For women’s movements, the right to choose, or lack thereof, has often been the catalyst for action. For a woman seeking alternative birth care, that choice exists in her (and her family’s) decision about how and where a child will be born. For some, that means relying on the care of a midwife: a woman who is traditionally trained in natural, home birth and who addresses both the physical and emotional needs of an expectant mom.
The trouble for Alabama mothers who make this choice is that practicing midwifery is illegal.
Local advocates for women’s birthing rights have proposed House Bill 67, which would decriminalize the practice of midwifery by a certified professional midwife (CPM). Representative Mike Ball (R-Madison) sponsored the house bill.
If passed, the women who practice the age-old tradition could return to doing what many refer to as a calling: delivering babies at home.
Most doctors and lawmakers, though, are in agreement that the safest possible outcome for both mother and child is inside a hospital, where both the personnel and technology exist to treat delivery-related emergencies.
To the families who support the Alabama Birth Coalition (ABC) and its proposed bill, the lack of authority and autonomy given to pregnant women is a blatant infringement upon rights. Women who choose a home birth may do so because of financial, religious or cultural reasons; they may live in a rural area without obstetric care or disagree with the practices of the local hospital’s birthing plan.
“If you want something other than an OB in this state, your options are pretty abysmal,” said Jennifer Crook, a certified professional midwife who holds two master’s degrees in public health and maternal and child care. Because Crook cannot practice midwifery in the state, she lobbies for ABC now, advocating the passage of legislation that would decriminalize her profession. “For most of humankind’s history and Alabama history,” Crook said, “this type of traditional assistance was what most women had access to.”
Today, anyone caught assisting with or attending a home birth is subject to a class-C misdemeanor. Although the District Attorney office did not confirm or deny any recent prosecutions, Crook said she knows women who were charged, and the fear of criminal charges prevents most women from working — even underground. Yet there are midwives, both locally and from adjacent states where the practice is legal, who work in Alabama discreetly. Women who choose to birth at home are not breaking any laws.
Two sides of the dispute
The Midwives Alliance of North America Statistics Project claims that approximately 1 percent of births take place at home in the U.S., with numbers rising 41 percent between 2004 and 2010. Ten percent of that increase occurred over the span of just one year, between 2009 and 2010. That trend is reflective of the concerns families have over birthing statistics in the U.S. — namely, the high caesarean section and infant mortality rates — but these numbers are also reflective of women’s desires to be treated as women who are pregnant, not patients with a medical condition.
Although the majority of local lawmakers and medical associations insist that well-informed, well-intentioned women are putting themselves and their children in serious danger by electing a midwife-attended birth, Gov. Robert Bentley recently supported legalizing midwifery. In an interview with the Florence Times Daily, Gov. Bentley said, “I feel that midwives that at least have the proper training, that have backup so that if there are any problems, they could get the mother — in those 1 or 2 percent of births — to the hospital quickly, [then] I have no problems with that.”
Organizations like the March of Dimes, the Alabama Pediatric Society, the Alabama Hospital Association and the Medical Association of the State of Alabama (MASA) do have a problem legalizing midwifery. “Births can take a turn for the worse in a very short amount of time and without that life-saving equipment and doctors and nurses and technicians who know what to do, it can be life or death,” Niko Corley, Director of Legislature and Public Affairs for MASA, said.
“There’s always going to babies born in taxicabs, in elevator shafts. If you look at the statistics, most of them will probably be okay. Again, there’s always that case where something does go wrong that was unanticipated in otherwise healthy birth, in otherwise healthy women. Those are the situations where it can mean life or death,” Corley said. “That’s why you need the doctors and nurses.”
Hannah Ellis, a volunteer for ABC, said she’s grateful for those doctors and nurses and the role they serve in the community. More than 100 babies were born outside of hospitals last year, she said. “Women are making this choice. Home birth is the safest when there is an integrated system of home birth providers, birth center providers and hospital providers working together to make things the best they can be for moms and babies.”
“Families are doing it,” Crook echoed. “They’re either doing at home or driving out of state to access legally recognized midwives or are hiring a midwife who may be appropriately trained, but we don’t know because we don’t have regulatory methods in the state, or they’re hiring a midwife wiling to risk prosecution.”
Despite an identical bill before the state senate being tabled at committee last month, advocates are still hopeful for legislative change. The bills are the latest effort of the ABC, which as has fought to reinstate midwifery for a decade.
MASA is less certain of the traction the bill has. “This isn’t a widespread push,” Corley said. “These types of movements are carried out by a very few, but a very vocal few.”
The rise and decline of Alabama midwives
In the 1930s, more than 3,000 registered midwives were operating in Alabama. “Most of them,” Crook said, “were working in the impoverished areas in our state. The Alabama Department of Health used to train and license midwives.”
During her years studying the practice, Crook came to the conclusion that Alabama has the richest midwifery history in the nation, though the practice was widespread both here and abroad. “Tuskegee had the first school of midwifery,” she said.
Dr. John Kenney spoke at the graduation for that first class of certified midwives, as recorded by the Journal of the National Medical Association, on March 14, 1942. “The exercise is auspicious in that it symbolizes the transition from the old order of midwifery to the new,” he said.
In the 1970s, Alabama was again a forerunner as the first state to make midwifery practiced by anyone who is not a nurse illegal. After years of slowly ceasing the issuing of licenses, these midwives were phased out of the system. At the same time, Crook said, states like Florida were creating government-supported boards to determine safe practices and training requirements for midwives.
There are differing opinions as to why “lay” midwives were rendered obsolete in Alabama. Corley pointed out that lawmaker and medical associations in the state use “lay” midwifery to describe anyone who is not a nurse.
“Once Medicaid came into existence,” he said, “all of a sudden there was a population base and insurance base to support rural hospitals where there had never been before. There, you had a significant number of Medicaid patients — those folks who had relied on these granny midwives permitted by the health department. … They had just apprenticed through folks who had done this for a long time, and it’d been handed down. All of a sudden with Medicaid, you had physicians who were willing to see these patients. It opened up rural Alabama and other states to maternity care provided for low-income folks, provided by the people who know the most about healthcare: physicians.”
Ina May Gaskin believes that safety had little to do with the decision and was instead inspired by new financial incentives for hospitals. Gaskin is a CPM who founded the Farm Midwifery Center in the 1970s and has since written a number of books, like the recent Birth Matters, and been the subject of numerous documentaries, like the acclaimed Birth Story: Ina May and the Farm Midwives. Gaskin became well known in the 1970s for her book Spiritual Midwifery, which presented birth from a natural and spiritual viewpoint.
“Midwifery was not made illegal because of safety — quite the contrary,” Gaskin said in a recent interview. “It only became illegal in Alabama in the late 1970s when Medicaid began to make it profitable for hospitals to take care of women who could not previously afford hospital care,” she said.
The books The Last Midwife in Alabama and Motherwit: An Alabama Midwife Story by Onnie Lee and Katherine Clark further examine the history. Today, those interested in midwifery are seeking answers in research to determine safe practices.
Deciding who delivers babies
While many state governments and organizations like the American Public Health Association (APHA) recognize the accreditation process for CPMs, opponents to the house bill do not. Instead, the state and medical associations are supportive of nurse-midwives, registered nurses allowed to attend births under hospital supervision.
Because of restrictions on nurse-midwifery, there are fewer than 20 nurse-midwives practicing in the state, according to Crook, who said these nurses do prenatal care or conduct research at UAB instead.
The ABC believes that allowing CPMs to practice legally offers women who will choose home birth the safest possible option for healthy outcomes. MASA believes that type of legislation would be dangerous.
According to Corley, the types of dangers include cord prolapse (the umbilical cord exits the birth canal prior to the baby’s head, cutting off the oxygen supply), uterine rupture and breech birth. “There’s a whole host of things that can go wrong very quickly,” he said. “There are standards of care for physicians and nurses as well that are widely accepted standards that the profession deems the appropriate protocol for certain situations.”
Robin Allison Collins is the director of program services for the Alabama chapter of March of Dimes. On behalf of the organization, Collins released the following statement: “The March of Dimes supports Certified Nurse Midwives and Nurse Practitioners and the vital role they play in the delivery of healthcare. We also respect the families’ desire to own more of the birth process. But at the end of the day we must choose the path that gives both mother and baby the greatest chance for survival.”
Like others who oppose midwife-attended homebirth, the March of Dimes addressed a perceived desire in mothers for an “experience,” claiming, “to grieve for the loss of the desired birth experience or environment is preferable to the unimaginable loss of a child.”
Despite those concerns, only nine states in the U.S. expressly prohibit the practice of midwifery. In many states, like Texas, New York and Tennessee, women may choose to birth at home with a midwife, in a birthing center facilitated by midwives, or in the hospital with an OBGYN.
Because having a baby at home in Alabama is legal, members of the ABC believe their opposition unduly relies on scare tactics to keep midwifery illegal. The real fear, asserts the ABC, should lie with mothers who are choosing home birth without any trained assistance.
“Certified Professional Midwives (CPMs) and Certified Nurse-Midwives who attend home births do bring medical equipment with them to births,” Gaskin explained. “Oxygen tanks, anti-hemorrhagic medications, resuscitation equipment and the like. They are particularly alert to recognizing early signs of problems and are quick to transport to hospital before a complication reaches a dangerous stage.”
Gaskin trains residents and doctors in skills that were developed in home birth settings. “One in particular,” she said, “is the so-called ‘Gaskin’ maneuver for dealing with a baby whose shoulders become stuck after birth of the head by turning the mother over. Many a doctor has told me that learning this maneuver has saved his or her career, because of the injuries to mothers and babies that happened with other methods. Incidentally, I learned the maneuver from Guatemalan midwives who typically work at home. Home is sometimes the place where common sense reigns.”
At the farm where Gaskin practices, of the 2,844 mothers, 94.7 percent delivered without the need to be transported.
If something does go wrong, continuity of care is key — meaning the mother must have an established relationship with an OBGYN at a local hospital, and the midwife must be able to transition care smoothly.
Because of the laws, this type of transition is complicated. Kayleigh Naylor is studying to be a CPM and worked with a midwife in Mobile, often transporting women across state lines to a birthing cottage in Mississippi. She says she couldn’t say if she would ever do a home birth in Birmingham. “Part of the problem is the experience of having had situations that were emergencies — being able to bring that mom into the hospital and make a really smooth transition with her. I wouldn’t want to be in a situation where all of a sudden the mom has no continuity of care, and she’s going into an environment where they have no idea what’s going on with her and she has no support.”
The American Academy of Pediatrics (AAP) compares that transition to seatbelt laws, explaining, “In Alabama, we have laws governing seatbelt use for adults and car seat laws for children. These are not for the overwhelming majority of car rides that are routine and low risk, but for the safety of those citizens when a routine outing becomes a dangerous accident. We don’t expect people to be able to put a seatbelt on at the last second to save them. We use the seatbelt every time, so that it is there when needed. We do this to keep ourselves and our children safe.”
Huntsville-based pediatrician Pippa Abston sees a flaw in this type of argument. Once an outspoken skeptic of home birth and midwifery, Abston said after years of research, she concluded that “CPMs could help fill an unmet need for prenatal care and birth services in rural counties without labor and delivery hospitals or obstetricians.”
In response to preventative measures, Abston said, “Criminalizing home births attended by trained midwives is disproportionate to other legal limits we place on adults. For instance, one of the most common and health-damaging influences on fetuses and children is cigarette smoke exposure. We do not criminalize smoking by pregnant women (or around them by others), and I’m not suggesting we should, even though the effects on infant mortality exceed what is reported for total home births without removing higher-risk scenarios.” Here, Abston refers to the statistics on home births that often include all infants born outside of a hospital, with or without the assistance of a midwife.
The fault in creating so-called preventative laws, according to those who oppose them, comes down to inconsistencies in government interference. “We do not formally criminalize being pregnant or impregnating a woman while poor,” Abston said, “or even do much to reduce such poverty, although the effects of poverty on fetal and infant death wildly exceed any other known risk factor. We do not tell older mothers they can’t get pregnant, even though the risks to the mother and baby are increased. We do not make home birth with no trained assistance illegal, the most dangerous birth choice I can think of. So where is the rationale for labeling home birth with certified midwives as criminal?”
Gaskin points to another inconsistency in this type of legislation, namely increased assisted fertility rates. “There’s a just-published study that has found that in California, from 2009-2011, there was a 24- to 27-fold increase in multiple births and significantly higher rates of preterm births, lower birth weights, fetal anomalies and stillbirth among infants born through assisted reproductive technologies (ART) or artificial insemination (AI) compared to babies conceived naturally. According to the study, the risk of stillbirth goes up by a factor of four in ART and AI pregnancies, compared with pregnancies conceived the old way. But no one who gets upset about the allegedly poor outcomes from home births ever raises a voice about the well-documented losses and higher rates of serious anomalies caused by ART, which involves far higher numbers of actual babies.”
The American Academy of Pediatrics report, though, also cites the high infant mortality rates as cause for hospital-assisted birth. “Delivering in the hospital with medical supervision provides the seatbelt for when things go wrong. With the Alabama infant mortality rate increasing 10 percent last year to 8.9 per 1,000 births, why would we begin to offer our children anything but the safest place to begin their life?”
The problem with statistics
According to the CIA World Factbook, 5.9 in 1,000 infants die for every 1,000 live births in the United States. That figure includes all infants who die within the first year of life and ranks the U.S. worse than 49 other countries.
With high rates of birthing interventions (epidurals, episiotomies, induction, etc.) and high rates of caesarean sections in Alabama hospitals, as well as a statewide infant mortality rate worse than that of 48 other states (and countries like Puerto Rico, Latvia and Kuwait) some women are not convinced hospitals are the safest options for their birth.
By contrast, four babies delivered at the Farm have died in as many decades, none in the past 10 years.
Scientific data, however, on the outcomes of in-hospital versus midwife-attended births has always been murky territory. Often the data is collected from birth and death certificates, which indicate whether a child was born outside of a hospital but not necessarily the circumstances surrounding that birth. A baby born to the hands of a midwife would be classified the same as a baby born to the hands of a police officer on the side of a highway — simply as “out-of-hospital.”
“The state just changed the way they do their birth and death certificates to be more in line with national standards. Right now, what we have is not highly accurate data,” Corley said.
Corley pointed to a large online community of home birth skeptics, like homebirthdeathstatistics.blogspot.com and a site spearheaded by Dr. Amy Tuteur, an OBGYN who blogs at the Skeptical OB. Her post on March 11 was titled, “Home birth mothers, is your midwife emotionally manipulating you?” Many of those reports are conducted by the website authors and not published in peer-reviewed journals.
Studies like “Maternal and newborn outcomes in planned home birth versus planned hospital births: a meta-analysis,” published in the American Journal of Obstetrics and Gynecology, are widely quoted by those who oppose midwifery, as its conclusion reported that “Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”
The study is also widely discredited by midwife proponents for not excluding unplanned or unattended home births in their statistics. “It’s a common tactic to use data that doesn’t distinguish between planned home birth and births that happened outside hospitals because the mother couldn’t get there in time or didn’t know she was pregnant or belonged to a religious group that doesn’t believe in hospital care. Dishonest studies, in other words,” Gaskin said, whose newest book addresses that very concern.
“If you look at the studies [like] one published in 2005 in the British Medical Journal that only looked at births for low-risk mothers who had a planned location of home for their birth and who used appropriate trained and certified midwives, and the outcomes are night and day,” Crook said.
The conclusion for that report claims, “655 (12.1 percent) women who intended to deliver at home when labor began were transferred to hospital. Medical intervention rates included epidural (4.7 percent), episiotomy (2. percent), forceps (1.0 percent), vacuum extraction (0.6 percent), and caesarean section (3.7 percent); these rates were substantially lower than for low-risk U.S. women having hospital births.”
Another recently published study in the Journal of Midwifery and Women’s Health looked at 17,000 women and newborns and reported that “states found that among low-risk women, planned home births result in low rates of birth interventions without an increase in adverse outcomes for mothers and newborns, and result in health benefits to mothers and their infants.”
Of those 17,000 women, 11 percent were transported to the hospital for emergency care, 93 percent of women had normal physiological birth with a caesarean rate of 5 percent.
Why caesareans matter
“We should remember,” Gaskin said, “that the home birth movement in the U.S. that began in the 1960s happened because at that time, 67 percent of U.S. women were having their babies pulled into the world by forceps, and all of these were hospital deliveries. Forceps were famous for injuring both women and babies. I don’t know of any doctors today who would argue that it would be good to go back to such a high rate of forceps deliveries. My point is that hospitals don’t always get it right. Home birth acts as a balance to over-utilization of technology, while not being antithetical to technology.”
Of the 2,844 deliveries at the Farm in the past four decades, 1.7 percent ended in caesarean section.
A report released by American Congress of Obstetricians and Gynecologists (ACOG) states that “in 2011, one in three women who gave birth in the United States did so by caesarean delivery. Caesarean birth can be life saving for the fetus, the mother, or both in certain cases. However, the rapid increase in caesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that caesarean delivery is overused.”
The report urges physicians to consider the short-term and long-term risks of vaginal versus caesarean birth, indicating that for some clinical conditions, such as uterine rupture, a C-section is the safest option for both mother and child. “However, for most pregnancies, which are low-risk, caesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery,” the report stated.
The ABC and its supporters cite Alabama’s caesarean rates as one of the major reasons mothers might seek out-of-hospital birth. In Alabama, 35.5 percent of births end in caesarean. That rate varies hospital to hospital and city to city.
Corley suggested that looking simply at the caesarean rates creates a false sense of reality. What is actually happening inside the hospitals is not told by the black and white figures, he said, but instead can only be understood by examining the overall health of individuals.
“Alabama is a state with significantly higher rates of diabetes, hypertension, obesity and a number of other factors that all go into, really, a generally less healthy state,” Corley said.
As a university lecturer, Crook asks her students to consider the argument that unhealthier moms lead to caesareans.
“Say we’re under the assumption that caesareans are performed in high-risk cases for people who haven’t received adequate care,” Crook said. “Out of all the hospitals in Birmingham, where would you expect to see the highest caesarean rate? If you think about and look at the population of a hospital’s maternity care and — operating under the assumption that the health of the mom and the health of the baby is not the greatest — which hospital in Birmingham would you expect to have the highest caesarean rate? You would have put it on Cooper Green, maybe UAB, but if you start looking at the statistics, you see: It’s all the private pay hospitals. It’s moms with private insurance.”
According to a 2011 report from the Alabama Department of Public Health, Brookwood Hospital, which delivered 3,709 babies that year, had the highest caesarean rate in Alabama — 43 percent — while Cooper Green had 21.8 percent rate for only 298 babies.
For other hospitals in the county, the percentages were as follows: Baptist Medical Center, 31; St. Vincent’s East, 36.6; UAB, 32.3; St. Vincent’s Birmingham, 36.8; Medical West, 41; Trinity Medical, 42.1.
“Because right now, in Alabama, if you check yourself into a hospital during labor, you have a one-in-three chance for getting a C-section, families don’t like their odds,” Ellis said.
Birth business turf
If midwife advocates don’t believe safety is the reason for outlawing midwives, then what is the motive? Some point to money, claiming that hospitals do not wish to lose even a small slice the maternity care pie.
“I am concerned that at least some of the opposition is a turf battle,” Abston said. “Some of it, though, is well-intended and is likely due to not reading the medical literature carefully enough.” Abston urges her colleagues to spend time reviewing scientific articles on home birth.
Denying financial motives would be a mistake, according to Crook. “Look at what you get for an uncomplicated, un-medicated vaginal birth in the hospital and what you get paid for caesarean. … How long does it take to do a caesarean? In and out in 30 minutes. With natural birth, it may be a six-hour birth or a 36-hour birth. Underlying all of this is that maternity care is a really big business. It’s a top moneymaker for hospitals,” she said.
Ellis is worried that the legislators who support keeping midwifery illegal are acting on behalf of their donors — large physician associations like MASA, the organization Corley represents. According to followthemoney.org, a website that tracks political donations in the U.S., between 2008-2012, MASA has made more than 1.2 million dollars in donations to state legislators. Many of those elected officials sit on health committees.
In order to discredit the idea that a turf battle was playing out between midwives and OBGYNs, Corley examined how many patients Alabama OBGYNs stand to lose if midwifery were legalized. By applying the same percentage of women who opted to use midwives in Tennessee to the number of live births and obstetrics providers in Alabama, Corley determined that the roughly 500 OBGYN providers in the state would lose one patient each.
“The push for legalized midwifery is not widespread, Corley said.
Will anyone reconsider?
“The thing you’ve got to remember about this is that no child, no baby, is going to die that would not have otherwise done so if the law stays like it is. You can guarantee there will be some who do die if it’s changed. Because even good-meaning, well-intended folks that would protect this are putting themselves statistically in significantly more danger than with a hospital birth,” Corley said.
Local hospitals, like Brookwood Medical, have made attempts to gear their maternity care more toward natural birth. “They’re trying to go after and capture these folks that want to have a more homey feel while they’re in labor,” Corley said.
Abston agrees that higher risk mothers need hospital care. “In the higher risk situations, taking quality of local resources into account, the hospital setting would usually be safer. In the end, though, the decision should still belong to the mother. I would point opponents to policy statements by both ACOG and the AAP, professional organizations strongly favoring the hospital setting in all cases, which clearly recognize the woman’s right to make an informed decision of birth setting,” she said.
As a pediatrician who supports a woman’s choice, Abston is working with her colleagues to reconsider their stances. “But there is a long tradition of presenting a unified front in medical lobbying. I’ve spoken to physicians who agree with me but who won’t oppose the stance of those in control of the group decisions, because they want their issues supported by the group when it is their turn,” Abston said.
“It is important not to make decisions about policy based on unfounded fears and bad data. We owe it to each other and ourselves to base decisions on good information and to avoid interfering with each other’s private choices as much as possible within the bounds of civilized society.”
Recognizing women’s individual responses to labor is at the core of the argument for Gaskin. “Women aren’t robots or machines,” she said. “Their feelings actually matter more than is generally realized. A frightened woman is full of stress hormones that can lead to birth complications, which is why midwifery has been a necessary profession the world over, stretching back into time well before there was ever a medical profession. It’s important for us Americans to remember this history, because our country was the first society in the world to eliminate the profession of midwifery and that caused us to lose much of the birth wisdom that stems from midwifery.”
For Naylor, part of that wisdom comes by recognizing how all the resources might benefit one another, and how one method is not necessarily unquestionably right. “I’m not saying there haven’t been midwives who have practiced poorly to the detriment of mothers, which is unacceptable, but doctors do that as well,” Naylor said. “I’m of the opinion that there should be regulations and community standards for midwives.”
If this bill is unsuccessful, the volunteers of ABC said they will try again next year. Corley said he wouldn’t expect anything different.
Next week, Weld will continue to look at Birthing in Birmingham and mothers who have chosen to have home births.