in the legislation… It really helped pave the way.”

But not all North Carolina midwives or home birth moms think CPM licensure is a perfect solution.

“It’s a difficult question because if it becomes legalized, then the medical community and the government starts to have a say over what happens,” the North Carolina mother who spoke on condition of anonymity said. “Immediately, there’s less freedom, and there’s more medical intervention.”

The mother describes herself as the “opposite” of a home birth evangelist, even though that’s the choice she made for all of her births. Her first birth was “lower-case t” traumatic. Her baby got stuck, but her midwife was able to take care of them both safely at home. The mother also has a close friend who faced life-threatening complications during an HBAC (home birth after C-section).

“For anybody who has any kind of random health condition, I’m like, ‘Don’t do home birth,’” she said. “Everyone has to prudentially examine their lives and their health… It introduces all sorts of deep questions that make a lot of people uncomfortable about life and death and fate and chance and how much control we really have over things. It’s heavy.”

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“There’s an element of randomness and tragedy that’s built into life, and I feel like you have to approach birth with a level of reverence for the fact that things can go wrong,” she continued.

The mother said part of the reason she chose home birth was to end the cycle of C-section births in her family.

“My mother and my grandmother…didn’t have anything to share with me knowledge-wise,” she said. “For the sake of my daughters, I want to end this generational dependency and this broken chain.”