Physician and Midwife Groups Forge Unprecedented Alliance in Idaho

FOR IMMEDIATE RELEASE: Wednesday, April 1, 2009

Idaho Pushes Midwife Movement to the Tipping Point
Physician and Midwife Groups Forge Unprecedented Alliance as Idaho Becomes the
26th State to Pass Legislation Legalizing Certified Professional Midwives

BOISE, ID (April 1, 2009)—Governor C.L. “Butch” Otter signed into law today a bill to license and regulate Certified Professional Midwives, making Idaho the 26th state to legally authorize them to provide out-of-hospital maternity care.

In a notable reversal of longstanding anti-midwife policies, medical groups worked together with legislators, midwives, and advocates to reach consensus on a law that provides for independent practice, mutual collaboration, and the rights
of parents to choose where and how their babies are born.

“This is a great day for midwives and home birth advocates all across the country,” said Kyndal May of Idahoans for Midwives. “We truly have reached the tipping point, breaking through the medical lobby’s longstanding opposition and
developing a legislative consensus model that other states are looking to follow.”

Certified Nurse-Midwives (CNMs), who practice primarily in hospital settings, are legally authorized in all 50 states, while Certified Professional Midwives (CPMs), who specialize in out-of-hospital birth, until today were legally authorized to practice in just half the states. Representatives from The Big Push for Midwives Campaign noted that Idaho typifies recent legislative trends across the country, as a growing number of states come closer to passing CPM legislation.

“We’re seeing unprecedented advances this legislative season,” said Katie Prown, Campaign Manager of The Big Push for Midwives. “For the first time, physician groups are coming to the table and negotiating in good faith, and bills that
had long been stalled in previously antagonistic committees are suddenly starting to move.” States that have recently seen significant legislative advances include South Dakota, Indiana, Illinois, Iowa, North Carolina, and Alabama. Idaho joins Missouri and Maine as among the most recent states to legally authorize CPMs to provide maternity care.

“It’s clear that organized medicine has finally realized that, between current economic trends and the drive for healthcare reform, the demand for access to CPMs and out-of-hospital maternity care is only going to grow,” said Susan
M. Jenkins, Legal Counsel for the Big Push. “It simply makes good sense to pass laws that provide for regulatory oversight, transparency, and accountability, all of which are necessary to ensure safe practice.”

Thousands of people from across the nation watched the Senate floor vote on live video from the Idaho statehouse last week, cheering on their fellow midwife advocates on Facebook, Twitter, and email groups. “It’s very exciting to be part of
a growing national movement,” said Michelle Bartlett, CPM, Legislative Liaison for the Idaho Midwifery Council. “I’m humbled to hear from so many advocates in other states who are looking to us as a model for how to work with every
stakeholder to craft CPM legislation that addresses the needs and concerns of all of us who care about the health and safety of mothers and babies.”

Idaho is a priority of The Big Push for Midwives Campaign, a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to forge a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low-birth weight and premature births.

Physicians group out of step as Health Care Organizations supporting CPMs increases

WASHINGTON, D.C. (February 17, 2009)—Two major health care organizations have joined the growing number of groups calling on policy makers to increase access to Certified Professional Midwives (CPMs) and out-of-hospital maternity care. Acknowledging the large body of evidence supporting the safety of home delivery with CPMs, who are specifically trained to care for mothers and babies in out-of-hospital settings, nursing and perinatal health care organizations criticized the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) resolutions calling for bans on CPMs and home birth. The groups also joined Consumer Reports magazine in highlighting the need for a major overhaul of the U.S. maternity care system. “I am very proud to be an American, but I am embarrassed that our country, founded on the ideals of individual liberty and freedom, can also support ‘authoritative’ initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies,” said Nancy K. Lowe in an editorial published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). “What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services.” Consumer Reports magazine cited the desire for economic gain as one of the driving forces limiting access to CPMs and Certified Nurse-Midwives (CNMs), who are licensed in all 50 states and practice primarily in hospital settings, but who remain subject to anti-competitive regulations promoted by the AMA and ACOG. CPMs are legally authorized to provide out-of-hospital care in just half the states, while advocates working to reform the law in the remaining states face stiff resistance from physician groups seeking to establish a monopoly on the maternity care market in the U.S. “Midwives provide a safe and cost-effective alternative to the current model, where the market is dominated by high-cost, high-tech specialists producing less-than-optimal outcomes,” said Katie Prown of The Big Push for Midwives Campaign. “Babies delivered by midwives are far less likely to be pre-term or low birth-weight, which are two of the leading causes of neonatal mortality and of the enormous costs associated with long-term care. Midwives and out-of-hospital birth are an integral component of responsible health care reform, and the AMA and ACOG know this. That’s why they’re fighting so desperately to protect their turf, even if it means denying women maternity-care options in the process.” The National Perinatal Association (NPA) added to the growing list of organizations calling on the AMA and ACOG to end their vendetta against midwives and home birth and instead follow the World Health Organization’s (WHO) call to “‘work in a spirit of recognition and respect for each other’s authority, responsibility, ability and unique contribution.’” The Big Push for Midwives is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to build a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low birth-weight and premature births. Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

ACOG State Legislative Update–Who’s afraid of a few “lay” midwives?

The ACOG recently published their yearly state legislative update. The main topic was those troublesome ‘lay’ midwives and home birth. While the document is full of the typically misinformed information and erroneous assumptions about midwives, it has the flavor of someone who is afraid–very afraid. Let me quote from the document and set the record straight.

The report first mentions that home birth bills are on the rise in states across the country, fueled by state midwifery guilds and MANA (Midwives of North America) and its credentialing organisation, NARM (North American Registry of Midwives). It complains that because of Republican majorities in states and the crafting of a model bill by The American Legislative Exchange Council (ALEC) that many of these bills are not only being introduced, but passed. They are afraid of the trend of conservative lawmakers who lump home schooling and home birthing together.

Interesting…I home schooled my children back in the day when we were considered pioneers and many states still considered us lawbreakers. The question of the day was “what kind of quality education could they possibly get?” and “what will you do about socialization?”. Funny, no one asks those questions much anymore. Home schooling has been around long enough now for people to see the fruit, and the educational outcomes from many public schools and accompanying issues with negative peer pressure has made many a doubter look longingly over to the other side of the home school fence. Perhaps home birthing will enjoy the same awakening if enough people buck the system to embrace birth as a normal event?

To quote again from the document: “The ‘lay midwives’ internal philosophy on state regulation and licensure appears to have shifted. In the past, their position on licensure reflected the dominance of midwives who did not want to be regulated, opposed state licensure, and defended within their individual guilds the right to stay unlicensed and practice underground. While there are midwives who still do not want to be regulated and who do not support the current licensure campaign, for the most part you don’t see them speaking publicly against licensure in the legislature or elsewhere. Even the nurse-midwives no longer can be counted on to speak publicly against home birth or lesser trained midwives.”

Excuse me while I take a moment to laugh out loud at this one. Even the nurse-midwives have turned coat and can’t be counted on to speak out against home birth? Maybe a good portion of them are simply tired of following obstetrical authoritarian’s non-evidenced based protocols and have had enough of a glimpse over the fence at the outcomes of their home birthing sister midwives to just decide not to say anything at all. Some of them have home birth practices of their own. I recently attended a Christian midwifery conference and there were midwives in attendance of every persuasion–‘lay’ midwives, CPMs, CNMs, whatever you call yourself. No one wore a name tag with their credentials, just our names. You know what sifted to the top? Not a title—wisdom (experience+knowledge), knowledge, skill. No matter what your title, you learned a few new things from someone who had put something solid into practice and knew that it worked. CNMs learned from CPMs and vice versa. It was quite refreshing.

Next point in the ACOG document says: “The term direct entry is used to refer to midwives who enter the profession of midwifery directly without earning a nursing degree. Both certified professional midwives (CPMs) and certified midwives (CMs) are considered direct-entry midwives, although their level of education and training varies markedly. CPMs are largely self-taught and their training is typically through aprenticeship. CPM was the title chosen by MANA and NARM in the mid-1990s for their credentialed direct entry midwives. By comparison, CMs must undergo three years of university-affliated training, and while there is no nursing prerequisite, these direct-entry midwives must complete the same science requirements and sit for the same certification exam as a nurse-midwife. ….More states are adopting the CPM credential as a requirement for midwifery licensure, and not the CM credential which both ACOG and ACNM recognize. Of the roughly 21 states that license midwives to attend home births, all use the CPM credential. By their lack of training and because they do not work collaboratively with hospital-based obstetric providers, CPMs are the least qualified midwives to attend a home birth.”

So much is wrong in that one paragraph, I hardly know where to start. True that all midwives who enter the field without first becoming a nurse are called direct entry. It is odd that both the ACOG and ACNM recognize and approve of this route, as long as you can pass the certification exam and will work collaboratively with a hospital-based obstetric provider (can you say CONTROL?). But if you get an equal didactic education somewhere other than their own hallowed halls and your clinical experience occurs in a home birth setting, then you are seen as decidedly inferior. Anyone who calls the process to become a CPM a ‘lack of training’ has not actually seen the hoops you must jump through, nor understood the knowledge required to pass both the clinical and written exams. In this situation, I think ‘lack of training’ can be interpreted “we can’t control them!”. And the last time I looked, CPMs and CNMs were using many of the same textbooks to obtain their education. Much has been said about the apprenticeship model recommended to receive the clinical training necessary for certification as a CPM. Because a physician must go through an internship before he/she is allowed to practice independently, I fail to see much difference. Both models offer the opportunity for hands-on experience under the supervision of a person with infinitely more experience and knowledge. It is an ideal way to learn how to apply your book knowledge into practical terms. They call it internship, we call it apprenticeship. A rose is a rose is a rose.

“To bolster their case for licensure, midwives like to cite European countries’ experience with midwives and home birth. This may play well with an uninformed public, but the analogy is flawed. The conditions that make home birth relatively safe in some countries–the Netherlands for example–do not pertain to much of the US. The Netherlands is a geographically small, densely populated country where everyone lives within 20 minutes of a hospital.”

Very misleading statement! Yes, it is a small, densely populated country, but everyone does not live within 20 minutes of a hospital, as reported. The hospital situation in the Netherlands is not at all like the US. There is not a hospital in every town, and even in towns with hospitals, because of the dense population, the traffic alone sometimes prohibits speedy arrival at a hospital. Most are operated by the government or universities, not privately owned, so there really aren’t that many hospitals. Every city and village doesn’t have a hospital, yet the Netherlands enjoys a MUCH better infant mortality rate than the US. Most of their births occur in their homes and are attended by non-nurse midwives because they treat pregnancy and birth as a normal event, not a medical emergency. Usually only the high risk pregnancies are encouraged to birth in their hospitals with obstetricians. Hmmmm, OK so if home birth is safe in that country only because they live so close to a hospital and we’ve blown that theory out of the water, we’ll have to assume their statistics are better than ours for other reasons. Could it be that perhaps if you treat birth as a normal event and you don’t induce, augment, confine, over-monitor and otherwise harass a laboring woman, things just might work better? That would be a hard one for the ACOG to swallow.

“In their recent testimony to state legislators, midwives have been citing a 2005 study on the safety of home births by direct entry midwives in the US. (Johnson KC, Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330;1415) This study concluded, “certified professional midwives achieve good outcomes among low risk women without routine use of expensive hospital intervention.” ACOG continues to assert that studies comparing the safety and outcome of births in and out of the hospital are problematic, not scientifically rigorous, and unconvincing.”

In other words, they see the proof, but they just can’t wrap their minds around it. They believe what they want to believe.

“…in Missouri, ‘lay’ midwife bills get introduced year after year. These bills have been stopped–up to now–mainly by deft political maneuvering and hardball tactics employed by the State Medical Society, not by any persuasive testimony about comparative safety or quality of care.”

Quite an admission, wouldn’t you agree? They go on to discuss how nurse-midwives have previously been their front-line defense against these bills, but now they are a fickle ally. Maybe there is a growing respect between the two sets of professional women, in which the knowledge each possesses is no longer mistrusted.

“Physician back-up for midwives and out-of-hospital deliveries is a growing concern in some states. …In 1993, California licensed midwives to do home deliveries under physician supervision. But implementing regulations for the 1993 law were only recently finalized after years of wrangling over key issues including the physician supervision requirement in the authorizing legislation. Medical liability insurers in the state were refusing to cover physicians who back-up midwives and midwifery proponents in the legislature threatened to waive the requirement for physician supervision altogether.”

It was the ACOG who got the requirement for physician supervision thrown in at the last minute. With the liability insurers already refusing to cover physicians who backed up midwives, it created a situation impossible to abide by for CA midwives. Or was that the idea….?

It’s slightly amusing that this review refers to legislative handbook developed by MANA as being full of “lobbying advice, tactics and propaganda”. Is everyone aware that the ACOG is basically a lobbying organization for the advancement of obstetricians and gynecologists? Isn’t this a little like the pot calling the kettle black?

Lastly, the document mentions the problem of hospitals refusing to do VBAC (vaginal birth after cesarean) deliveries as being one of the reasons many women are seeking out other alternatives, including home birth with midwives. The most up-to-date studies all support VBAC attempts as being the safer approach to subsequent births in the majority of situations. Yet hospital after hospital have closed out this option, choosing to bow under the pressure of regional medical standards and insurers demands, rather than evidence-based studies. What are women to do who don’t wish to undergo major surgery to birth their babies again, especially when the number of primary unnecessary cesareans is so unreasonably high? They go to the only sane choice available–they turn to highly skilled, highly educated home birth midwives.

Honestly? They sound a little worried.

Carla Hartley, a hero in the birth community

Just got back from the Trust Birth Conference in Redondo Beach, CA late last night and this is all fresh on my mind.  As a practicing midwife in an illegal state and serving a portion of the state where there are no other practicing midwives, it can get a little lonely.  Sometimes you feel there are more holes in the dike that you have fingers to plug up and opportunities for fellowship with others who truly understand are limited.  Educational opportunities for those who don’t live near an on-site school are limited also.  I’ve had to pay for and travel to places far and wide to learn new skills for the lack of an experience preceptor.

But over 25 years ago, a woman obviously called by God for such a purpose, set out to simply provide for the education of her own apprentices, but ended up founding a distance learning program that has the reputation of being one of the toughest, yet best in the nation.  She did so to her own detriment, often forfeiting her own financial well-being, sleep and reputation, just because she believed so strongly in the purpose of promoting more midwives who believed in birth and trusted it.  Not that we were to approach it with ignorance, but with knowledge and confidence.  Without her, I would not have been able to afford a quality midwifery education.  It wouldn’t have even been an option with my location.

Carla has again provided me with an opportunity to mingle with some of the biggest and brightest stars in the birthing community.  I’m so full right now, it’s hard to articulate.  I met, ate, shook hands, hugged, conversed, shared, listened to, took pics with, rode in vehicles with….names that only formerly resided on the covers and pages of books, magazine articles and research studies.  Now they are faces I know.  I also met fellow AAMI students and relished in getting the know the personalities and faces behind the names I only previously knew from online study groups.  Thank you, Carla, for the opportunity of a lifetime.  Thank you for caring enough about your passion to put yourself out there for either praise or criticism once again for not only MY benefit, but the benefit of a cause bigger than both of us, and more important to humanity than ever before.  Time will hopefully prove that you are truly a hero for our times.

Heather, we must have been in some of the same workshops but I didn’t get to meet you in person.  I wanted to feature your lovely drawing from Dr. Michel Odent’s workshop on whether our culture can survive the current cesarean epidemic.  He warned us that we need to learn to ask the right questions.  Because medicalized and medicated births, along with our current cesarean rate completely obliterates the beautiful hormone release that was meant for the bonding of mother and child, we need to be asking ourselves what the effect of several generations of birth without the influence of love hormones may be doing to our culture.  Here is Heather’s current drawing and a link to her blog.

Loved what Karen Strange had to say during the neonatal resuscitation course:  “Birth was meant to work as if no one else was there.”  YES!

Enjoy the panel on shoulder dystocia and the acronym, BREATH:  Breathe…panic is your worst enemy.  Calm yourself down and think.  Reassure the mother and those present (including baby), Exam, for position.  Assess, to see if there is something obvious that is holding baby up, like arms pulled toward baby’s back.  Turn, depending on your assessment of situation, move mother, then move baby if unsuccessful.  Help, the baby out.

Dr. John Stevenson:  met this precious physician from Australia who was “deregistered” from his livelihood as a doctor for practicing homebirths and continued to attend them for years to come because he saw something in these births he had never really noticed or seen too much in the hospital births previously…the lovely scene of bonding that we who catch babies get to experience again and again.   A mother and baby awashed with hormones meant to bond them for life.  Once you see it, you know…

Dr. Sarah Buckley:  her article on Ecstatic Birth and chapter 13 from her book, “Gentle Birth, Gentle Mothering” are the basis for an entire session in my childbirth classes.  It was wonderful to meet her in person, hear her lovely accent and learn even more from her workshops on the hormones of birth and prenatal testing/ultrasound.  Yeah?

Sheila Stubbs:  I didn’t get to attend Sheila’s workshop (thanks to Carla who provided so MANY terrific choices), but we rode to and from the airport together as we arrived and departed.  Sheila’s book, “Birthing the Easy Way” is one I highly recommend to clients who are sitting on the fence about homebirth.  Her wonderful sense of humor, practical analogies, personal stories and included facts and studies are a perfect combination to read.  She doesn’t understand the impact her book has made on so many lives, just seeing herself as a simple stay-at-home mother of many, but I hope after this conference she will know.  I SO enjoyed meeting you, Sheila.

Shonda Parker:  I didn’t get to attend her workshop either, as I had so many choices and since I am going to get to hear her in late April at the CMI conference, I just bought several of her books, including her newly updated “Naturally Healthy Pregnancy” and spent some time talking to her in the exhibit hall about the phase of our lives with learning to release our children into adulthood and how much we miss them when they leave.  You have a lovely presence, Shonda and I can’t wait to get to learn more from your books and workshops in April.

Rixa Freeze:  I love what you had to say about trusting intuition and the many examples of times when it proved to be the truth.  We need to learn how to separate our fears from real authoritative intuitive knowledge.  Thank you for being there and your work on these and similar topics for your degree.  And the Caramelized Pear and Toasted Pecan sounds yummy.

And for Carla:  The chance to finally meet you in person after only getting to know you through email and the phone was unforgettable.  I will never be able to thank you enough for the sacrifices you and your family have made.  History will prove you are truly a woman for our time.

The Trust Birth Conference

I’m going. This conference is sponsored by Ancient Art Midwifery Institute and Carla Hartley. She says it will be her last one and it is worth putting everything else aside to attend. Some of the biggest names in the birth community will be there. Dr. Sarah Buckley, Dr. Michel Odent, Dr. John Stevenson, Jan Tritten, Heather Cushman-Dowdee (Hathor, the cow-goddess), Rixa Freeze, Henci Goer, Mindy Goorchenko, Gail Hart, Ricki Lake, Gloria Lemay, Sheri Menelli, Shonda Parker, Karen Strange, Sheila Stubbs, Debby Takikawa, and many others. Everyone is talking about it…be one of the ones who gets to attend this life-changing event.

Click here for just one of the YouTube clips.  Friday sessions here.   Saturday morning here.  Saturday afternoon sessions here.  Sunday sessions here.

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.

Finally a place…

All my other blog sites have always been a mixture of personal, business, family, etc.  I wanted a space that was purely dedicated to all things birth and my involvement in it.  A place where I can rant about interventions, spread the news about new research, share the good experiences and ponder the more difficult ones.

I am a midwife.  In this journey I have learned much, but I never feel as if I have arrived.  I am on a quest for knowledge and don’t feel as if I’ll ever find the end of that path.  But each discovery only wets my appetite for more.

Today I had a prenatal visit with a mom who is slightly postdates.  While examining her I found instead of a head as a presenting part, an extremity instead.  But was it a hand or foot?  I felt distinctly each little knuckle, then followed their path to discover what was most likely fingers curled into a tiny fist.  Though it was through a thinned out uterus and sac, it was a sweet moment to be the first to shake hands with this new little person, yet unborn.  Let’s hope she moves her hand down and out of the way before labor ensues.  Soon I hope.