Bring in the Midwife!

November 12th, 2007

Midwives resist standardized care

By Robyn Fiedler

With one hand pressed against her protruding stomach, Sabrina Dodge rests on a couch in Monica Daniel’s living room. Lifting up her large sweater without reservation, she continues talking about the terrible cab services in Ithaca.

Dodge is in her sixth month of pregnancy and has opted to have her baby naturally with the aid of a midwife. This is her fifth visit to Daniel, a home-birth midwife who has been practicing at her home office in Ithaca for 14 years.

Daniel takes her blood pressure, feels her rotund belly and then measures from the pubic bone to the top of the baby. Twenty-eight centimeters. The measurement is right on track.

“I spend a lot of time getting a three-dimensional feel of the baby because the measurement is very limited,” Monica says as she massages Dodge’s tummy. She locates the feet and then the head of the baby. As she touches the baby’s head, she feels a kick.

Midwifery is an ancient practice that has managed to survive through the development of modern medicine. The role of midwives in America has evolved over time, becoming increasingly more scientific and less spiritual. But while some hail the more rigorous training of today’s nurse midwives, others fear traditional midwifery is becoming a casualty of the “medicalization” of pregnancy.

Daniel argues that midwifery is an art form – a specialty and a profession that has survived despite the advent of new technologies and medicines. Midwives are autonomous practitioners who are responsible for assisting women through a natural childbirth. They counsel women, check for complications, carry out emergency procedures and deliver babies.

“It’s about choice,” said Mary Yglesia, a mother of three children, all delivered by a midwife. “Women should have the ability to choose where they want to birth their child and have the ability to have excellent care providers whatever their choice may be.”

When a woman contacts Daniel for a home birth, her options are almost unlimited as far as where and how she’d like to have her baby. Daniel makes sure everything is just as the woman wants.

“My job, as I see it, is to give people information, encourage them to study, research and discover what is really good for them,” Daniel says. “Everybody has their unique needs.”

Kate Finn, another practicing midwife, had her first baby as a water-birth in a tub outside. “That tells you the breadth of how far you can go with birth, if you’re making your own choices about it,” Finn said.

Although 80 percent of the world’s mothers have their babies delivered into the hands of a midwife, the practice is rarer in the United States. Midwives attended 8 percent of deliveries in the United States in 2004. Only 1 percent of births were at home.

History of midwifery

In colonial America, midwives attended the majority of births. It was considered indecent for men to be present; thus few doctors caught babies. During this time, pregnancy and birth were risky because of a lack of medical procedures to deal with complications. Prior to the 19th century, women faced birth not with joy and anticipation, but with fear of death and eternal judgment.

As one of the few medical practices dominated by women, midwifery wasn’t a highly regarded profession in the 18th century. In 1716, New York City began licensing midwives, making them civil servants. At this time a division between surgeons and midwives developed, as doctors began to assert that their modern scientific processes were better for mothers and infants. Midwives relied on an education through apprenticeship and tutoring courses. In response to the accusation that midwives weren’t well educated, Dr. William Shippen opened the first formal training for midwives in Philadelphia in 1765. Regardless, high-class families soon began to turn to physicians for what they believed would be a healthier birth.

By the 1900s, physicians were attending about half the nation’s births, including all births to middle- and upper-class women. Midwives took care of women who could not afford a doctor. Soon pregnancy was no longer considered frightening to women, with the possibility of a painless birth. Dr. Joseph DeLee, the author of a frequently used obstetric textbook of the time, proposed a sequence of medical interventions designed to save women from the “evils” that are “natural to birth.” Thus, it became routine, almost relied upon, for women to be drugged when giving birth. The term “twilight sleep,” which refers to the combination of analgesia and amnesia produced by a mixture of morphine and scopolamine given by a hypodermic injection, was coined in 1914.

In response to the previous 20 years, nurse-midwifery — midwives with a formalized education in nursing — began to dominate the field in the 1920s.

“Nurse-midwives had to become subservient to the medical model, which created highly professionalized, midwifery educational programs in order to gain legitimacy,” said Finn.

It was then that Stephen and Ina May Gaskin founded “the Farm” in Summerville, Tenn., a community focused on respect for the Earth and one of the first out-of-hospital birth centers in the U.S.

Ina May Gaskin was one of the first direct-entry midwives. Direct-entry midwives don’t have a formal education in nursing or midwifery but rather learn through self-study, apprenticeship, midwifery schools or university-based programs. A direct-entry midwife, also known as a lay midwife and considered a Certified Professional Midwife, takes a more traditional and spiritual approach towards birth.

The Farm is an example of the country’s movement toward deinstitutionalization and deviance from medicine. A desire to escape what some perceived as the desensitizing environment of the hospital emerged alongside a string of legal conflicts between the medical profession and the women’s movement.

A revival of midwifery occurred in the 1970s, when a crisis in health care was accompanied by considerable optimism about the possibilities for reform. Women began rejecting the “twilight sleep” and attending births of their friends.

In 1979, a national study discovered lingering behavior and motor deficits in children whose mothers had received anesthesia in large doses of analgesics. The Food and Drug Administration convened a special meeting, and the press attention increased the interest in natural childbirth and homebirth.

The Opposition

But some believe that direct-entry midwives are not qualified to handle physical complications that may arise during pregnancy and childbirth, including fetal distress, failure to progress, postpartum hemorrhaging and ruptured uterus.

The American College of Obstetricians and Gynecologists is a professional association of medical doctors specializing in obstetrics and gynecology in the U.S. ACOG has policies against lay midwifery in particular.

“Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning even in low risk pregnancies,” says ACOG’s Statement of Policy regarding out-of-hospital births in the United States. “ACOG believes that the hospital, including a birthing center within a hospital complex, that conforms to the standards outlined by American Academy of Pediatrics and ACOG, is the safest setting for labor, delivery and the immediate postpartum period.”

A board-certified obstetrician-gynecologist, a general pediatrician, advanced-practice nurses, a radiologist, a clinical pathologist and anesthesia personnel should be available during childbirth for any emergency complication, according ACOG. The only setting in which most of these professionals are found is within the hospital.

But as Finn explains it, most obstetricians are direct competitors of midwives and so, often disagree with home birth. With a different standard of practice, they are hesitant to support midwifery.

“[Direct-entry programs are] focused on birth as a natural, normal phenomenon,” Finn said. “This is critical because when you see birth in a home setting, you see birth in a wide variety of normal experiences. In a hospital setting it’s medically managed; even if it’s midwifery care, it’s under the approval of medically directed guidelines. So they’d have less tolerance for what I would consider variations of normal.”

The New York State Midwifery Practice Act, which was changed in 1992, made New York one of the first states to license direct-entry midwives and nurse midwives under the same law and the same midwifery board. New York won’t recognize the Certified Professional Midwife credential as worthy for a license, regardless of a midwife’s experience.

CPMs received cease and desist orders and practicing midwifery became a felony for these women who didn’t have formal training in nursing. In response, many midwives left the state.

The Advocates

Dr. William Saks is the only physician in the area that works with midwives, at Schuyler Hospital in Montour Falls, NY.

“Women deserve to have a natural birth,” Saks said in an e-mail interview. “As long as they and the fetus are healthy there is no reason for medical intervention. Anything can happen during a delivery whether it is at home, the birth center, hospital, car, etc. … These people understand the risks and the consequences.”

“The question is,” continued Saks, “Is modern medicine overstepping its bounds? Why subject 90 to 95 percent of all births that will be normal to interventive medicine?”

In 2000, Ken Johnson and Betty Anne Daviss conducted a study that screened all homebirth midwives in the United States, Canada and Mexico, which was published in British Medical Journal. Over five thousand CPMs sent in reports of births. The results showed that only three percent of homebirths resulted in ceasarian. Only 5 to 6 percent had to be transported to the hospital. In 2000 1 percent of babies died during homebirths, and there were no maternal fatalities.

The Future

For some, the uncertain future of midwifery is troubling.

“If you eliminate the CPM or the licensed midwife or the direct-entry trained midwife then everybody’s choices have been severely limited. And all you get is the maternity-in-a-box care,” said Mary Yglesia, a former licensed midwife.

Kate Finn believes that on the horizon of the profession is a movement to require a doctorate in nursing to be able to practice midwifery.

“Unfortunately, rather than nurse-midwives and direct-entry midwives seeing enough common vision to band together to say ‘we can move midwifery forward together’, nurse midwifery continues to have its stronghold in the medical community, which means that they continue to, about every decade, raise their education requirement from certificate programs to bachelors degrees to master’s degrees,” Finn said.

Direct-entry midwives would like to continue to do what they do best: serve the women who desire a natural birth.

“We don’t need to dance to the drummer of the medical establishment that says you have to have a formalized degree from a university in order to do what we do,” Finn says. “This model prevents us from being responsive to our clients.”

_________________________________
Robyn Fiedler is a junior journalism major who was surprised to learn that midwives sometimes use baseball gloves during births. Email her at rfiedle1[at]ithaca.edu.

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