Rebekah Panagos was a teenager when she learned that most U.S. women give birth in the hospital.
Like her eight siblings, the 37-year-old Pemberton Township woman was born at home with the assistance of a midwife.
At nearly 3 years old she witnessed the birth of her younger sister.
When her three children were born, it was also at home, with a midwife present.
“This is what we were meant to do. This is what birth should be,” she said. “I see myself as a lifeguard of birth.”
Three years ago, Panagos became a licensed certified professional midwife, the only midwifery certification that requires experience in home births. She has attended or assisted in hundreds of home births.
But unlike some New Jersey-licensed midwives, Panagos limits her practice to inside state borders.
Pennsylvania may only be a roughly 30-minute trip from her Burlington County home, but it’s a different world for midwives like her, who have no medical degree. The state is one of 17 where home birth is unregulated and midwife licenses are reserved for registered nurses with specialized training and medical affiliation.
Not that it has stopped others from assisting women with home births in the state, which ranked sixth highest in the nation for home births in 2017, according to a recent Maryland study.
A Gatehouse Media review of state professional licensing bureau and professional association records found 22 Pennsylvania residents with active midwifery licenses from states, like New Jersey, where the practice is not restricted to nurses. The North American Registry of Midwives (NARM), the largest certifying body of non-nurse midwives in the U.S., is aware of 45 active Pennsylvanians with its credential.
Since Pennsylvania doesn’t regulate home births, officials can’t stop non-nurse midwives from attending them, as long as they don’t claim to be licensed by the state, according to Kaitlin Murphy, deputy press secretary for the Pennsylvania Department of State, which oversees professional and occupational licensing. The state Board of Medicine can issue cease and desist orders, but Murphy had no data on the number of orders it has issued.
Rachel Rachlin is among four non-nurse midwives licensed in New Jersey, who lives and practices in Pennsylvania, where 1.9 percent of births in 2017 were home births, roughly double the national average of 1 percent, according to a 2018 study by the Maryland Population Research Center at the University of Maryland. In contrast, just 0.4 percent of births in New Jersey happened at home, the study showed.
A decade ago, Rachlin was working as a political organizer, a job she said that didn’t bring her much personal satisfaction. A friend suggested she look into becoming a doula, a role that provides women with non-medical support and guidance through the birth process and Rachlin was interested. After she attended her first home birth, she knew she wanted to pursue midwifery.
Rachlin entered a three-year accredited midwifery program and obtained a bachelor’s degree in direct entry midwifery; in 2017 she opened Refuge Midwifery in Philadelphia, where she specializes in home births. She has participated in 150 to 200 home births and sees fewer than 40 clients a year.
The Pennsylvania Association of Certified Professional Midwives supports licensing non-nurse midwives, which would give them the ability to bill insurance companies and Medicaid for services, said Rachlin, the association’s current president. The 2017 Maryland study found lack of insurance coverage is an “important limiting factor” for women who want out-of-hospital births in most states.
State licensing also would create a standard of care, public acknowledgement of professional qualifications, and a pathway to deal with grievances, though she added it would also mean facing restrictions that unregulated midwives currently don’t face.
Certified professional midwives can enter the profession through either a clinical apprenticeship with a licensed midwife, or a formal midwife educational program; they also must pass a clinical evaluation and written test administered by NARM. Their scope of practice is limited. They cannot administer drugs other than antibiotics and medications to prevent hemorrhaging.
Currently Pennsylvania has roughly 400 active certified nurse midwives licensed through the state Board of Nursing and state Board of Medicine, according to the Pennsylvania American College of Nurse Midwives. Most certified nurse midwives limit their scope of practice to medically affiliated hospitals and clinics, according to the American College of Nurse-Midwives.
As midwifery practice has evolved past what Pennsylvania law covers, it has prompted recent discussions about the need for a update, though no legislation has been proposed, according to Bill Patton, press secretary to the state House Democratic Leadership and spokesman for the House Democratic Caucus.
There has been no big push for licensing of non-nurse midwives in Pennsylvania in more than five years. Last year, one of the main professional organizations, the Midwives Alliance of Pennsylvania, dissolved after nearly 30 years.
In 2013, the state Board of Medicine last considered a regulation change that would have cleared a path to license non-nurse midwives, and allow them to operate independently, rather than attached to a hospital or doctor.
The change reportedly was proposed in reaction to a 2008 state court ruling that reversed a cease and desist order and $11,000 in fines against a Lancaster County certified professional midwife who attended numerous home births in the Amish and Mennonite communities, where they are common.
Six years before that ruling, in 2002, New Jersey updated its state occupation and professional license regulations and opened licensing to non-nurse midwives, including a third category called certified midwives — college graduates who undergo the same training as nurse midwives.
New Jersey law does not specify who can be a midwife, but before 2002 the only certification available was through the American College of Nurse Midwives, according to a state agency spokeswoman. Once the North American Registry of Midwives started certifying non-nurse midwives, the state expanded licensing to reflect a change in national standards.
The licensing expansion prompted push back from some. Soon after the state introduced its rule change, New Jersey lawmakers introduced legislation seeking to restrict midwife licensing to only registered nurses; the measure failed to gain traction.
Currently New Jersey lists 15 certified midwives and 23 certified professional midwives with active or pending professional licenses, according to its Consumer Affairs licensing bureau data base. Pennsylvania residents hold six of the certified professional midwives licenses, records show, though Pennsylvania does not recognize it.
For Panagos, who said she is one of three home birth midwives serving southern New Jersey, the advantages state licensing brings outweigh the accompanying restrictions.
She can bill health insurance companies for her services, rather than require families pay out-of-pocket like they do in Pennsylvania. She also can provide parents with birth certificates and Social Security cards for newborns. Licensing also gives clients a way to vet prospective midwives and their qualifications.
But Panagos counts among the biggest licensing benefits that she isn’t afraid to call a hospital if a client develops a serious medical issue during childbirth, she said. New Jersey also requires midwives have a doctor backup with hospital privileges.
“I don’t have to be fearful of the medical community,” she added.
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