Families have the constitutional right to choose where they give birth and with whom.

No! Home birth is not illegal in any state in the US. 

In simple terms, only certified nurse midwives (CNMs) are offered licensure in North Carolina to practice legally. North Carolina has continually refused to offer licensure for certified professional midwives (CPMs), which is the only branch of recognized midwifery specializing in low-risk, out-of-hospital birth. CPM is a national certification through the North American Registry of Midwives (NARM) and most other states in the US offer licensure for CPMs, including our surrounding states, SC, TN and VA. Practicing midwifery without a license in North Carolina is a Class 3 misdemeanor. Therefore, any unlicensed practicing midwives are taking a legal risk, but the family is not. Because of this, non-nurse midwives have been forced to practice “underground.” It can be challenging to find a home-birth provider (when it isn’t appropriate to share these midwives' names publicly or tag them on Facebook) but there are a handful of highly trained and experienced home birth midwives serving WNC!

Check out these maps provided by the National Association of Certified Professional Midwives (NACPM) to see which states recognize CPMs and more about state-to-state policies, education pathways, and legislation.

Short answer: politics, money, professional turf battles and stalled legislation. 

Unlike our surrounding states, North Carolina has continuously chosen not to enact legislation to license CPMs. This is not because CPMs have been proven unsafe (the opposite). "Safety" might seem like the public reasoning, but underneath has more has to do with the power, money and priorities of large medical lobbyists who want to keep their control of providers and patients in their system.

North Carolina banned all unlicensed midwifery back in 1983 and decided that only licensed Certified Nurse Midwives (CNMs) could legally attend out of hospital birth. Even though most CNMs only receive clinical experience in the hospital setting and most CNMs choose to practice in the hospital or birth center. 

South Carolina has had CPM legalization since 1976.

Tennessee has had CPM legalization since 2000.

Virginia has had CPM legalization since 2005. 

Since the early 2000's multiple bills have been introduced to try and legalize and license CPMs in North Carolina. None have passed, sometimes due to lack of fundraising for lobbying efforts, getting stuck in the long process of making a bill a law, having strong and powerful opponents like the medical lobbyist group who don't want out-of-hospital competition, not having the right bill sponsors, or even when CNMs and CPMs have different agendas during the bill cycle. 

In North Carolina we are behind the times with licensing CPMs and decriminalizing midwifery. 

There are only one or two CNMs offering home birth services in the Asheville area. Luckily for families of the WNC community, there are many non-nurse midwives practicing in the area, they are just harder to find. Many of these midwives, whether CPMs or not, follow NARM's standards for continuing education requirements, Neonatal Resuscitation Program certifications and CPR, as well as gather to hold council, peer reviews and regularly practice hands-on skills to stay current.

To learn more about the NC CPM legislative efforts, check out https://ncforcpms.org

To learn more about the requirements for CPM certification and recertification, check out https://narm.org/certification-recertification/

Short answer: Statistically, yes, when you are "low-risk" and birthing at home with a trained midwife. 

But what does safety even mean? 

When medical groups discuss safety, they are often only talking about maternal and neonatal deaths/outcomes. What about other factors that make up a sense of safety? What about maternal satisfaction? It is hard to quantify things like a lack of perceived trauma, rates of postpartum depression, breastfeeding success, rates of physiological vaginal birth, intact perineums, rates of unnecessary inductions and cesarean sections, and whether or not a mother feels like she was listened to and respected during the process, regardless of how the birth unfolded.

Midwives specialize in the art of listening to women and being patient with the birth process— both of which help prevent the need for interventions which can themselves sometimes lead to more "complications" and poor outcomes for mother and baby. 

In general, birth inherently comes with risk regardless of where you birth. In our ever-evolving technological world, birth (and death) are some of the last human experiences that we cannot control, predict or manipulate with great success. Birth requires at least some elements of surrender, patience and being with the mystery of life.  

Safety is actually quite subjective. What makes one woman feel safe might set another on edge. Safety isn't just physical— psychological and emotional safety matter too. Some women feel safest when they can birth with someone they know and trust, someone who isn't a stranger. They might feel safest if they can stay home, have the freedom to move around and eat and drink as they please. Some women feel safest in a hospital with continuous fetal monitoring, where they can have access to pain relief, have an OR and NICU down the hall and know their provider went through 12 years of medical school. Some women feel routine interventions are trustworthy and supportive while others feel they lead to the "cascade of interventions" and birth trauma. 

Trauma in the hospital often comes from feeling unheard, losing bodily autonomy, and experiencing a sense of disrespect or having your concerns or wishes dismissed by a provider. 

So what does safety mean to you?

Where do you imaging feeling safest? Who do you feel safest with? Where does your nervous system feel the most held? What are your personal and family values around health and wellness, sickness and injury? What systems do you regularly engage with? Is the western medical system your jam, or do you lean more alternative or complimentary? Do you prefer the hierarchy of an expert healthcare provider or do you prefer individualized, collaborative, family-centered care? Do you value protocols and hard boundaries or do you appreciate more flexible and personalized approach?

That being said: studies continue to show that home birth for women who are "low-risk" has been shown to be just as safe as hospital birth, with fewer interventions. Below is a list of peer-reviewed studies and data-analyses looking at the safety of home birth in comparison to hospital birth. 

Midwives Alliance of North America (MANA) statistics project

Maternal outcomes and birth interventions for planned home births

Outcomes of planned home births with registered midwife verses planned hospital birth with midwife of physician 

Perinatal mortality and morbidity of planned home births verses hospital births

Midwife attended planned home births versus hospital births in Spain

Outcomes of planned home births with CPMs in North America

Planned home births verses planned hospital births in British Columbia

And here is an annotated guide to all of the literature (from 2013) on the evidence of planned home birth

I highly recommend watching these documentaries and books to learn more about home birth:

The Business of Being Born (2008, but still accurate!)

• A classic birth documentary by Ricki Lake, analyzes the US hospital maternity system and shines a light on why it is the biggest money making sector of hospitals in the US, as a business.  Critiques the OB heavy care for low-risk pregnancies, discuss the risks of over-medicalizing birth with unnecessary interventions and the "cascade of interventions" that often happens. Also compares our maternal and neonatal outcomes to European countries who utilize midwifery care as the norm (spoiler, we rank lower in all categories!).

Why Not Home? (2016)

• A documentary about hospital OBs, CNMs and L&D nurses who choose to give birth at home with community midwives when they get pregnant, instead of birthing at the hospital they work at. "What if the choice of where to give birth wasn’t limited by cost or insurance coverage, fear or misinformation? What would change if families had access to the care provider of their choice in the setting that best fits their unique needs and values? It’s worth at least asking, “Why not home?”"

These Are My Hours (2018)

• An intimate and slow documentary of a single birth, from start to finish, from the perspective of the laboring woman. This is a realistic glimpse into what labor and birth can look like at home-- the mundane events, the arc of intensity, the sounds, the emergence, the rest. Emily Graham (the birthing mother) and Carey Glenn (her midwife) are both home birth midwives who live in Greenville, SC. Carey's practice Rooted Birth serves Greenville and Upstate SC. 

Pushed: The Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block

• A groundbreaking look into how our culture views childbirth by an investigative journalist who views our birth norms and lack of evidenced based care as a reproductive rights issue. Why are half of all birthing women on drugs to speed up their labor during their birth? Why are a third of babies born by cesarean in our country? Why is it so hard to find out of hospital care providers and alternative birth options? Jennifer Block has an true gift at looking at the whole picture of maternity care in our country and proposes: "Either women's bodies are failing, or the system is failing women."
• Bonus book if you like Pushed-- her broad topic women's health second book-- Everything Below the Waist: Why Health Care Needs a Feminist Revolution. 

Check out this article: "Why Choose Home Birth?"

In short, OB care is often short visits, only medical, hierarchical and treats all pregnancy as a complication while midwifery care includes longer visits, is holistic, relationship-based and views pregnancy as a normal part of life. 

Birthing in the hospital with OB care and birthing at home with home birth midwives is a very different experience. Some clients compare OB care and home birth midwifery care to night and day. Midwifery care is a radically different model of care-- one where you are centered, trusted to know your body better than anyone else, you have power to make decisions and your voice and those decisions are respected-- but also there is still a care provider guiding and monitoring (with vitals, tools, eyes and hands) for normal wellness, signs/symptoms of complications, emergencies or something other than the variations of normal. 

Most women who want a hospital vaginal birth and hire OB's don't consider that they are hiring a surgeon to be their care provider. OBs are wonderful care providers for managing higher risk pregnancies and are excellent at performing cesareans (which are definitely needed sometimes, but surely not at the state rate of 30% according to the World Health Organization). They aren't always the best care providers for low risk women wanting a low intervention, family-centered or natural birth. 

OB prenatal visits are an average of 10-15 minutes spent with the doctor in the office. Vitals, weight, fetal heart tones and "do you have any questions?" Some women feel rushed and unheard. Focused on answering urgent medical concerns, managing risk with diagnostic tests, and preventing complications with interventions. Treats pregnancy and birth as pathology to be managed. Care is standardized when it comes to labs, ultrasounds, screening tests and recommendations for inductions. It can be hard to opt or advocate for individual care. The OB practices in Asheville work in team practices, meaning they all have scheduled days they are in the office and scheduled days they do deliveries. Patients try and meet all of the care providers and depending on when you birth, whatever OB is working the day of your birth will do the delivery. Other younger children are not allowed to be present for the labor and birth. 

During the labor and birth, OBs come into the room to check in and check cervical dilation for a few minutes about every 4 hours until pushing, and are present for the birth of the baby and birth of the placenta. The doctor catches the baby and the cord is "delayed" for 60 seconds but typically still cut quickly after birth. The placenta birth is usually rushed within 10-20 minutes. A few hours after the birth you transition upstairs to the MotherBaby floor where a nurse (or pediatrician or doctor or lactation consultant or photographer or birth certificate worker) comes in (and often wakes you up) about every 2-3 hours for the next 24-48 hours of the hospital stay. There is a small window sofa for partners to sleep on. Co-sleeping with baby is not allowed and babies must be placed in the bassinet when you are resting. For vaginal births, OB care only offers one postpartum visit at 6 weeks. 

The labor and delivery nurses at Mission Hospital, way more than any OB, are the main care providers families interact with. Although most of them are wonderful, some families have a hard time regulating their nervous system or progressing in labor when there are new people in their space they haven't met prior to labor. 

Yes, there are some amazing OBs in our community who respect clients wishes, aren't pressuring with interventions, and let you decline routine tests that feel unnecessary-- but that isn't always the norm in most practices. It is simply a different system/paradigm that they practice in. 

If someone wants or needs to receive OB care, or establish co-current care with an OB, I highly recommend MAHEC. Even high risk families can choose to receive midwifery prenatal care from one of their wonderful CNMs and they are able to individualize care more than other OB practices in the area. 

Home birth midwifery prenatal visits are an hour (+) long sometimes in your home or sometimes in a cozy office. Plenty of time for conversation and education-- getting to know you and your family, your values and preferences deeply. Lots of education, guidance and trouble shooting on nutrition and hydration, movement, supplements, sleep, stress, work, kids, relationships, etc. Vitals and plenty of time discussing baby's movements and position with belly mapping, palpation and fetal heart tones with a doppler and/or fetoscope. Rooted in the believe that pregnancy and birth are normal life events and often go smooth when there isn't routine intervention and when the woman feels trust and safety with her midwife.  Treats pregnancy and birth as physiological events. Emphasis on informed choice when it comes to labs, ultrasounds and screening tests— educating families on the benefits, risks, alternatives and options to decline, and then trusting families to make their own best decision. Home birth midwifes provide full continuity of care, and work in either solo practices or partnerships, where you will work with the same midwife(s) the whole pregnancy, labor and birth, and back in your home for postpartum. Home birth midwives typically offer about 4-6 postpartum visits, and most, if not all, are in your home. Emphasis is on making sure you feel resourced, nurtured and supported-- check ins and validation that you and your baby are well and lots of education and troubleshooting with breastfeeding and sleeping. 

The Midwives Model of Care (from the NACPM website) shares how the midwifery model of care are:

• Founded on relationship, trust, and personalized care that has been shown to "reduce the incidence of birth injury, trauma, and cesarean section."
• Prioritizes not just the physical but the psychological, spiritual and social well-being of the mother and baby through the childbearing year. 
• Provides the mother with "individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and (comprehensive and extended) postpartum support."
• "Minimizing technological interventions" while having patience and an understanding for the flow of physiological labor and birth. 

The Midwifery Model of Care (from the International Confederation of Midwives) believes that:

• "Childbirth and the postnatal period are profound experiences, which carry significant meaning for women and their families" and these experiences and how women are treated during them stay with them forever. 
• "Midwifery care is holistic and continuous in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women." It is truly individualized care instead of a one-size-recomendation-fits-all approach. 
• "Midwifery care takes place in partnership (trusting relationship) with women, recognizing the right to self-determination (and autonomy), and is respectful, personalized, continuous and non-authoritarian." 
• "Midwives respect and have confidence in women and in their capabilities in childbirth. They promote and advocate for non-intervention in normal childbirth."
• "Midwives empower women to assume responsibility for their health and for the health of their families."

Midwives treat straight-forward, physiological birth as the norm, while having the skills and knowledge to step in and act if labor or birth veers out of the norm or needs skills, meds or hands-on support. 

Midwives honor normal birth as a physiological process, an everyday miracle, instead of a pathological process to be interfered with. 

Standard of care in our community: Mission Hospital (MAHEC physicians) offers routine, scheduled cesareans for babies who are positioned breech (bum down instead of head down) at full term or require them for women who show up in labor with a breech presenting baby. Unfortunately, doctors are no longer routinely trained in medical school to learn maneuvers and skills for delivering a breech baby vaginally.  The "Term Breech Trial" from 2020 is mostly to blame why US hospitals no longer allow/support/recommend vaginal breech births. Findings from that trial showed that planned cesarean delivery for a term breech baby was deemed "safer." However, it has been quite controversial and there have been many critiques and flaws pointed out, along with newer information coming out that shine light on the risks of planned cesareans and the safety of vaginal breech when assisted by a skilled breech  provider. Even ACOGs statement on breech has changed to include: "A planned vaginal birth of a single breech fetus may be considered in some situations."

Mission Hospital supports vaginal twin births as long as baby A is head down and require twin birthing moms labor and birth in the operating room in case a cesarean is needed. If baby B is breech they will do what is called a "breech extraction" and expedite the birth by pulling on the baby's feet. Most OB practices in town are supportive of VBACs (vaginal birth after a cesarean) after one prior cesarean where the scar is transverse on the lower uterine segment, as long as it has been 18 months since your surgery and the placenta is not located on the incision site.

We are lucky to have many home birth midwives in our area who have sought out breech, twin and VBAC experience, training and workshops and are skilled in offering vaginal breech births, vaginal twin births, and vaginal birth after cesareans. 

Home birth midwives can share their experience, training and comfort level with these variations of normal and discuss if they will offer home birth for your unique case. Only you can decide what feels safe to you and where the ideal place is to birth your baby. 

Resources on VBACs: www.thevbaclink.com/vbac-facts/  www.vbacfacts.com

Resources on breech vaginal birth: www.breechwithoutborders.org

Home birth costs range based on the type of midwife, their experience, and whether or not they work in a team or with an assistant. The average global fee for home birth services (all prenatal care, on-call time, labor and birth support and postpartum care) in the Asheville area is $5,500-$7,500.  

Due to lack of licensing for CPMs and low reimbursement rates for CNMs, we currently do not have any home birth providers in the Asheville area who takes insurance. However, some providers are able to receive Health Savings Account (HSA) funds to pay for services and some providers can be reimbursed for home births if clients have Christian HealthShare plans like Samariran Ministries. 

We are so lucky to have so many different home birth midwives and providers around the Asheville area. 

Certified Nurse Midwife (CNM) options:

• Ellie Lee, CNM currently takes a small number of clients, mostly repeat clients within 45 minutes of Asheville. 
• Melissa Poole, CNM currently offers midwifery consultations. including well-women and gyn care, pregnancy and birth prep, contraception support, and birth ready and breech bodywork. She is slowly starting a home birth practice but will only be taking one client per month. You can inquire about her availability and book sessions with her through Flow of Life. She also has a portable ultrasound for position checks and early pregnancy confirmation.
• Jude Wrzesinski, CNM is now retired. 

Obstetrician and Doctor options:

• Dr. Graeme Potter, MD (OB) has a home birth practice called Dogwood Wellness. She is located in Sylva and serves home birth families west of Canton. 

CPM, direct entry and traditional midwife options:

• Given the legal climate for non-CNMs in NC, these midwives are a bit harder to find and are not listed online. However, is a robust community of midwives and traditional birth attendants in WNC and Asheville who support families autonomy and celebrate their decisions to birth at home with midwives, regardless of licensure. 
• You can contact me if you are home birth curious or are pregnant and looking to connect with a home birth midwife in the area. 

Send me a message if you want to talk more about home birth midwifery options in the Asheville and WNC area. 

You can also join the Facebook group "NC Homebirth Community" to get connected to other families choosing home birth and to find a midwife. I am an admin for this group.

I am passionate about families finding the midwife who feels like the best fit for your values and birth desires, and I love talking about the home birth midwife options in our area. 

I am well connected with the options and offerings, and I am happy to share more of my personal offerings when you reach out. 

I love offering home birth midwifery option consultations to help educate families on different care providers and if home birth feels right to them. Send me a message if you want to learn more about home birth midwifery support options in the WNC area.