Midwives without nursing degrees risk prosecution

By Michele Munz
ST. LOUIS POST-DISPATCH
Sunday, Jan. 20 2008

Missouri, Illinois drive midwives underground • First of two parts

Kris’ husband, Bill, is setting up a round, 2-foot-deep tub between the living and dining rooms, next to a bookshelf with pictures of their two sons and their Halloween artwork. The boys are asleep in their room.

The house is dark, only a soft glow breaks through from the kitchen. Kris doesn’t want any distractions, just her husband’s confident eyes and familiar smell.

And that’s the way it should be, the midwife says — the mother is in control.

As a few hours pass, the midwife and her apprentice patiently wait in the kitchen, chatting and sipping coffee. They let Kris quietly labor with her husband in the living room, only interrupting to check the baby’s heartbeat, or to get her to drink some water and nibble on cheese and crackers.

The midwife brought a handful of items, such as an umbilical cord clamp, scissors and a knit hat for the baby, laid out on a sterile pad on the dining table. She also has an infant resuscitative bag and mask and oxygen tank, just in case.

Her gray hair pulled back in a pink bandanna, the midwife, 61, has a calming, self-assured presence. She doesn’t time contractions or check how much Kris’ cervix is dilated. She won’t tell Kris when or how long to push. That’s for her to decide.

More than four hours pass. The midwife relieves Bill so he can get a little rest, and sits next to Kris on the couch. Kris hasn’t said a word, focusing all her energy on her labor. She moans every couple of minutes when she feels a contraction. But now, the moan becomes more of a wail. The midwife senses Kris is tiring.

“This is hard, but you’re doing it,” the midwife says. “Just allow the contraction to come over you. Let your body open up to the baby.”

The midwife is breaking state law to help Kris. If the midwife were arrested, she would be charged with a felony. Midwives say birth can be an empowering experience that is safer for most women if allowed to occur naturally, instinctively. Kris had a Caesarean section with her first child, and anesthesia left her feeling ineffectual with her second.

Not this time.

“Don’t be afraid now,” the midwife says. “This is what you’ve been waiting for.”

A MATTER OF CHOICE

The midwife is part of an illegal underground network in Missouri and Illinois helping women have babies at home. The two states are among 13 that prohibit or outlaw midwives without nursing degrees. But parents face no penalties for using them.

Midwifery is a tradition that goes back centuries, whereby women support each other through pregnancy, birth and early infancy. Much of that tradition was born out of necessity, when there were few doctors and even fewer hospitals.

Today, midwives serve on the front line of a different kind of reproductive choice made by more than 37,000 women in the United States each year. These mothers seek an intimate and empowering birth experience that is gentler for their babies — away from the hospital world of scheduled births, drugs and medical interventions that are becoming more routine.

Midwives, advocates say, build a deep relationship with their clients using a holistic approach that results in healthier moms and babies. Midwives set aside an hour for each prenatal visit. They stay with the mother throughout labor, and check on moms and their new babies at least six times in the first three months after delivery.

“The biggest aspect of good prenatal care is education, but education takes time, and it takes developing a relationship between the midwife and the family,” said Dr. Laurel Walter-Baumstark, a family physician in Hermann, Mo., who has worked with midwives and sits on the board of the National Association of Birthing Centers. “There is just no better model of preventive maternity care than the midwifery model.”

Midwives, and the mothers who turn to them, see birth as a physiological process, one that becomes increasingly dangerous as one medical intervention leads to another. Doctors typically have a more clinical view, and often rely on medical devices, drugs, anesthesia or surgery to facilitate birth.

Medical interventions are on the rise. The rate of labor inductions in the U.S. has more than doubled since 1990 to 22 percent. The 2006 rate of births by C-section has reached 31 percent, the highest ever. But the Centers for Disease Control and Prevention says it can find no medical reason to justify the increases and says the interventions are not producing better maternal or infant health outcomes.

“The medical system is on its own horse. It’s a train with no brakes,” said Susan Hodges, president of the Citizens for Midwifery. “Maternal and newborn health is not the measuring stick for care. It’s how much money am I losing, and will I get sued if I do this?”

The rising rate of medical interventions needs to be looked at critically, said Dr. David Redfern, an obstetrician in Springfield, Mo. But the answer is not easing restrictions on who can deliver babies or abandoning hospitals, he said, adding that safety, not money, is a doctor’s primary concern.

“It makes sense to utilize midwifery services,” said Redfern, who testified against midwives in legislative hearings last year. “But how we get there is very important, and we have to take patient safety into consideration.”

After almost 20 years of legislative debate, midwifery was legalized in Missouri last summer, when Sen. John Loudon, R-Chesterfield, inserted a vague clause into a larger bill. A circuit county judge, however, ruled that legislative procedures were not followed and struck down the law, which has been sent to the Missouri Supreme Court on appeal.

Whatever the outcome, midwife advocates and doctors promise another showdown this legislative session over a more comprehensive bill that would license and regulate midwives.

In Illinois, legislation to legalize midwives was passed by the Senate for the first time, after amendments were added that required some college education. Advocates have high hopes for a compromise in the House.

“We’re going to continue to pursue this bill until the competence of midwives is assured for young mothers — that’s it,” said state Sen. William Haine, D-Alton, whose wife has had five babies at home.

‘THE BIONIC WOMAN’

Hiring a midwife for her first pregnancy intrigued Jenny Morrison, but as a science teacher at the St. Michael School in Clayton, she needed to see the facts first.

So she and her husband, Sean Masicott, took months to read books and medical articles, search websites and watch videos. They were more than halfway into the pregnancy when the couple decided to birth at home with a midwife instead of continuing with their obstetrician.

“We wanted to make sure it was safe and the right choice,” said Jenny, 33.

Midwives in Missouri and Illinois get their clients through referrals from a trusted source. They typically handle two births a month and get paid $1,500 for their time. Secrecy is essential, which is why the midwives have asked that they not be identified. Jenny found her midwife — the same one Kris hired — through her doula (a labor coach).

The midwife apprenticed for four years under two illegal midwives. During her training, she observed about 150 births and learned how to manage wrapped umbilical cords, stuck shoulders and excessive bleeding. A midwife now for three years, she has delivered about 50 babies, including some over 10 pounds, some more than three weeks overdue and some from mothers with C-section scars. Her specialty, she says, is suturing small tears in the perineum, where her experience as a seamstress comes in handy.

She was called to Jenny’s home in Edmundson around 5 p.m. on Sept. 11.

As the birth grew near, Sean was in a birthing tub with his wife, so close he could almost feel her pushing, he said. “I was just so happy to be next to her, to see how strong she was.”

It was a difficult birth, Jenny recalled. She pushed for nearly an hour. The midwife felt the umbilical cord wrapped around the baby’s neck. She had Jenny get on her hands and knees and lift one leg. That allowed the baby’s shoulders to come loose and tumble out of its cord.  The new mom scooped up her baby girl in the warm water. It was a joyous and peaceful moment, she said. It was exactly what she wanted.

“I felt like the bionic woman,” Jenny said. “I was completely exhausted, but I felt a sense of pride I never felt before.”

The midwife hears this and nods. Her first child was delivered more than 30 years ago by forceps while she was unconscious. Her second child was delivered in a drug-induced haze.

Birth was something scary and dangerous, she thought. Her outlook changed after she joined a breast-feeding group when she was seven months pregnant with her third child. The women described their births as wonderful and satisfying.

The midwife hired a rare doctor in north St. Louis County who performed home births. She labored for 28 hours at her suburban home. She wasn’t rushed, and she remembered nearly ever detail.

“That’s why I’m breaking the law to do this,” she said. “Women need to get their power back.”

It’s why she is willing to live on-call, getting pulled away from her grandchildren’s birthday parties or dinner with friends. She puts aside her own worries, like her husband’s ailing health. She must be calming and positive for her clients.

Yes, she says, there have been close calls, though they are rare. She recently had to resuscitate a newborn who wasn’t breathing. She called 911 and regained a heartbeat before the paramedics arrived. The baby was fine, but the paramedics knew she was working as a midwife. She feared what might come of it. So did her husband.

“Every time she walks out the door, I wonder, ‘Is the next time I talk to her going to be in a jail cell?'” he said. “It petrifies me.”

Jenny appreciates the midwife’s risk. She feels lucky to have found her.  “It was the most amazing experience,” the new mom said. “I’m so proud of myself for doing it, and I wouldn’t have been able to do it without her.”

DEBATE OVER SAFETY

The technical term is direct-entry midwife — midwives who lack nursing degrees.

Most are trained by an experienced midwife through an apprenticeship, usually three to five years. Others attend one of the 10 midwifery schools approved by the U.S. Department of Education. They are suppose to handle only low-risk pregnancies and transfer care to an obstetrician or hospital when needed.

Many midwives now earn a national certification in out-of-hospital births known as the Certified Professional Midwife, which was developed in the early 1990s. Since its creation, 22 states have passed laws using the credential or its testing equivalent as the basis for legalizing and regulating midwifery. Two other states use a different test.

The 24 states that regulate midwives do so with little controversy. Still, Missouri and Illinois doctors groups say expectant mothers aren’t safe under a midwife’s care. They believe the midwife certification is inadequate, and some emergencies can’t be dealt with quickly enough during the lag time from home to hospital.

Dr. Rodney Osborn, an anesthesiologist and president of the Illinois Medical Society, said the apprenticeship model doesn’t provide midwives enough experience in deciding when a mother is safe to have a baby at home.

“Even in the best of hands and in the hospital, things still go wrong,” Osborn said. “You need the best of trained people to manage those issues in order to have good, safe result for mom and good, safe result for baby.”

Advocates point to the most rigorous study of home births with Certified Professional Midwives published in 2005 in the British Medical Journal. Researchers reviewed the outcomes of more than 5,400 births in Canada and the United States, including those transferred to the hospital.

Researchers found significantly lower medical interventions with births supervised by midwives. Mothers also were highly satisfied — less than 2 percent said they would choose another type of caregiver next time.

But such statistics can’t tell the whole story, said Dr. Gordon Goldman, the Missouri section chair of American College of Obstetricians and Gynecologists.

“Most of the time, they are going to get away with” a midwife birth, Goldman said. “But when (a death) happens — even if it’s one in 1,000 — it’s 100 percent for you and your baby.”

Those in the medical field are divided about whether midwives are safe. The American Public Health Association, the world’s largest organization of public health professionals, advocates increased access to out-of-hospital births attended by midwives. The World Health Organization says midwives are the most appropriate care provider for low-risk births.

“The real issue for the people of Missouri is not safety, it is the freedom and right of women and their families to choose the kind of birth best for their own needs,” said Dr. Marsden Wagner, former director of women’s and children’s heath for the World Health Organization.

While 99 percent of all births in the U.S. occur in hospitals, states need to recognize that some parents are going to choose home birth, said Katie Prown, a midwife advocate who helped draft legislation that legalized midwifery in Wisconsin and Virginia. “So what can we do to make it safe?”

The debate has changed dramatically in the past few years, Prown said, with grass-roots efforts winning broad bipartisan support over the medical lobby.

“We’re at a tipping point in midwifery legislation in the United States,” she said. “Twenty years ago, physicians could just walk in and say, ‘This is not safe,’ and that’s all it took.

“It’s different now.”

A LIMITED OPTION

Doctors say a system already exists for women to have a home birth in Missouri and Illinois: Midwives with a nursing degrees. But non-nurse midwives say they only want training in pregnancy and home birth, not nursing degrees with hospital training.

Access is also a problem. There is only one nurse midwife in Springfield, Mo., and four in northern Illinois who have home-birth practices.

Cindy Bernard, a nurse midwife for 31 years who had a home-birth practice in the late 1980s, blames several factors: few nurse-midwife degree programs and more lucrative job opportunities. And, Bernard said, a nurse midwife must have a signed collaborative practice agreement with a physician who agrees to work with the midwife in some capacity. Many doctors refuse to sign.

“(Nurse midwives) are choosing a different kind of practice because they can, rather than spending 24 hours a day, seven days a week on call,” said Bernard, who now works triage in the women’s evaluation unit at St. John’s Mercy Medical Center.

While there are few other options for non-hospital births, direct-entry midwives shouldn’t be allowed to practice just so that a mother can have a child at home, said Goldman, an obstetrician for the past 33 years.

“So what should we do? Dumb down the process so you have a choice?” he said.  “What about the fetus’ choice?”

AT THE TRAILER

An underground midwife from Illinois drives her 16-foot trailer to a St. Louis-area park once a month. She started using the trailer as her office after driving to women’s homes for prenatal visits became too inefficient.

She said she feels safer in Missouri than in Illinois, where several midwives have received “cease and desist” orders from the state medical licensing department.

The 52-year-old has been a midwife for 14 years. She apprenticed with two midwives for three years. She never graduated from high school.

She delivers about four babies a month, which some midwives say is too much. She acknowledges her time is stretched because of the workload. She has even missed some births, but she says she can’t turn anyone down.

“Where else are they going to turn?” she said.

The Illinois midwife has delivered about 425 babies, including 10 sets of twins and 15 breech babies — her specialty, she says.

Nearly all breeches are delivered by C-section because of the potential dangers. A 2000 study concluded surgery was safer, but recent reports suggest certain patients may have safe vaginal deliveries with caregivers experienced with breeches, though few are.

The pregnant women coming in and out of the midwife’s trailer stretch out on a bench seat while she stoops to feel their bellies. They urinate in a cup in the closet-size bathroom and step outside to weigh. They lament that they must do this in secrecy to protect their midwife.

Laura Asher, 27, a preschool teacher from Alton, said she wishes midwifery was more mainstream. She delivered her second son, Oren, at home with the Illinois midwife and her apprentice on Nov. 28.

“It was really just very peaceful, loving and warm, and I was really impressed with what the midwives did,” she said. “I’m really thankful I was able to bring my baby into the world in that way.”

The Illinois midwife says she doesn’t think about how she could be charged with a crime. A woman’s birthing needs are foremost on her mind. “When you’re speeding,” she said, “you don’t think of getting a ticket.”

‘YOU DID IT’

“Stay the course. This is hard, but you’re doing it,” the midwife tells Kris, now in the most difficult phase of labor.

Kris gets into the tub, equipped with a heater to keep the water warm. The temperature and buoyancy are soothing. About 15 minutes later, the midwife notices a twinge in Kris’ grunting.

“That sounded pushy. Are you feeling like you’re wanting to push?” the midwife says.

“Yes,” Kris answers, the first word she has spoken in hours.

The midwife pulls on latex gloves and sits at the edge of the tub. Her apprentice shines a flashlight into the water. Kris is kneeling, hanging over
the side, facing her husband, who is kneeling on the floor. Their arms are wrapped around each other. She starts to cry. “You’ve done such amazing work, Kristen,” the midwife says. “It won’t be long now.”

Only Kris’ mother, who died 10 years ago, called her by her full name. It gives her strength.

At 5:35 a.m., the contractions are coming faster. She squeezes her husband.   “You’re doin’ it, baby,” he tells her. “Come on, breathe.”

The midwife has her lift one knee to open her pelvis. The baby is close. She asks Kris if she wants to feel her baby’s head. Kris doesn’t reply.

“I feel your baby’s head, cheeks,” the midwife says. “You’re easing that baby out. I feel a little mouth, touching lips.”

The shoulders come free. “There’s your baby,” she says softly. “Reach down, and grab your baby.”

Kris is the first person to pick him up. She meets his dark eyes and pulls him to her chest. She leans against the edge of the tub and gently strokes his dark hair. The midwife keeps a watchful eye, gently splashing warm water on his tiny body. The baby lets out little coughs but barely cries. “You did it,” Bill tells her. “You did it exactly like you wanted.”

Kris gets out and showers while Bill holds his new son. His name is Drew. Using a fish scale, the midwife weighs him — 7 pounds, 6 ounces.

She spends two more hours at the house, cooking scrambled eggs, cleaning and completing her notes. She packs her equipment in a rolling suitcase. She leaves Kris with a list of things to look out for, like excessive bleeding or if Drew catches a fever.

The midwife hugs Kris and tells her how amazing she was. The midwife will be back tomorrow to check on the family.

As always, she has her cell phone in her pocket, waiting for the next call.