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September 23, 2010
Use of Midwives Rises, Challenging the State to Respond
By JESSICA REAVES
After three “really traumatic” hospital births, Alyssa Ruben was determined to have her fourth child at home. She hired a midwife, and eight months later, Ms. Ruben delivered a healthy baby girl at her home in Geneva.
“It was amazing,” she said.
It also was illegal. Under state law, the only legal home births are those attended by a physician or a nurse midwife, an advanced-practice nurse with a secondary degree in midwifery. Kimberly McCarty, who attended Ms. Ruben, is a direct-entry midwife, an unlicensed practitioner who lacks a nursing degree. Ms. McCarty completed a three-year, informal apprenticeship with another direct-entry midwife.
Haunted by a fear of felony charges and jail time, Ms. McCarty moved to Wisconsin, one of 27 states where direct-entry midwives can practice legally. Ms. Ruben, who is expecting her fifth child in October and plans to become a midwife herself, soon followed with her family.
“My husband got a new job in Wisconsin,” she said, “but we knew we wanted to move there because of the midwifery laws, and also because Kim is there.”
While Ms. Ruben’s devotion to her midwife is exceptional, her decision to forgo a hospital delivery is not. After decades of decline, home births are on the rise in the United States, up 5 percent from 2004 to 2005, and remain steady at 25,000 in 2006 — the last year for which figures are available — according to the National Center for Health Statistics.
Reasons for choosing home births vary. Some women cite religious beliefs. Christian Scientists, for example, categorically refuse medical interventions, while some ultra-orthodox Jewish views on female modesty rule out a hospital birth. Other women opt for home births to avoid Caesarean sections, which are also increasing.
Each year, 700 to 1,000 babies are born at home in Illinois, many of them in rural locations, according to the Illinois Department of Vital Health Statistics. Licensed home-birth practitioners work in just 7 of the state’s 102 counties, and most are concentrated in Lake and Cook Counties, leaving the majority of Illinois home births unattended, or attended illegally by someone whose education and licensing are unregulated.
That could change as early as November. After 30 years of trying to get the legislature to license direct-entry midwives, Illinois’s midwifery organizations are guardedly optimistic. In May, the State Senate passed the Home Birth Safety Act. A House vote is pending.
The bill’s supporters say it toughens standards and protects pregnant women and fetuses from untrained practitioners, while allowing qualified midwives to practice openly and to transport emergency cases to hospitals without fear of reprisal or arrest. (Women often register home births as “unassisted” to protect their midwives.)
State Representative Robyn Gabel, Democrat of Evanston, is the bill’s chief sponsor. “It’s an uphill battle in the House,” Ms. Gabel said.
That the bill has made it this far is testament to the midwifery community’s newfound political acumen and its first lobbyist, hired by the Coalition for Illinois Midwifery in 2006.
The bill’s opponents, including the American College of Obstetrics and Gynecology, the Illinois State Medical Society and the American Medical Association, argue that home births are inherently more dangerous than births in medically supervised settings. Also resisting the bill, though more quietly, are members of rural midwifery groups that have operated under the radar and off the grid for years, and would prefer to remain that way.
“We just don’t think home is a safe environment for delivery,” said Dr. Jacques Abramowicz, co-director of the Fetal and Neonatal Medicine Center at Rush University Medical Center and a Fellow of the American College of Obstetrics and Gynecology. “Childbirth is very dynamic, and it can be a very dangerous process. In the vast majority of cases, nothing happens. However, if an emergency occurs, it happens very fast — in two, three, four minutes.”
Rachel Dolan Wickersham, president of the Coalition for Illinois Midwifery and the vice president of the Illinois Council of Certified Professional Midwives, is the midwife groups’ lobbyist. She said she was frustrated by the bill’s opponents in the medical community.
“There’s just no room for negotiation,” Ms. Wickersham said. “It’s a turf battle. It’s about power and control. These women are going to have babies at home. There’s no question about that. Why would anyone want to keep the situation so that the person attending them has no regulated training or is afraid to transport them to a hospital in an emergency?”
Whether home births are riskier has not been definitively shown. There is evidence to support both physicians’ and midwives’ positions.
But in 2008, Childbirth Connection, a nonprofit, maternal health research organization, co-authored a report based on hundreds of studies of maternity care in the United States. It said medical interventions, even in low-risk pregnancy and labor, had increased substantially in the past two decades. The number of induced labors, for example, doubled from 1990 to 2005, while Caesarean sections accounted for a record-high 40 percent of United States hospital births — versus 4.5 percent in 1965.
Meanwhile, according to the federal Centers for Disease Control and Prevention, maternal mortality in the United States is on the rise. Midwifery advocates say these figures support their contention that the majority of Caesarean sections are unnecessary and potentially dangerous.
After three hospital births, Jamie Stoltzfus of Decatur knew she hated the way epidurals made her feel, and thought a water birth, in which the baby is born into a pool or bathtub, might be a good alternative for her fourth delivery.
Her doctor was unenthusiastic. “She said something like, ‘Oh, honey, hospitals don’t really do that,” Ms. Stoltzfus said. “It’s too messy to clean up afterward.’ ”
Now expecting her seventh child — her fourth home birth — Ms. Stoltzfus said she had no qualms about using a direct-entry midwife. “I know my midwife’s qualifications are as good or better than some of the doctors I’ve used in the past,” she said.
Kristina Stevens graduated from nursing school at the University of Illinois at Chicago in May and began a three-year course to become a legal nurse midwife. She supports the Home Birth Safety Act.
“There’s a trend of more women having home births,” Ms. Stevens said, “and they need trained practitioners.”
Obstetricians are not practicing in the southern part of the state, she said, because liability costs are so high. “They need to make room for people who will do that work,” Ms. Stevens said, “and there has to be legislation to support those people.”
Dr. Abramowicz conceded that poor women in some areas do not have anyone to attend their deliveries. “But the solution is not to allow very untrained people to become licensed,” he said. Instead, he said, the government should give incentives, including school-loan forgiveness programs, to rural obstetricians.
While economics and geography certainly inform the midwifery debate, one question cuts to its core: What is the extent of a pregnant woman’s autonomy? Midwifery advocates say women are often patronized or ignored when medical decisions are made during hospital deliveries.
Cassandre Creswell of Chicago, whose first child was born in a hospital, had her second at home to avoid the “combative experience” of defending a natural-birth plan in a delivery room.
Dr. Abramowicz conceded the point, saying, “To tell you we are ecstatic when a woman comes in with a birth plan would not be the truth.”
But, he added, hospital births can be a collaborative experience between patient and doctor. “We’re not telling women what to do,” he said. “We’re telling women what we think is best.”
That is unlikely to sway women like Alyssa Ruben.
If she developed risk factors, Ms. Ruben said, “I would obviously go to the hospital.” But, she added, she vastly prefers the care from her direct-entry midwife.
“It’s very woman-centered, totally different than what happens in the hospital,” she said. “I’m in charge of my labor and my pregnancy, not taking a back seat the way doctors want you to do.”
This article has been revised to reflect the following correction:
Correction: September 24, 2010
A previous version of this article had the incorrect given name for a nursing school graduate who is starting a three-year course to become a legal nurse midwife. It is Kristina, not Chirstina.