This blog has been a long time coming. Kind of like a three year metaphorical pregnancy, during which I have realized my initial stance on home birth was not only wrong but harmful to related women’s advocacy issues. I imagine I may not get positive reactions from some colleagues, after joining them in opposition to the home birth legislation—they may feel I have betrayed our common cause. I may also get annoyance from those in favor of the legislation, for having been so slow to come around. I am sorry. It is entirely my fault. I hope you will forgive me.
In short, there is no conclusive evidence that favors hospital vs. home birth in cases of low-risk. The training of certified professional midwives (CPMs) is rigorous. There is no imminent likelihood of our state doing anything substantial to address perinatal mortality or expand rural hospital/ prenatal care services. If the perinatal mortality rates in our poorest counties improved even slightly toward the average rates for home birth, because of prenatal care from midwives, we’d have a reason to celebrate. Most of all, I do not believe the duty of the state to a child can supersede a pregnant woman’s right to make choices about her own care, safe or not. In the end, it is simply not our decision to make.
I am in favor of establishing a Board of Midwifery in Alabama, according to the framework set out in SB 246 and HB 178 without amendment. I support the right of a woman to make her own decisions about her body. I apologize for my error in failing to understand the significance of a position on home birth and in failing to do a good job with my prior reading. That’s the short and sweet version. Because the underlying issues are complicated, I’m going to discuss them in parts, over several days. If you decide to argue differently, you might want to wait and read the whole series first, including the links.
A Field Trip
After hard re-evaluation and thinking, I decided I would speak in favor of these bills. For the sake of thoroughness, I also wanted to be able to describe for you what would likely take place in our state if we had certified professional midwives—not just the data but something more descriptive.
I contacted Hannah Ellis with the Alabama Birth Coalition, an all volunteer, grassroots organization advocating for healthy mothers and babies. As part of their intention to increase access to evidence-based maternity care in all settings, they support certified professional midwife licensure in Alabama. If you would like to sign their petition, as I have done, it is here. Similar efforts have been effective in other states, and I am impressed to have an example of citizens serving as advocates for their own needs—really driving the bus—rather than well known persons trying to steer a movement for others who aren’t even participating. This is what I’d like to see for single payer—the uninsured and underinsured getting seriously active and insisting on change.
Hannah kindly agreed to take me on a field trip to meet some midwives in person. She took a whole day out of her schedule for this, and I can’t thank her enough.
The first midwife I met was Tori Dennis. We didn’t know right up until the last moment if she would be available—one of her clients could have gone into labor. Unlike most physicians I know, she is on 24-7 call to the mothers in her care. She led us into the cozy, simply furnished living room, where she had set up some equipment as if it would be done for a home birth. There was an inflatable tub (with clean, individual liners) for pain relief in warm water during labor, and she had hurricane lamps lit to show me what it might be like in some of the homes without electricity. She had oxygen and a resuscitation mask/ ambu-bag ready. There was a portable tray with instruments set up on a sterile drape, ready to be moved quickly from room to room if needed.
In the bedroom, she had more sterile draping, a labor stool, a Swiss ball she said was good for positioning during labor, and 3 bags full of everything you could think of for a home delivery short of a ventilator. I half expected her to pull one out, by the time she was finished. Each bag had several plastic sleeves with organized contents—just to pick a few items, she had pitocin in case of hemorrhage, vitamin K shots, antibiotic ointment for the baby’s eyes, cord clamps, suction, a Doppler, and a fetoscope. The prenatal bag had test kits for group B strep and other infections, blood sugar monitors, everything needed to draw prenatal blood work, vitamins and more. The post-natal kit had cards for the routine newborn screening state labs, paperwork for registering the home birth and obtaining birth certificates. That’s just a few of the many supplies—I have not been able to think of anything missing.
Tori asked me if the setup was different from what I had expected, and I couldn’t answer—I really did not have any idea at all. I knew it would be different from Little House on the Prairie, but that’s about as far as I had gotten. It was very professional and well-thought out, especially the planning for situations both with and without electricity. She said the midwives had been called on to help in disaster situations, partly because they had experience doing medical work without electric power.
We sat down and she told me her story. She grew up in Pennsylvania, near an Amish community, and came from a background where home birth was normal. While getting her RN (magna cum laude) from the University of Pennsylvania, she had a “light bulb moment” seeing a 19 year old in the teaching hospital strapped down to the rails in labor and her baby pulled out with forceps by an inexperienced resident. It seemed barbaric, she said. The woman didn’t even know she was in a teaching hospital or that there were other ways babies could be born. This memory stayed with Tori after graduation, when she worked in a neonatal ICU. At that time, crack cocaine was in its heyday, and pregnancy could be complicated by abruptions of the placenta. She saw some of the worst things that could happen to disrupt healthy pregnancies and births.
Later, as an Army nurse, she assisted with the surgical aspects of women’s reproductive care. When she finished her military service, she and her husband just wanted some peace and quiet. They came to Tennessee and bought a farm. She had no particular plan to become a midwife. Then she heard about a nearby birthing center. She initially worked as an RN, with the certified nurse midwife (CNM) there, and then got her certified professional midwife (CPM) training so she could do home births.
Tori spoke of mothers with no running water or electricity, with holes in their floor and rats, and people using buckets for toilets. Mothers who paid her in vegetables and for whom she had to purchase Rho-gam injections out of her own pocket. She showed me a simple, hand-tied quilt given in payment by an Amish mother—not one of the expensive versions she could have sold. For these families, she was not just serving as a prenatal care source and a birth attendant but a public health nurse and social worker—she had to teach basic cleanliness practices. She talked about breastfeeding being even more vital in poor homes, where parents might mix powdered formula from WIC with creek water.
She told me about checking on a one month old Amish baby with RSV, who was in distress unrecognized by the family, and convincing them to let her take the baby to the hospital. She looked frustrated as she talked about the barriers to care in Alabama for families in similar circumstances, such as the Mennonite community. “We’ve got people going without any care at all,” she said. “Can we not stop arguing and just get them some help?”
She said about half her clients were Amish, poor Amish, not like the ones on television. Others were middle class or wealthy women, including physicians and lawyers, who had done research and chosen home birth. Some were past victims of rape or sexual abuse who could not face being examined by male obstetricians or the hospital environment where a male nurse might be on duty. Many others were just poor and could not get in with an obstetrician.
She has a verbal collaborative arrangement with a local obstetrician and she only takes low risk clients. For her, this means no drugs/ alcohol/ smoking, excellent nutrition (I can’t tell you how many times both CPMs I visited stressed nutrition), no chronic diseases, no first time mothers with breech presentations, no multiples, and VBAC (vaginal birth after c-section) only in very specific cases. For the higher risk clients, she would not abandon them—instead, she would provide prenatal care in collaboration with the obstetrician and be present as a doula during the birth. She uses her own car to pick up mothers without transportation for their ob appointments and to the hospital in labor. She has a low threshold for transfer to the hospital, although her transfer rate is only 2%. She felt the hospital should be no more than 20 minutes away and would arrange for an alternate home setting for a woman who lived further away.
Sadly, the birthing center where she first worked has closed. CNMs at birthing centers in Tennessee are required to be covered by malpractice insurance, and the rates had become too high. CPMs are not encumbered so for home births. Which brings up an important issue. One of the threatened amendments to Alabama’s legislation would force CPMs to carry malpractice insurance. This could be similar to the TRAP bills for abortion clinics, something that would prevent CPMs from practicing. I asked some of my ob friends about it. They are angry about the perception that a midwife could be involved in a problem delivery, transfer the baby to the hospital, and then walk away without being sued. They don’t perceive the waiver in the bills to be adequate for their protection, so they want to require midwives to carry insurance also. I heard some arguments that midwife insurance would protect the families themselves from financial disaster.
I disagree. I would lay part of the blame for our malpractice climate directly on the fact that we are now all heavily insured. Some patients feel like they are getting insurance money and will sue even if they are not so angry they want to take a doctor’s house or license away. They believe that money is there to cover their expenses, not necessarily as a punishment. Civil suits were supposed to replace shooting each other—I’d rather lose my house than get shot, if a patient is that angry. They weren’t meant to serve as a safety net. We could do that another way—single payer healthcare would be a start, plus no-fault medical injury compensation funds. We have messed up in creating this situation. I see no reason to foist our mistakes on another professional group.
I could keep going on about my visit with Tori—I spent a couple of hours talking to her. Basically it would just come down to her being a saint and wishing we had a whole bunch just like her in Alabama. I do not know if she is typical of her profession. I hope she is.
Next we drove to The Farm, an intentional community reminiscent of the 60’s, with a birthing center of international renown. I met with Carol Nelson, one of the midwives, in their prenatal clinic exam room. The walls were covered with all sorts of pregnancy and motherhood related art, mixed in with posters about newborn hearing screening and nutrition.
Although Carol also had good stories to tell me about home birth, I was most fascinated with her take on the political aspects. In Tennessee, midwifery was never against the law because it was set apart and not considered medicine. The midwives and mothers wanted to establish a Board of Midwifery partly to guard against the increasing trend to crack down on midwives in other states and partly to increase the quality of midwifery care from those who were insufficiently trained. Interestingly, the pediatricians, although they did not actively support the legislation, did not oppose it. The Tennessee Medical Association did lobby against it hard. In the end it passed with strong grassroots activism.
She told me how the licensure standards for CPMs came about. It was not a haphazard thing—they had job analysis done, to determine exactly what skills and qualifications were needed. The National Commission for Certifying Agencies (NCAA), created by the Institute for Credentialing Excellence (ICE) developed the CPM standards. It is an internationally recognized certificate. We trust the credentials of a broad range of other health professionals structured by the same agency. You can read more about the CPM credentials at the North American Registry of Midwives site. I’m going to talk more about training as well in a later segment of this series.
Carol talked about how midwives had helped bring about some of the changes in obstetric care now considered standard, like rooming in with the mother and an increased focus on breastfeeding. Midwives are participating at the highest levels of policymaking in healthcare, with the World Health Organization, which advocates for increases in the midwife workforce, the Institute of Medicine, and the American Public Health Association (APHA). APHA is strongly in favor of increased access to good quality out of hospital birth providers, including Certified Professional Midwives.
A Tennessee Pediatrician
To round things out, I thought I’d better contact a pediatrician in Tennessee who has cared for the infants resulting from home birth. I called Dr. Rufus Clifford, in Columbia, Tennessee. Dr. Clifford is on the Board of Midwifery.
He had nothing negative to say about the midwives at all and felt they were well accepted in the pediatric community. He mentioned that they had been quite helpful in providing home visits for newborns for families that couldn’t get to his office soon after a home birth, and that he felt very comfortable with their skills. When I pressed him to tell me about problems, he paused and said, “Well, they are awfully hard on each other. When they meet for peer review, they are just awfully hard and don’t cut each other any slack at all.” I don’t see that as a negative. Physicians could give each other a little more grief and do better for it.
It sounded to me as though the midwives were protective of their credential—they want it to stand for quality care, and they weren’t about to let anyone step out of line and put their profession at risk.
That’s it for Part 1, the longest segment of this series. I hope you will stay tuned tomorrow for Part 2, on safety.