Women who give birth at home deserve the best care

Tuesday, January 8, 2008 | 9:08 a.m. CST; updated 8:21 p.m. CDT, Thursday, July 17, 2008

This year the Missouri legislature will, once again, be asked to consider the issue of midwifery. Missouri is the only state in the nation which states in law that midwifery is part of the practice of medicine. This means that only doctors can be midwives.

Current Missouri law places mothers and babies in danger, particularly those who give birth at home. It is legal in Missouri to have a home birth, but it is not legal to hire a midwife to help with that birth. For those families who do find a midwife, the illegal status of midwives means that their insurance does not pay for the birth. Midwives receive their pay out of pocket and often serve families with limited incomes.

I am a home birth physician and an expert in natural childbirth. I take several calls a year from families who live in rural areas and who have rapid labors. They cannot reliably make it to a hospital that provides maternity care. They have no option but to give birth at home. They cannot find a midwife. I don’t know what to tell them. In more than 40 states, midwives are legal and available to at least try to make it to the homes of women in this situation, to help with a baby that needs help getting started or to help a woman who is bleeding heavily.

The current situation puts physicians like me in a legal bind. If I care for a family who has seen a midwife, I am not supposed to know that, or perhaps I will be a party to the felony. But if I don’t know that they have had care from a midwife, how can I know what has already happened in the pregnancy? How can I provide excellent care if I have to stay ignorant and uninformed? Women and babies do best in a system where doctors and midwives work together.

Nearly 1,000 babies are born at home in Missouri each year. Every one of them deserves the excellent care of a skilled midwife. Legalizing well-trained midwives would be a big step towards that goal.

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Angelita Nixon January 8, 2008 | 11:55 a.m.

This is a terribly unfortunate Catch-22 to which Dr. Allemann alludes - here she is in what could be the ideal position to support women having their births their way, providing valuable medical expertise and even facilitating transfers of care when needed (midwives doing their jobs well, that is, identifying potential complications in a timely manner). Yet she and the many other supportive physicians and midwives are legally barred from doing so. Because of some ridiculous Missouri-only snafu? How is that helping Missouri families who are making sound and informed choices by requesting a skilled attendant to care for them?

People should have lots of good options from which to choose when it comes to their health care - midwives and surgeons alike! Really, that's fine with me. Isn't that the good old American way, where healthy competition drives the market, and poor performers simply go out of business?

Women and families who actually care about their births are quite rare these days. Those who choose to give birth with confidence, trusting in their bodies, using natural means for managing the hard work of it, and avoiding unnecessary (and expensive) interventions definitely earn my respect! They are keeping themselves healthy, they are taking responsibility for their own decisions, and they are using valuable health care resources wisely and judiciously. Hmm - shouldn't we be encouraging more of that?

I am fortunate enough to live in an area where I can legally attend and professionally assist women having birth in the setting of their choice. It puzzles me that situations like the one in Missouri still persist. What could it be out there that impedes good, skilled midwifery and medical collaboration? Dr. Allemann, you are a rare breed - thank you for your wisdom and your courage! I wish there were more physicians like you.

(Report Comment)
Liza Coutu January 8, 2008 | 2:07 p.m.

As one who chose to have a homebirth just a month ago, I am grateful to have been able to have that option. I would not have made it to the hospital in time for this baby, as my labor was very unusual for me, and the baby came suddenly after a long, seemingly unprogressing labor. My midwife did not make it in time, so I gave birth unassisted, but she provided wonderful care during my pregnancy and was there moments after the baby was born to make sure everything was fine, even cleaning everything up and making breakfast for me before leaving. I'm just so glad that I had planned to be at home, because the sudden birth of my baby, if I had been planning to go to the hospital, would have been very frightening and stressful. I was well-informed and ready to handle things on my own. I attribute that readiness to the excellent care and involvement of my midwife. Thank you, Dr. Allemann, for this wonderful letter. I hope things change for the better in Missouri.

(Report Comment)
Sarah Perdue January 8, 2008 | 2:07 p.m.

Dr. Allenman,

Thank you for your letter. I live in Alabama. We are working to legalize licensed Certified Professional Midwife attended home births. I believe both doctors and midwives provide needed and valuable care for pregnant and laboring women. It is frustrating to have doctors, nurses and hospitals as our biggest opponents when there is such a great opportunity for cooperation.

Midwives are trained to assist women with out of hospital births and can help women who are far from hospitals, healthy women who choose to birth outside of hospitals, and provide services during disasters and pandemics when hospitals are not available or safe for laboring and pregnant women.

Supporting midwives gives pregnant and laboring women more choices and is in the best interests of public health care because it provides more options in times of disaster.

Thank you for your support of midwives. Good luck changing the laws in Missouri.

Sarah Perdue

(Report Comment)
Mary Ueland January 8, 2008 | 2:10 p.m.

The situation in Missouri is ridiculous. I don't know how else to describe it.

It's legal for the gas station attendant or my neighbor to be the planned attendant for my birth (as long as it's an "occasion" act and the person is definitely not a professional or knowledgeable about delivering babies!), but as soon as I decide to ask a Certified Professional Midwife with skills and training and experience to help me safely deliver my baby, it's a felony?!?

Why? Is this law really for public safety, or rather to put a high wall around an industry that doesn't want legitimate competition?

Why does the Missouri legislature discuss this topic every year, but seemingly very few of them want to "take the hit" they fear from the medical community, just for standing up and restoring our law to a place of reasonable common sense - legal Certified Professional Midwives??

I hope that the legislature get brave this year and pass a reasonable midwifery bill. If they do, they'll certainly have my respect.

(Report Comment)
Laurel Smith January 8, 2008 | 2:25 p.m.

As a mom who travels to another state in order to birth with a legal midwife in a home environment, I heartily echo Dr. Alleman's statement that "Women and babies do best in a system where doctors and midwives work together."

Missouri families should be given the option of a legal midwife. Midwives with an internationally recognized credential (the CPM) are the perfect candidates for a new licensure program as has been proposed repeatedly in Missouri.

Besides the fact that passing a reasonable bill legalizing and providing licensure for Certified Professional Midwives is simply the right thing to do, it also fits perfectly with the stated goals of the legislature to increase access to affordable quality health services. It is time for the Missouri legislature to stand up to the medical lobby, stop the restraint of trade against professional midwives, and affirm the rights and responsibilities of Missouri parents as informed decision makers for their children.

(Report Comment)
Russ Fawcett January 8, 2008 | 3:11 p.m.

Thank you Dr. Allemann for your thoughtful assessment.

To the Missouri Legislature and the Missouri State Medical Association - I apologize if my words sound a little harsh, but this is not that complicated…

Planned home birth with a Certified Professional Midwife is a safe choice and women will choose to birth at home and will choose a midwife to keep them safe. Approximately 10% of women who plan to birth at home transfer to hospital to seek additional care, generally for non-urgent reasons.

What purpose does it serve to make these transfers difficult? Clearly it is not in the best interest of these families.

Increasing access to the Midwives Model of Care in Missouri will improve maternal health, improve the quality of maternity care and reduce costs.

It is not defensible to maintain these barriers to care any longer. All that is needed is to craft a few pieces of paper and for the Missouri General Assembly to vote Aye.

This is not that complicated.


(Report Comment)
Michelle Sanders January 9, 2008 | 9:54 a.m.

Thank you Dr. Allemann for supporting midwives! You are certainly right that women benefit from the collaboration of doctors and midwives.

Anyone who believes that midwives are outdated should look at the 2005 BMJ study that showed that the homebirths of low-risk woman attended by CPMs are as safe, with fewer interventions, as hospital birth.

It's time offer low-risk women the opportunity to be cared for with the Midwives Model of Care- legally!

(Report Comment)
Sarah Bemis Coats January 9, 2008 | 2:09 p.m.

Awesome to see physicians standing together with midwives despite the awful legal climate in the state! I gave birth at home in Florida with Certified Professional Midwives (CPM).

After working for Obstetricians for several years it was nice to experience the hands-on care I received from my Midwives. Both care providers are wonderful, but the Midwifery Model of care makes so much more sense, especially for low risk women! My prenatal visits lasted an hour and I had time to get information on anything that concerned me and true informed consent before all procedures/tests.

Because CPM's are legal in Florida I had a back-up OB/GYN lined up in case I required transfer to medical care. My midwives carried oxygen and anti-hemorrhagic drugs, and were trained to cope with shoulder dystocias, to suture tears, etc. They were certified in neonatal resuscitation as well as adult CPR.

My pregnancy and birth went perfectly well and I was able to give birth at home with my midwives without any complications. I truly hope the Missouri's women soon have the fantastic opportunity that I did- The choice to birth where and with whom they choose!! Sounds like they have at least one great doctor on their side!

Best wishes,

(Report Comment)
Beth Dixon January 9, 2008 | 4:28 p.m.

How disappointing and sad that Dr. Allemann is willing to mislead, misinform, and even if it's unintentional, deceive readers about midwifery care in Missouri. Her statement above is just simply NOT true. It IS legal in Missouri to hire a midwife...a Certified Nurse-Midwife (CNM)! CNMs are legal in Missouri and in all 50 states. The majority of them practice the midwifery model of care. A CNM in Missouri has her RN license, has gone on to get her Bachelor's and Master's degree and passed a Board Certification exam to be registered and practice in the state of Missouri. They are regulated by the Board of Nursing as an Advanced Practice Nurse, and they have prescriptive privileges in collaboration with an M.D.
While it is true that the majority of CNMs in Missouri practice in clinics or at hospitals, I work with a CNM that assists women to have safe, gentle home births in the midwifery model of care. We have assisted over 350 women to have the kind of births they want at home over the past 9-10 years here in Missouri, and we have an excellent collaborative physician to back us up. The majority of our clients who have insurance get at least a portion if not all of their expenses reimbursed. We do all but one or two of our prenatal visits in our client's homes (they come to our office once or twice prenatally and once postpartum) and of course, our clients birth in their own home.
It is distressing to think that, in what seems an obvious attempt to persuade people of the injustice of Missouri's laws about midwifery, those who would want to change it appear to lack the integrity to tell the whole truth. In most of the editorials and articles promoting the change to our current laws, I have NEVER seen it mentioned that it is legal to have a CNM attend a home birth. I would love to see CPMs become "legal" and be able to give more women the option to have their babies at home LEGALLY. I know that there are CPMs practicing in Missouri right now (although illegally) that have great skills. There needs to be some sort of registration, regulation, and accountability for those who practice any profession, and I'm sure most CPMs would be willing to practice and operate under those guidelines. It protects all consumers of health care to have someone overseeing the profession. I would encourage everyone to work for a change in the law to better provide women with the kind of care they desire, but do it under the authority that is placed over them at the current time. Change the laws, but practice under them until you do. Be truthful. Have integrity. Midwives and midwifery all over the U.S. and the world suffers and gives opponents ammunition to rally uninformed voters against midwifery care when there is division, deception and misinformation used by those who need to instead focus on unity, common goals and trustworthiness.
Beth Dixon, RN BSN

(Report Comment)
Russ Fawcett January 9, 2008 | 10:04 p.m.

Greetings Beth,

First of all, let me extend my best appreciation to you for your support of licensing CPMs in Missouri. We are in complete agreement!

I also am like-minded in that all care-givers in the service of women and families should be working together to 1) support women in achieving the best maternal health, 2) steadfastly defend a woman’s right of self-determination while providing the best information and 3) strive to keep childbirth safe. Along these lines, I will go further and say obstetrics is part of the safety of all birth models and I celebrate and applaud all working in the service of women and families.

At the same time, I need to correct a number of your misconceptions:

1) There were no inaccuracies in Dr. Allemann’s article.
2) Certified Nurse Midwives are wonderful and bring the Midwives Model of Care to women in all settings and have tremendous training; however, to claim that the nurse-midwives are readily accessible is incorrect. The vast majority of the (~1000 annual) home births in Missouri are attended by Direct Entry Midwives.
3) Physician “collaboration” is a euphemism for Indentured Servant and the required signature provides zero value – it is simply another obstacle to care. Consistent with ACNM’s stated objectives, nurse-midwives (along with CPMs) in Missouri should be authorized for autonomous practice.
4) The biggest obstacle to improving access to midwifery care in Missouri is the leadership of the Missouri State Medical Association (not the physician’s community of practice).

I’m sure you will agree that advancing midwifery in all settings is in the best interest of all families in Missouri.

We know what the right answer is. We know we need to license CPMs for autonomous practice in Missouri. We know we need to remove the barriers to access to nurse-midwives in all settings. We know we need tort reform to improve the environment in which obstetrics is practice.

Dr. Allemann made no mistakes.

I agree it would be best to work together. In the absence of interest from MSMA, we will work the problem and do the right thing.


(Report Comment)
Beth Dixon January 10, 2008 | 2:07 p.m.

Greetings and thanks to Russ for your thoughtful response. I agree that we have more to agree on than dispute. Which is why we should work together to change the laws rather than be in any way hostile or adversarial about the respective practitioners.

Russ, you completely avoided the obvious issue I brought up about the legality of using a midwife...You acknowledged that CNMs give midwifery care--(and I'm sure that there are exceptions where some CNMs don't adhere to that model, especially in hospitals)--yet you say they are not accessible! That does not address the issue of legality, which has been an issue with several home birth clients of ours---they want to abide by the laws placed over them in acknowledgement of the authority that we all need to respect--even as we acknowledge many of the laws under that authority need to be changed!
Here's the quote (statement) that I was referring to in my response that Dr. Allemann may mislead people with...

"Current Missouri law places mothers and babies in danger, particularly those who give birth at home. It is legal in Missouri to have a home birth, but it is not legal to hire a midwife to help with that birth. For those families who do find a midwife, the illegal status of midwives means that their insurance does not pay for the birth. Midwives receive their pay out of pocket and often serve families with limited incomes."

The above quote is the MISTAKE (or untruth)--IT IS LEGAL to hire a MIDWIFE (CNM) to help with a home birth. Some insurance companies DO pay for people who hire a CNM. You cannot argue with the truth of these statements! However difficult it may be to find a CNM who practices in the homebirth setting, it is misleading to tell people that it is illegal to have a midwife! It is not if they are CNMs.

I don't know very many CNMs, but the ones I do know all support the midwives who want to practice carefully and with accountability, and yet it appears that those same direct entry midwives or CPMs, with what seems to be exclusivity, appear to want to lump CNMs in with the "adversaries" or keep people misinformed about the availability of CNM care. You call CNMs "indentured servants" but I have not seen that at all. I think it is possible that even Dr. Allemann has worked with CNMs. Has she nothing to say about that?

(Report Comment)
Ida Darragh January 11, 2008 | 4:09 p.m.

I have been a licensed midwife for 25 years in Arkansas, your neighbor to the south. I can state unequivocally that licensing home birth midwives works to the benefit of mothers and babies. State regulation assures that midwives are well-trained and accountable, rather than working underground as the CPMs must do now in Missouri. The few states that still prohibit the legal practice of Certified Professional Midwives are coming into the 21st century by passing new laws to license home birth midwives. It is time for Missouri to step up and join the progressive states in providing more legal midwives for the families who are choosing home birth.
Ida Darragh, CPM and licensed midwife in Arkansas

(Report Comment)

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