Birthing rights

Kim James was 17 when she first learned what a midwife does. Though she still can’t place her finger on it, she knew it was what she wanted to be.

“It is something that always interested me, and I am not sure why,” she said. “It’s not lucrative, the hours are terrible and most of the work is done in the middle of the night.

“But,” she adds, “it is extremely rewarding work.”

James began working in 1989 at Cherche La Femme, Columbia’s first birthing center. The center was co-founded by a certified nurse-midwife, Sharon Lee; a physician, Elizabeth Allemann; and an administrator, Jean Sax. The center offered women an out-of-hospital setting as well as home births.

Allemann and later Laurel Walter were the two physicians on staff at Cherche La Femme, which closed in 1999. The two physicians, the only ones in Columbia who continue to offer home births, are at the forefront of efforts to change the rules that govern midwifery in Missouri.

When Cherche La Femme opened, no license existed for those who wished to pursue midwifery without a nursing degree. But in 1994, the North American Registry of Midwives introduced its national certification program, which has since been recognized in 24 states; Missouri is not one of them.

Still, James completed the training requirements, receiving her credentials in 1996. Along with Allemann, Walter and others, she wrote letters and visited legislators at the Capitol in hopes of getting the state to recognize her credentials and those of the other women throughout the state who held them.

James has worked as a child-birth educator at the Whole Health Birth Center, run by Walter, since it opened in 1999, offering emotional support and coaching pregnant women. She is quick to point out that she does not, cannot, fully practice her chosen profession of delivering babies.

“It’s disappointing to live in a state where this credential is not recognized,” said James, one of nine certified professional midwives still living in Missouri. “It gives me a sense of purpose to hold this torch in a state where we will have to inevitably accept this model at some point in time.”

Midwifery — the ancient profession of assisting a woman through pregnancy and delivery — has been at the center of a heated debate in the state legislature this year as a bill to change the restrictions governing the practice has advanced further than at any other time since 1985.

Opponents of the bill continue to reject the certified professional midwife credentials held by James and others, arguing that only doctors and nurses should be licensed by the state to deliver babies.

Supporters of the bill say the professional midwife certification is a national credential and requires midwives to have and document out-of-hospital birth experiences. Letting women such as James preside over home births would give families more legal options, advocates say.

For the majority of Missouri’s medical establishment, however, that level of training is simply not enough.

“To my understanding, what this bill offers is a sanctioning of untrained personnel,” said Randall Floyd, an OB/GYN at Columbia Regional Hospital. Certified professional midwives, he said, lack medical training to provide home health care and would be unable to recognize and prevent problems during both pregnancy and the birthing process.

To James, such statements suggest an ignorance of the training process for the credential she holds.

“There seems to be a lack of understanding on the part of the medical community as to what this training entails,” James said. “It leads to misunderstandings as to how well prepared we are for the job.”

The path to midwifery

Midwives come in several varieties.

Nurse-midwives — the only kind licensed in Missouri — are nurse practitioners with midwifery certifications issued by the American Midwifery Certification Board. They can write prescriptions in all 50 states, including Missouri. Sixty-eight percent of nurse-midwives have master’s degrees, according to the American College of Nurse-Midwives. Though they are permitted to do home births, 90 percent of them work in hospitals. Regardless of setting, they are required to have a collaborative agreement with obstetricians who assume responsibility. They are not required to do out-of-hospital births for their training.

Certified professional midwives aren’t required to attend nursing school and can receive their credentials after completing an apprenticeship under a more senior midwife, including a certified nurse-midwife or a physician. They can also attend a school accredited by the Midwifery Education Accreditation Council.

The legal status of certified professional midwives varies from state to state. Applicants are required to attend 40 births and must be the primary decision-maker in 20 of those births. Ten of those must be home births or other out-of-hospital settings. These women generally specialize in home births.

Debbie Pulley of the North American Registry of Midwives, the organization that grants the professional midwife credentials, said many applicants exceed the minimum home-birth requirements.

“In many cases, these apprentices attend well over 100 births,” said Pulley, the registry’s director of public education and advocacy.

The last group of midwives have no formal credentials. These practitioners — generally known as traditional or lay midwives — have learned through an apprenticeship or self-study.

All midwives, regardless of training, are supposed to transfer women to the hospital if complications arise during a home birth.

Missouri first established a licensing procedure for midwives in 1901 regulated by the State Board of Health. According to an article from the Journal of Midwifery and Women’s Health, applicants were required to pay a $5 fee and to pass an examination in obstetrics. In 1959, the state defined midwifery as the practice of medicine and has since recognized only midwives with formal nursing training.

Any person found regularly practicing midwifery and charging fees for their services outside these regulations could be charged with a felony. While such midwifery remains illegal in 10 states, Missouri is the only one that makes it punishable by jail time.

The proposed legislation, which is stalled in the Missouri Senate, would create a licensing procedure for midwives who have completed the skills-based and written examinations issued by the registry of midwives. The state would set up a board that would provide oversight and review. Under the legislation, certified professional midwives would be required to disclose their background, history and emergency transfer plan to clients.

Home births

Home births in themselves are not illegal. Of the 77,709 births reported in Missouri in 2004 — the most current data available — 263 were planned home births, according to the Department of Health and Senior Services.

Nurse-midwives, however, attended only 58 of those at-home births.

Nearly 78 percent of the home births were attended by people who were not nurse-midwives and who marked themselves as “other midwives” on the birth certificate. There is no reliable way to know whether the “other midwives” were practicing outside of the law.

Yet it is clearly happening, says Walter, who has received calls from women throughout the state who want her to attend home births.

Because Walter operates the birth center full time, she said, she has had to restrict doing home births to Columbia residents. She attended 20 home births in 2003, 27 in 2004 and 23 in 2005.

“Right now, people are using midwives who are illegal because they don’t have any other option for the kind of care they want,” Walter said. “When women don’t have access to legal midwives in their communities, they often choose to have an illegal midwife attend their birth.”

Laurel Smith, vice president of Friends of Missouri Midwives, said she drove to Kansas so her sixth birth could be legally attended by a certified professional midwife.

“Practically speaking, there are very few options for parents in Missouri who want planned home births and are low-risk,” she said. “They do not have an option without literally breaking the law.”

Low-income families who want home births face the barrier of cost, because Medicaid does not provide reimbursements for home births in Missouri. Chad Cordell of Columbia and his wife, Danielle Maness, said they chose a certified professional midwife two years ago — even though those credentials aren’t recognized in Missouri — because they couldn’t afford the services of the two physicians in Columbia that offered home births. Walter charges $3,000 to $6,000 and Allemann charges $2,500. A hospital birth at Boone Hospital Center can range from $5,000 to $10,000 depending on complications and services.

“We never wanted to have a hospital birth, we were always set on a home birth,” Cordell, 27, said. “The lay midwife was the most affordable option for us.”

Parents who can afford it — and live close enough to doctors providing at-home births — have an advantage.

“I feel lucky to live in Columbia,” said Amy Jerke, 32, whose second home birth on April 6 was attended by Allemann.

“Human beings would not have been able to evolve if we were not able to push our babies out,” she said. “Obviously, this process works.”

Risky business

Based on her conversations with women statewide, Walter says, Missouri’s restrictions have made home births more dangerous than they need to be.

“That situation makes it much more difficult to coordinate care with hospitals because of the fear that the midwife would be charged with a felony,” Walter said, referring to the emergency transfer to hospitals if something goes wrong.

State rules governing the practice have created a shroud of secrecy for both the families who desire home births and the professional midwives who could offer them.

When Keith Nisbett moved from Texas to Rolla in 1989, he was shocked to discover that midwifery outside of the nursing profession was considered a felony. Texas had a licensing procedure for such midwives, and people could look through phone books and interview these women. His first two children were born at home in Texas, he explained, and his wife felt the most comfortable with that type of care.

His wife was six months pregnant when they arrived in Rolla, but one thing was clear: They did not want to have a hospital birth.

In 1990, he started going to the Capitol on a weekly basis, urging the state to establish a licensing and regulation process for women who were not nurses but wished to practice midwifery.

“I didn’t want to be doing this by myself,” he said, referring to attending home births. “I felt strongly that the law is not what it should be and tried to get it changed.”

Nisbett and his wife would see a physician about three or four times during that pregnancy for prenatal visits and to arrange an emergency transfer if one was needed during home birth. They also enlisted the help of a lay midwife — Nisbett calls her his “backup” — who was not a nurse.

After seeing an earlier version of legislation that would legalize midwifery for women without nursing credentials, Nisbett said, he decided he would birth his children at home on his own. “I didn’t want to continue to put her in the position of being charged with a felony,” he said.

Six of his 10 children were born at home, he says, with just himself and relatives providing care.

Outsiders within?

Nurse-midwives statewide say they face difficulty practicing their profession, both in hospitals and home settings. Despite being permitted to offer these births, those that work in hospitals do not always have privileges to deliver babies.

Figures from the Department of Health and Senior Services show that certified nurse-midwives attended 1,958 hospital births, or about 2.5 percent of all births in 2004.

Valerie Bader of Columbia, a certified nurse-midwife, said she lost her delivery privileges at Boone Hospital Center when malpractice insurance became too costly. Mary Anne Coatney, another certified nurse-midwife, said she did not have birthing privileges while working at University Hospital from 1996 to 2003. Coatney said she was told that all the births were supposed to go to the doctors doing their residencies.

This is often the case, said Debbie Frees, a former clinical faculty instructor at MU’s defunct Nurse-Midwifery Program. The program stopped offering courses in 2001.

Frees said the program ended because births had to go to resident doctors, and there were not enough clinical sites where students could practice. She now works as a nurse-midwife at Buffalo Regional Hospital in Sedalia.

Certified nurse-midwives who wish to offer home births are also limited. There are 91 certified nurse-midwives in Missouri, according to the State Board of Nursing. Only two of them have found doctors willing to meet the requirements of state law and sign on for home births, said Debbie Smithey, president of Missouri Midwives Association. One of the limiting factors is the availability of physicians willing to assume responsibility for home births.

“That’s why most of us are not practicing midwifery in Boone County, because it is virtually impossible to find a physician who will agree to a collaborative practice,” said Coatney, whose daughter was born at home. “Nurse-midwives have had an impossible time working in this state.“

Five of the certified nurse-midwives in Missouri live in Columbia, state records show. Coatney is attending graduate school for a family nurse license, Lee is a nurse practitioner at the Columbia/Boone County Health Department and Bader works in the nursery at Boone Hospital Center. Efforts to reach the other two were unsuccessful.

Missouri has some of the most restrictive laws in the nation regulating nurse-midwifery, including being the only one that requires doctors who agree to sign on for home births practice within a 30-mile radius. This restriction further limits the availability of home births, especially for parents who live too far away.

Of course, not every nurse-midwife wants to practice home births. Bader and Frees both said they were the most comfortable in hospital settings and had no desire to attend home births.

When Lee founded Cherche La Femme in 1989, she hoped to offer women the choice of an out-of-hospital birth. For the next 10 years, the center performed about 500 total births; Lee herself attended 350 home and hospital births.

The center had to close due to financial problems involving insurance, Lee says, noting that Medicaid would offer only partial reimbursement for out-of-hospital births.

There was also a lack of cooperation from the medical community, Lee says. The physicians she worked with, Allemann and Walter, had working relationships with University Hospital. One time, she said, she tried to transfer one of her patients to Boone Hospital Center because that was where Medicaid would cover this particular client. A private physician refused her transfer.

“I would still be doing it if there weren’t all those barriers,” Lee said.

Certified nurse-midwife Rachel Williston said she could not find a willing doctor to sign on in Kansas City. After finding one in Kansas City, Kan., and commuting for about a year, she relocated there two months ago to begin her own home-birth practice.

Reading the research

Home-birthing advocates nationwide maintain that childbirth is a natural, normal process that does not always require medical and technological intervention. The familiar setting allows for women to be more relaxed. Supporters also say midwives tend to spend more time with their patients than doctors, providing more personalized care.

Beyond comfort for the mother, advocates say the mainstream medical community has become overly reliant on unnecessary medical procedures such as episiotomies — cuts made between the vagina and the anus to widen the opening for the baby’s head — and C-sections — surgeries in which a woman’s abdomen and uterus are physically cut to extract the baby.

Walter and others point to 2004 statistics from the Centers for Disease Control and Prevention, which show that C-sections were used in 29.1 percent of U.S. births — an all-time high and well above the World Health Organization’s recommended rate of 15 percent.

Some doctors say the increase of C-sections can be attributed to fear of malpractice suits. Obstetricians pay some of the highest rates for liability insurance in the country.

Other obstetricians, such as Floyd, say doctors do not do C-sections without the mother’s consent.

“There is no surgery that is done on anyone without their permission,” he said. “Informed consent is a standard that is applied in health care in the United States. No one is forced to do anything.”

In 2005, the British Medical Journal published the results of the first study that focused on certified professional midwives. The project surveyed 5,418 women who planned to have home births with certified professional midwives — the same credentials held by women like James. Twelve percent of women were transferred to the hospital when labor began, the study reported, and medical intervention rates, including C-sections, were lower than for low-risk U.S. women having hospital births.

Proponents of the legislation to legalize certified professional midwives in Missouri continue to cite the study.

But physician David Redfern of the Missouri State Medical Association takes issue with the results. The figures are skewed in favor of midwives, he said, because women with high-risk pregnancies generally use obstetricians.

The comparisons were not valid, he said. While midwives mostly care for low-risk women, they were not compared with physicians who only cared for low-risk women. The study’s authors used birth certificates in comparing data, but these documents do not specify whether the mother was low-risk or high-risk.

In the study, 20 percent of the women cared for by certified professional midwives were first-time mothers compared to 30 percent in the doctors’ group. First-time mothers tend to be at higher risk, he said, and often have higher rates of diabetes and high blood pressure. These groups are more likely to need intervention, he said.

The choice factor

The issue is also one of choice, Allemann says. The state should not play a role in where — and with whom — a woman decides to give birth. By forcing certified professional midwives underground, she said, the state essentially forces hospital births for families who may want different options.

But that choice is not purely a personal one, said T. Laurence Huffman of the Missouri Academy of Family Physicians, who testified against the Missouri legislation in February. Huffman said a home birth ending in the death of a baby or mother could have “innocent bystanders,” such as other children in the family.

For Peter B. Greenspan, a Kansas City-based OB/GYN who works with a certified nurse-midwife in a hospital setting, such a choice is too risky.

One patient was in labor for several days, he said, and was finally brought in by a lay midwife after an unsuccessful attempt at a vaginal birth. He said the baby had hydrocephalus — a condition in which excessive fluid accumulates on the brain — and the infant’s head was five times larger than normal.

“This is a person who claims to be able to deliver babies, but yet wasn’t able to make that diagnosis,” Greenspan said.

He cited another instance involving the same midwife: A diabetic was delivering a 10-pound breeched baby, meaning that the child was arriving bottom-first, and the midwife tried to deliver the baby vaginally.

In both instances, he said, the babies died. Greenspan said such situations will only increase if the state licenses people without formal medical training to deliver babies.

Walter said that while hospitals are important for high-risk pregnancies, preventive care can help many women remain low-risk.

Even with such preventive care, Floyd and other obstetricians said, birthing can become hazardous in a matter of seconds. Problems such as seizures during childbirth, excessive bleeding and umbilical cord complications must be addressed in a hospital, where the technology is readily accessible.

Missouri’s future

The potential for the bill to cause fragmentation among different types of midwives is a serious issue, says Allemann, who has advocated more than 20 years for the state to license midwives outside of the nursing profession.

Because the proposed legislation would allow certified professional midwives to practice without a written collaborative agreement from doctors — a requirement for nurse-midwifery — the bill has drawn a mixed response from certified nurse-midwives.

Some see opportunity.

Williston said she’s interested in exchanging her certified nurse-midwife license for a certified professional midwife license. She would be able to better serve women in both Missouri and Kansas, she said, because she would no longer be limited by the 30-mile radius requirement.

Coatney said the state’s new board of midwives should include nurse-midwives, allowing for both kinds of midwives to practice more freely.

Lee agreed, saying she did not doubt that certified professional midwives were well-trained. But she feels the proposed legislation overlooks nurse-midwives and the restrictions they face, including having a collaborative agreement with a physician.

“We’re still standing out here unable to practice,” she said. “That doesn’t make sense.”

On the other hand, Redfern, an obstetrician with more than 15 years of experience, thinks certified professional midwives should be required to have the same written collaborative agreement with physicians that applies to nurse-midwives.

“I am a little hesitant that the lay midwives want too much autonomy, and I am not sure that that is an appropriate thing,” he said.

At least 20 women in the state have expressed interest with the North American Registry of Midwives about receiving certification as a professional midwife.

If the state legislation gains approval, Mary Euland of the southwest Missouri town of Mansfield may be first in line.

At age 23, she has been one of the youngest to testify and present research to legislators supporting the safety of home births. After shadowing a nurse-midwife for four months after high school, she decided she did not want to follow that path.

“I plan on becoming a (certified professional midwife) when the bill passes,” said Euland, who has visited the Capitol numerous times since January. “I don’t plan on doing that until I would not be a felon.”

Euland said some women in her community may live a full hour from the nearest hospital and would like to use the services of trained professional midwives who could come to their homes.

Even if the bill is passed, James says, she will continue to work with Walter.

“That is the model of care I feel the most comfortable with,” she said. “Legalizing the midwifery model of care should give families the benefits of both models of care, and the choices needed for the best outcomes.”

There is still considerable work ahead to make such choices available, Allemann said. Regardless of whether the bill passes she will continue to advocate for the holistic health of all mothers and babies.

“I want to continue the dialogue within organized medicine that has begun,” she said, adding that she and others plan to be active in upcoming elections.

“Mothers are patient and persistent,” she added. “Most of us aren’t sure how we would be here if our mothers had given up.”