COLUMBIA — Nicole K-Weber knew she wanted her children to be born without medical intervention. She was less certain about whether she would feel more comfortable in a hospital, a birth center or her home.
She gave birth to two daughters, one in 2005 and another in February. In both cases, she was at home in Columbia and had the assistance of a midwife and physician.
She describes Ivy White, her midwife during her last pregnancy, as motherly, intuitive and knowledgeable — about birth and women.
"During my prenatal visits, Ivy would ask all the medical questions," K-Weber recalled, "but I also felt like she really cared about how I was doing, what I was feeling, what difficulties I was coping with, what joys I was experiencing."
A 54-year-old midwife, White has assisted with about 600 births and birthed four of her own children without leaving home.
Her colleagues at the Columbia Community Birth Center say she is a well-respected practitioner, but until this summer she faced the possibility of arrest and seven years in jail if found assisting a birth without a physician present.
In July, everything changed. The Missouri Supreme Court upheld a 2007 law allowing certified midwives to practice without fear of prosecution. A Cole County Circuit Court had previously ruled that the law was unconstitutional since it was tucked into an unrelated health insurance bill.
For the last 50 years, Missouri has defined midwifery as part of the practice of medicine. Direct-entry midwives, those without medical or nursing degrees, could be charged with a felony for practicing their profession. Non-nurse midwives could not fully practice in 10 other states, but only Missouri had a punishment as severe as jail time.
"Quite literally, I wasn't sure I'd see this in my life," White said, still with a bit of disbelief. "It's just nice to know if a doctor doesn't get here on time that I can serve."
That hasn't happened yet for White, who has worked for 20-plus years in out-of-hospital birth services. She insists that it's not about her.
"It's about the babies," she said. "And it's the only birth they get."
Nurturing is White's lifestyle and her profession. She lives in a 110-year-old farmhouse right outside Columbia where she grows herbs and tomatoes and tends to two dogs, three cats and her 16-year-old daughter.
As administrative director of the Columbia Community Birth Center, she employs her charm, seemingly infinite patience and delightful giggle to keep spirits high among laboring mothers and a staff that's on 24-hour call.
White considers herself a product of the '70s counterculture movement when women began taking Lamaze classes, birthing at home, growing their own food and eating organic.
"The difference is that back then we didn't have the literature and evidence-based studies available today," White explained, citing research that low-risk home births have a mortality rate similar to hospital births.
She gave birth to her first two children in hospital settings. She says her initial experience was in a mostly bare hospital room with only a clock on the wall and none of today's medical interventions. During her second pregnancy, she suddenly felt scared when nurses hooked her up to an intravenous drip and electronic fetal monitor.
"I hadn't educated myself fully on what was happening and felt at the mercy of the machines," she said. "It leaves women feeling vaguely disconcerted because they just gave birth, but the experience wasn't the peak, life-changing experience they expected it to be."
When White's neighbor decided to give birth at home, she asked White to watch her children. White was immediately "bit by the birth bug."
Soon after, she started following midwives, most of whom worked secretly and had no formal training. She washed the dishes or looked after the mother's older children.
"When I had ladies come to my home who knew my children's names, it was a breath of fresh air," White said. "I trusted them, and they trusted me. I felt loved and empowered."
White's soft-spoken voice barely hints at her brash determination. When she became one of the first in the nation to receive national certification, introduced by the North American Registry of Midwives in 1994, she knew Missouri would not recognize her credentials.
"I considered myself a conscientious objector willing to risk prosecution, and I realized that was a possibility," she said.
White didn't consider moving to a state where midwifery was legal because she wanted to help change the Missouri law. She took on active roles within the Missouri Midwives Association, serving as vice president and chairwoman of the legislative committee in the 1990s. She visited the state capitol two or three times a week during legislative sessions and even wrote a bill to attempt to make midwifery legal in Missouri.
Before becoming a certified professional midwife, White had assisted with about 200 births in rural Amish and Mennonite communities. Often, she had to push kerosene lanterns together and boil water while attending to the mother.
She is quiet about where she did her apprenticeship and the identity of her mentor. Although, she says after a moment of thinking, the statue of limitations has been reached for any births she might have assisted.
For the past six years, she has worked legally at Columbia Community Birth Center, previously known as Whole Health Center. A physician is present at each of the center's births and exams. But it's White who keeps the center running smoothly.
Typically, she works 40 hours a week ordering supplies, maintaining records and answering e-mails. She helps deliver three to four babies a month in addition to performing prenatal and postnatal exams.
Each of the center's clients is assigned a midwife, who is available to them at any time until six weeks after the birth.
White carries oxygen, anti-hemorrhage medication and other medical equipment to home births. Women with heart problems, diabetes, addictions and other health issues are advised to choose hospital births. The center helps women establish emergency plans in case they must be transferred to a hospital.
"Most of our patients are the cream of the crop," White said. "They are healthy, motivated and highly educated women who have researched their options."
She said physicians aren't trained to be midwives, to hunker down next to a birthing tub for several hours. And the relationship midwives have with mothers is different.
"It's fun to catch babies, but here it's not unlikely for the mom or dad to be the one to do so," she said.
Mothers also control the environment. They decide whether to give birth at home or in one of the center's birthing suites. They select the background music and temperature. They determine who will witness the birth.
"We had one woman giving birth in the tub who was accompanied by 12 attendants," White said. "In front of the tub were three tripods with movie cameras. I had plenty to maneuver just to reach the mother."
Before giving birth, the women attend at least a dozen prenatal care and five postnatal visits of about a half hour each. The day after a woman gives birth she is visited by the physician and midwife at her home.
White keeps fueled with coffee, but sometimes it takes her two days to recover from a night of work.
The husbands don't seem to like the long hours, said White, who has been married and divorced three times.
"It's so funny because I've been doing this for years," she said with slight embarrassment.
Kim James, another midwife at the center, noted White's sense of humor, which helps both mothers and staff through the difficult parts of birth.
"She is a good combination of intelligence and nurturing," James said
Elizabeth Allemann, a family physician and the birth center's medical director, is often at odds with her colleagues about the value of natural childbirth and other midwifery issues.
"My emotions vary from sad to disappointed to outraged," she said. "Ivy is a very well trained and knowledgeable practitioner. ... The presence of a physician has never been shown to improve outcomes."
Despite the rejoicing among Missouri's midwives after July's ruling, the Columbia Community Birth Center has not seen much change.
A physician is still present at each birth. Its services, especially to women wanting home births, remain limited.
White is left unable to bill insurance companies for her services since the law didn't establish a state licensing procedure for midwives.
"It's hard for people who spend $300 to $400 a month on health care insurance to then have to pay out of their own pocket when they need health care services," White said sympathetically.
She insists that women should have the freedom to choose this method of health care. Or the method they feel most comfortable with.
White envisions a birth center that moves out of a more traditional office space and into a home.
Right now, she is eyeing a piece of property on St. Charles Road for her own center. It would only be five minutes from Columbia Regional Hospital with a yard for older children to play in. The staff could grow herbs. She'd also like to have chickens so mothers could have fresh eggs to eat.
She hopes it will happen in her lifetime.