The women in Alabama who choose home birth say it’s time the state recognizes that choice. In many states, that option is sanctioned by the recognition of the certified professional midwife.
According to Pushformidwives.org, 28 states use the CPM certification program as the basis for their licensure in lieu of creating their own midwifery terms. Of the 22 states where the licensure is not recognized, 14 states have active legislation to seek CPM recognition.
Alabama’s current legislative quest to decriminalize midwifery was the focus of a feature last week in Weld. (We suggest reading that story before continuing here.)
As proponents for CPMs in the state, led by the Alabama Birth Coalition (ABC), try to rally support for passing that bill, physicians, lawmakers and large medical associations maintain that home births are unsafe.
Currently, nurse midwives may assist in prenatal and maternity care at a hospital under the supervision of a physician. CPMs, however, are not sanctioned to practice in or out of the hospital in the state because their schooling and apprenticeship does not take place in medical school. Mothers may choose to have their baby in the hospital with the care of a nurse-midwife and/or OBGYN or at home, but the women who choose to birth at home may struggle to find anyone to attend that birth. Anyone assisting in or attending to a home birth is subject to a Class C misdemeanor.
Hannah Ellis, president of ABC, does not understand the reasoning behind the current law. “Mothers can give birth at home without professional help. That’s legal, but it’s not legal for a trained professional to help anyone giving birth at home. We believe home birth should be as safe as it possibly can be and the best way to have that safety is to have someone there who is trained,” she said.
According the Medical Association of the State of Alabama (MASA), that structure is in place to protect mothers. “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,” said Niko Corley, Director of Legislature and Public Affairs for MASA.
Still, Ellis said, Alabama mothers are choosing to birth out of hospital — for religious, cultural or financial reasons. “Keep in mind that Alabama has 37 counties who do not have hospitals offering obstetric services,” she said. “In 2009, 165 Alabama births took place out of hospital. In 2010, 174 Alabama births took place out of hospital. In 2011, 248 Alabama births took place out of hospital. So, in those three years, 587 births happened out of hospital in Alabama.” Those numbers do not include women who travel across state lines to birth with legally recognized midwives.
“You’d be hard pressed to find a physician to deliver a baby, planned, outside of the hospital,” Corley said. “He or she, being the physician, has got more training and more knowledge about this than anybody else who’s providing healthcare to pregnant women. The reason they don’t do it outside of the hospital is that they know something can go wrong. They don’t have the extra hands to help handle the situation.”
One woman, though, who preferred not to be named, said that in exploring a home birth for her second child after a healthy first pregnancy, her Alabama-based OBGYN did offer to deliver at home. Finding supportive OBs, according to the women who make the choice to birth at home, may be challenging, but not impossible.
While opponents to the bill claim that mothers put themselves and their infants at risk when they choose to birth at home without a doctor, that choice is still a legal one. Women may choose home birth, and they are choosing home birth. It’s the midwives who work for these women who put themselves at risk for prosecution.
Huntsville-based pediatrician Pippa Abston said that she was unaware there were those choices when she was pregnant. “I am the mother of two adult children, 22 and 24 years old now. Of course, home births were also illegal then in Alabama. There was really no perception of my having much choice in how things went. I saw a nurse midwife for my second pregnancy for a planned hospital delivery and was very pleased with her care, although unfortunately she was not present during the birth.”
Ellis herself traveled from her home in north Alabama an hour and a half into Tennessee for both prenatal and childbirth care with a CPM instead of birthing at home. The travel, she said, was worth the standard of care. “I’d do it again, but I’m not interested in giving birth alone, without assistance.”
The number of CPMs living in the state is unknown, though one such midwife, Jennifer Crook who now lobbies for ABC, said the field attracts women who are interested in traditional, holistic medicinal care.
“I’ve given five years of my life to get a nationally recognized credential where I could practice in the majority of the states, and here I am in my hometown, in my home state, born and raised here, and I can’t practice my profession,” Crook said.
Like Crook, Kaleigh Naylor struggles with the legal boundaries surrounding certified professional midwifery in Alabama. Naylor is training to be a CPM and said that though she wants to be optimistic that the laws will change, she knows the reality is that she’ll need to make peace with the notion that traveling across state lines is the only way she’ll be able to practice midwifery — until the state sees a major shift in advocating women’s rights.
“Sometimes I think I should give up and go into medical school, but how could we lose this tradition?” Naylor said, who studied in Oregon and apprenticed with a Mobile-based CPM, traveling to a Mississippi birthing cottage.
The Mobile practice attended three births a month. During a home birth with a CPM, there’s more than one trained person present, Naylor explained. “There’s the midwife and her assistant, or two midwives and an assistant. They’re all certified in CPR and neonatal resuscitation. In certain parts of the country, like Oregon, we had access to interventions. Those were interventions…that could be potentially life saving or were there just in case.”
In Oregon, Naylor said the midwives referred clients to local OBGYNs so that in the event of an emergency, a mother could transition as smoothly as possible to the hospital. “That’s why having mature midwifery care is important — so there’s not any time lost when you bring the mom to the hospital, and you come in and say this is what’s going on, and you don’t have to start completely from scratch in recognizing that there’s a problem. I’ve had a birth in an out-of-hospital birth that was a cord prolapse [when the umbilical cord exits the birth canal prior to the baby’s head, cutting off the oxygen supply]. We got to the hospital, and she had a caesarean section, and the baby was absolutely perfect.”
Anti-home birth advocates suggest that midwives have no way of conducting maternal and fetal monitoring, Naylor said. “They are being monitored. Their vital signs are being monitored. Their babies are being monitored. Most of the time you’re assessing things continuously. There’s a monitoring presence that’s also a supportive presence,” she said.
That supportive presence, according to Naylor, is key to the kind of care midwives provide. “Midwives are good at keeping a calm atmosphere surrounding a woman in labor. This skill can be an important way of preventing complications,” said Ina May Gaskin, founder of the Farm Midwifery Center in Tennessee. Gaskin described the variation in the ways in which women labor and why accepting that variation as normal is integral in preventing unnecessary interventions.
“Some women may have a labor lasting more than a day with their first baby, while others may have a labor of less than an hour,” she said. “Yet both are normal. Women who have more than one baby may show that much variation among their own labors. Some women can labor and give birth while in the position that most hospitals require, but some women will not be able to hold still in labor for hours on end, as the lying-down position is especially painful for most women and leads a large percentage to opt for an epidural, which has been shown to lengthen labor, and many simply won’t be able to push the baby out in that position, who would find it comparatively easy to do so in a more upright or hands-and-knees position.”
In addition to helping a woman find the right position, a midwife must monitor both mother and baby during labor to ensure both are safe. “The midwife I worked with in Mobile had a protocol of monitoring the baby every half hour to an hour during active labor and then every five minutes during pushing. Before a contraction starts, through the contractions, and for a little time after the contraction, we monitor.” Such monitoring, Naylor said, allows the midwives to get a clear idea of what’s actually going on with the baby’s heart rate and how the baby’s responding to contractions.
Although the midwives are committed to supportive, holistic care, skeptics of the practice ask mothers to remember that midwives might be influencing them to make a less practical choice. (Statistics on those reports may be found in last week’s story.)
“Keep in mind: this is not provided free, they’re being paid to do this,” Corley said. The average home birth costs between $3,000 and $5,000. In states where CPMs are recognized, insurance will cover some of that fee, depending on the mother’s plan.
A legal, midwife-attended home birth
Tracey Kennedy, 33, moved to Alabama from California last year. “The first thing I said when I arrived in Alabama and realized midwifery was illegal was, ‘Well, it looks like I’m just going to have to have an accidental birth because there’s no way that I would trust myself in America’s healthcare system,’” she said. Kennedy, like many mothers interested in midwifery care, is concerned by the high intervention rates and infant mortality rates in the U.S.
“I don’t feel like a woman should have to go through being a patient for having a baby. She should be glorified because she’s bringing life into this world,” Kennedy said. So, a year before getting pregnant, when the couple was still living on the West Coast, Kennedy began researching her birth options in California and decided on a CPM-attended home birth. Her husband, Jon Chan, was less convinced.
“He looked at me like I was crazy and said he couldn’t afford to lose me, let alone our child, so I showed him everything, all the research that I had been reading for the past year,” she said. Once the couple agreed on hiring a midwife, they found a woman in a nearby town to work with.
Admittedly, Kennedy said the midwife’s relationship with her grew “to be like my favorite aunt” during their visits. “I met with her when I was eight weeks pregnant, and we talked for 45 minutes,” she said. No doctor had ever spent that long talking to her. “She was very verbal with me about things that could happen, things that do happen. The average appointment was two-and-a-half hours. She answered all of my questions.”
Kennedy had not chosen an OBGYN as a back-up option when, at 25 weeks, her midwife measured her and said she was four inches larger than normal. “Usually anything more than five or six is borderline. I was still below, but we didn’t worry. At 36 weeks, the midwife comes to your house with your birth kit. She does that so she can figure out how long it will take her to get to your house, where you’ll set up the birthing tub, how you’ll get the water to and out of the birthing tub. She explains everything in the birth kit to you. We did that, and at 37-and-a-half weeks, my son still hadn’t turned, and I was measuring five inches larger. She was a little bit concerned and said, ‘I think it’s time you might want to have an ultrasound to be on the safe side.’”
The ultrasound revealed that Kennedy was experiencing polyhydramnios — too much amniotic fluid in the womb — and that her son was indeed not positioned correctly. “When my midwife got the results, she explained what was happening and said, ‘I want you to go find a doctor as a backup, because you never know what’s going to happen in a situation like this.’ I went to 20 different doctors in different counties in California. They all told me, ‘You’ll have to wait until you go into labor and be rushed to the ER. Or I got: ‘If your baby hasn’t been turned, he won’t turn.’ The most common I got was: ‘You’re too far along in your pregnancy for you to be accepted.’”
The couple did find a backup doctor, but opted to allow the midwife to attempt to re-position their son. “In less than 10 minutes, she did what over 20 doctors told me was not going to happen. She pushed on his butt and guided his shoulders, and he flipped. And there was no pain. There was no discomfort.” The suggested hospital procedure was to numb the uterus so that an OBGYN could manually re-position the baby.
After the midwife “flipped” her son, Kennedy said, “We checked his heart, and she showed us what he looked like on the sonogram. He was blinking, and his heart didn’t change. He was calm and relaxed. She had this long piece of spandex. She basically wrapped my belly in spandex to keep it tight and constricted to keep him where he was at. I kept that on for two or three days. And he was just right there, where he needed to be. At 39-and-a-half weeks, I had false labor for four days. It took me 24 hours to work up to active labor, 15 hours of active labor, half hour to push, and at 39 and a half weeks, my son was born.”
Her son, Xolani, is now a happy, healthy 20-month-old living with his parents in Birmingham. Any future siblings, Kennedy said, will be delivered by a midwife, legal or not.
An accidental home birth
“We had debated whether or not to have a home birth or go in the hospital, so we had options,” said Natalie Ferguson, a 32-year-old Homewood resident who has two daughters, Cecily, 2-and-a-half, and 6-month-old Marcella with her husband, Jason. “I feel like the hospital is part of a service, and they forget that they’re doing you a service. They take you out of the choice. Many times you’re not presented with choices when there are choices,” she said.
Despite that feeling, Ferguson did birth in a hospital for her first child. “We were with an OB I trust very much at Brookwood. He came at the recommendation of a number of people in the community when I started inquiring about an un-medicated birth. And he was totally on board, completely supportive,” Ferguson said.
When 24 hours had passed after Ferguson’s water broke with her first daughter, that OB recommended returning to the hospital in the morning to begin a patosin drip to induce labor. Ferguson feared the induction would lead to a caesarean section.
“I came home really upset and did my own research and called my doula. I found out they used to give women four days, then two days and now one day to labor. I told my OB he could monitor me for infection, and if he needed to take action if signs showed up, that’s fine. I wasn’t trying to be a jerk about it. The hospital policy didn’t fit with what I wanted to do. So I told him I wanted four days, and if I didn’t go into labor on the fourth day, he could do the induction,” Ferguson said.
She was pleased with his reaction. “He told me that the research I’d done today was more current than the research he’d done 10 years ago. He said he was on board and to come into the office tomorrow morning to draw blood and keep an eye on everything. I ended up going into labor on my own and got to have the delivery I wanted.”
But because newborn Cecily’s blood sugar was low, she spent the first five days in the neonatal intensive care unit (NICU). When Ferguson returned home, she researched low blood sugar in infants and discovered that midwives recommend nursing and skin-to-skin contact, among other traditional methods, to raise blood sugar.
“I spent the first five days pumping milk at the mercy of the NICU, when I might have solved the problem in my own hospital room. That left a bad taste in my mouth. I got the birth I wanted, but the first few days I had with her were a little stressful because it was presented as an emergency but might not have been,” she said.
So for their second pregnancy, they investigated birth options. “After that experience, we started talking about going to the Farm [Gaskin’s birth center] to deliver, especially with a healthy delivery — no tearing, no massive blood loss, none of the trauma for post-partum moms.”
Because Ferguson’s husband, who works for a computer software company that serves universities, has insurance based in Virginia, his plan covered a birth at the Farm. “His insurance did consider it a medical facility. It was under $5,000.”
The hospital bill for their first child was $17,000 for childbirth and $55,000 for the NICU. “We didn’t pay that because we’re insured, of course,” she said. Still, they were looking for something different.
The Fergusons informed their OB of the plan — to either use a midwife at home or travel to the Farm — and he agreed to continue seeing her. “His response was, ‘You know I can’t support that, but I’m glad I have that information, and I’ll let you know if there’s anything leading up to the birth that makes me think you could be at risk, and I think you’d need to be in the hospital.’”
One Friday near her due date, Ferguson said she had been experiencing a week’s worth of start-and-stop labor but was able to continue her daily routine. “So I called the doula…and said, ‘I might be in labor but this is just odd — no water broken. I’m walking around the house doing chores.’”
Ferguson’s husband came home from work, and the doula arrived. What happened next, she said, was totally involuntary. “I just had this feeling of Oh my gosh, I feel pressure. Oh my gosh, it’s burning. I think I’m having a baby. The doula said, ‘Reach down,’ because she can’t legally attend a birth. ‘Tell me if you feel a head.’ I said, ‘I can’t. It hurts too bad.’
“So Jason reached down in time to catch the baby coming out. At that point the baby was out.”
Ferguson said that though the experience was somewhat surprising, the family was not frightened. “It was not an emergency that we felt like we needed to call 911. … So we decided to stay home. We decided to call all of the doctors and let them know what happened.”
The next day, the Fergusons called the hospital, first connecting with an on-call OB who told them to call their own doctor. Next, they called the pediatrician who said that the baby needed to be immediately checked into the Well-Baby Nursery at Brookwood. (None of the medical personnel could be reached to corroborate this version of the story.)
Ferguson asked why, after having the baby and successfully nursing for the past 12 hours, she needed to go to the hospital. The pediatrician listed a number of reasons, namely the necessity for Vitamin K. When Ferguson agreed to bring the infant in on an outpatient basis, the doctor was unsure, having no protocol to follow.
“I finally got through to my doctor, and yes, it was abnormal, sure,” Ferguson said. “Her solution was to take the baby to Children’s emergency room. She had called them and told them our story. They could give her a Vitamin K shot, but we weren’t sure a couple-thousand dollar visit to the ER was worth it. We did some homework and found the midwife protocol for Vitamin K and found out why they give the children Vitamin K and gave it to her orally and went to the OB and pediatrician on Monday. And everybody was fine, and everyone had gotten over the fact that we had decided not to go to the hospital.”
Six months later, Ferguson said she feels like they made the best possible decisions for their family, though some people still ask why they didn’t call 911. “We’ll say because it didn’t feel like an emergency. My husband and I both have college degrees. We function well in society. Our kids play well with other kids. We’re just like everybody else in this community. Some folks were shocked by it. Some folks were amazed by it. I don’t feel like there’s a stigma against me, but if there is, I don’t care. I’ve got great children. We go to a Methodist church in town. I volunteer for the Birmingham Track club. I don’t feel like we do any of the weird stuff that you would assume. … I get the stereotype. I know what people say about people who birth at home. There are three college degrees between us. He works a professional job, wears a suit everyday. We’re not that stereotype.”
Not the stereotype
Cynthia Maldonado, a 36-year-old nurse anesthetist, said she definitely does not fit the stereotypical depiction of a woman who seeks home birth, though in July 2012, she gave birth to her son in her Birmingham living room with the assistance of a certified professional midwife.
“For lack of a better word, as my colleagues say, I am not a tree-hugging hippie type,” Maldonado said. “I wasn’t looking for a transcendental experience of candles and kumbayah. I really wanted to be respected as a woman, and I wanted this process that my body was made to do to be respected. I wanted to be given time.”
Maldonado’s fear as a first time mother was that she would not be given time to labor. “I see women in the hospital who are not given enough time. When they don’t meet x goal of however many centimeters at certain hours, they’re being pushed to progress. I see C-sections done everyday that are unnecessary because these women were brought in for inductions at 39 or 40 weeks.” The suggested standard for being late is 40 plus one week.
“I wanted someone who was comfortable with someone giving me 41 weeks who would give my body time to do what I know that it could do, someone who believed in my strength and my ability to do that. I went 40 weeks and five days. According to the medical profession, I was five days past due. Really, it’s normal to go that long as a first-time mom. There’s no ticking time bomb that says you’re going to explode at 40 weeks. In the medical community, that’s how I see it unfold. The fact that I was five days past due didn’t rattle any alarms.”
Because Maldonado works a local hospital, she said she knew about her options. “I’m in daily contact with women in labor, women having caesarean sections, having epidurals, etc. That’s my profession. We do epidurals for a living. That’s not what I wanted. I knew that I was healthy and had zero risk factors, and I knew that any time in my pregnancy that if that were to change, and I became unhealthy, that I would need to go to the hospital.”
The hospital, she said, is where you go when you are sick. Regardless of her professional and personal opinions, she still sought a hospital birth when she first discovered she was pregnant and scheduled an appointment with a colleague.
“When I started talking to her about my birthing plan, she looked at me like right and handed me their paperwork, which has their birthing plan in it. I said, ‘Wait a minute, you’re giving me a birthing plan?’ This particular group gives their patients a birthing plan — you will be in a recumbent position, you will have IV fluids, [etc.] I said, ‘I’m not okay with any of these things if I’m completely healthy at the time of my delivery.’ I said, ‘What if I want to be standing or squatting on all fours?’ And she said, ‘I’m not really comfortable with that.’ And I said, ‘I thought it was about my comfort.’ And I told her, ‘I don’t need continual fetal monitoring. I’d like to be able to walk the halls and move about freely. Unless there’s a reason for concern, I don’t see why I would need to be attached to the monitor. I would let you monitor intermittently, every 15 minutes or so.’
“I realized there was no way she was going to be okay with any of my desires so at the end of that meeting, I was honest and said, ‘I respect you as a surgeon and colleague, please don’t take this as a sign of disrespect. I will not be back. I thank you for your time.’”
So Maldonado called the ABC and asked for help finding a midwife. “I couldn’t do this in a hospital, and this is where I work every day.”
She called midwives who serve the Birmingham area who are licensed in Tennessee. “I chose one who had a similar philosophy of mine. I checked credentials. … After I spent an hour talking to her after our first appointment, I knew I was in the right place. She referred me to a different OB provider who would be open-minded to my plans. She required me to make an appointment with him — any responsible midwife provider would, in case anything goes wrong — to have a backup plan. I went ahead to see to him and got an ultrasound, to do my lab work, to make sure my placenta is in the right place.” That OB agreed to be there as backup and supported her decision.
“It was all about being put in touch with the right people. It was a blessing. As my pregnancy went on, I continued having my monthly prenatal visits in home. They averaged at least an hour. We talked about everything under the sun: how I was feeling, how I was sleeping, how my relationship with my husband was going, how work was going, how my stress levels were, what I was eating. I kept a food diary and turned it into her every month. She monitored my nutrition intake, monitored my labs. Every time, we felt the baby’s positions. My husband got to feel and listen. There was no sitting in the waiting room. She answered every question I asked. It was just me and her and her assistant and my husband on the end of the bed, talking,” she said.
That care, in Maldonado’s opinion, was more comprehensive than any care she had received from a physician.
“When I did go into labor at 40 weeks and five days, I just called to say, ‘Hey, I’m having some cramping and back pain.’ She came out to the house to check me. She had two assistants. One was another midwife. They came happy and cheerful, calm and confident. And I was already 10 centimeters, and I didn’t know it.
“At which point, things progressed really quickly. I had my son within three hours of her arrival.”
The experience she said was dictated by her own comfort with labor and pushing.
“Every now and then, she would reach down into the water and listen to the baby because they have a fetal Doppler that works under water. I wouldn’t know she was doing it until I heard the swishing sound of my baby’s heart rate. Whatever position I was in, she got around me somehow. They still monitored my baby every 10 minutes or so, during the contraction and in between to see how he was handling contractions, to detect fetal intolerance or fetal distress without being intrusive.”
Had Maldonado traveled to Tennessee from her Birmingham home, where her midwife is protected legally, she likely would have had a side-of-the-road baby.
“I’m very thankful I found someone who was willing to come into my home and deliver that kind of care, knowing that she was willing to put herself on the line by coming into Alabama. Because of our archaic laws, she was making all the risks. Not me. I wasn’t breaking any laws. It’s perfectly legal for me to have my baby at home. It’s only illegal for her to help me, which is the most ridiculous thing I’ve ever heard,” she said.
As for whether or not she feared an emergency transition into the hospital, she said that because she used the OB her midwife recommended that he would have accepted her without issue. “However, when you go into labor, you don’t know who’s going to be on call. There’s always the fear in this state that if you’re trying to have a home birth, and you show up at the hospital, and it’s not a doctor you trust, you might be treated like a leper, like an idiot.” Working in anesthesia for a decade, Maldonado said she sees it happen. “A patient comes in and says, ‘I’ve been trying for a home birth,’ and everyone rolls their eyes.”
There are horror stories you hear out of the emergency room, she said. Oh I had this woman come in who had this and this happen when she tried to deliver at home. “Well, if she had a professional, trained midwife with her, they might have recognized these complications earlier and gotten it to you before it was too late, or they might could have headed it off before it got that bad,” she said.
“Usually the horror stories are women who are birthing at home, unassisted, with an untrained, true lay midwife — ‘Lay’ midwifery is the term opponents use to make it sound as if dirty housewives are delivery babies. Women are going to birth at home anyway. That’s legal. What’s unsafe is not providing them with someone there trained to help who could transfer them to a hospital if they need it.”
Maldonado blames the “taboo” and “hush-hush” nature influenced by state laws for inconsistent data and public information in Alabama. “The midwives are fearful for their livelihood. I’m willing to go on record because I didn’t break any law. The risk was not mine to take. A lot of families are not comfortable saying that because they’re not sure. They don’t talk to anybody about it. They’re afraid and don’t know that there might be midwives out there or that they could travel to Tennessee for assistance.”
She said she knows dozens of women who have had home births right here in Birmingham, Alabama. “And we’re talking educated, healthy women who are making this decision because they feel like it’s the best thing for their family. They’re not choosing this because they saw something on TV. I’ve heard it all from these senators who say women birthing at home are selfish. I’ve never met a mom who doesn’t want the best for their baby. To say otherwise is really disrespectful to the woman.”
In the next story in this series, physicians will speak about their concerns surrounding home birth and certified professional midwifery.