Born in the USA (22 page)

These direct-entry midwives are trained professionals who offer safe, empowering care to women giving birth in the United States. Yet they are often treated with unbelievable harshness. In 1995, a direct-entry midwife with a home birth practice in upstate New York received a phone call from a couple saying that they wanted to plan a home birth with the midwife. The couple made an appointment and came to the midwife's home, where arrangements were made for the management of the pregnancy and home birth. Several days later, a police car showed up at the midwife's home. The midwife was put in handcuffs and hauled off to the police station. Her house was searched and her client records confiscated. It turns out that the home birth “couple” were undercover police officers who had taped their call to the midwife and were wired for the visit—entrapment. Obstetric cops and robbers. Her crime? She was a direct-entry midwife assisting at home births. The state had a new midwifery law and it was unclear whether direct-entry midwives were legal under the new law. She was to be a test
case. A long series of hearings and trials followed, and eventually the midwife found it necessary to move to a nearby state. New York's loss was the neighbor state's gain.
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Nearly identical scenarios have been played out in California, Illinois, Connecticut, and many other states. Home birth is not against the law in any state—in our democracy, families clearly have the freedom to choose where the births of their children will take place. But there is a variety of state midwifery laws that attempt to limit the practice of midwives, and these are frequently tested through complaints to the state.

Even though it is not against the law for a midwife to attend a planned home birth, doctors often wait for a home birth to be transferred to the hospital, and then complain to the state. Some of the most common complaints: the midwife was practicing medicine without a license, the midwife made a mistake that resulted in transfer to the hospital, the midwife is not properly trained, and so on. After an investigation, the midwives are usually cleared, but the harassment is nevertheless traumatic for them and will put the fear of God into other home-birth midwives practicing in that state. So while home birth is not against the law, in many parts of the country it is difficult for a family to find someone to attend a planned home birth, since doctors are threatening midwives and are no longer willing to attend home births themselves.

In many cases, these attacks on midwives are simply attempts by doctors to eliminate the competition. Current legal challenges of midwifery practice across the United States are similar to the persecution of the midwife Hanna Porn, who was accused not of malpractice but just of practicing midwifery. Cases against midwives are, with very rare exceptions, not initiated by the families the midwives serve, as is typical of litigation against obstetricians. Instead they are initiated by physicians. Typically a doctor, a group of doctors, or a hospital reports the midwife to the state agency that regulates midwifery, accusing her of practicing medicine without a license, a charge that may simply be a demonstration of the doctor's ignorance. In a few states, such as New Mexico and Oregon, if the complaint is against a direct-entry midwife, it will go to a board that specifically has the task of reviewing midwifery cases. However, in other states, such as California, the complaint will go to the general medical board, on which no midwives serve, only doctors. If the complaint is made against a nurse-midwife, it goes to the state nursing board, where, as in the story told earlier, there are often no midwives serving, only nurses. These cases often draw a lot of attention from the media, which usually take a negative view of midwifery
and home birth, as journalists (with some exceptions) tend to believe whatever doctors say. This negative publicity is exactly what the accusing physicians are after. The midwives who are charged, however, usually receive a lot of support from other midwives, local clients, and women's groups.
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Recently in Las Vegas, Nevada, a low-income Hispanic family decided that they wanted to plan a home birth, and they secured the services of a midwife.
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The pregnancy was normal, as was the birth, until, when the baby came out, the midwife noticed a small amount of meconium present on the baby's skin (meconium is fecal material that accumulates in the baby's intestines during pregnancy and is occasionally discharged at or near the time of birth). Although the baby was fine, since the midwife knew that occasionally a baby can aspirate meconium and develop pneumonia, she wisely decided to be very cautious and take the baby to the hospital for a checkup. Since the baby was not in acute distress, the midwife insisted that the mother stay home, as she was exhausted after her labor and birth.

When the father with his baby and the midwife arrived at the ER, the father explained to the nurse that the baby had been born at home. The nurse screamed, grabbed the baby, and ran out of the room. The father was given no support or reassurance. Instead he had to witness the doctors and nurses treat the midwife with open hostility. The father and midwife searched and found the baby in the neonatal intensive care unit, where a neonatologist proceeded to lecture the father about all the terrible things that might now happen to the baby because he had irresponsibly permitted the baby to be born at home. Contrary to the neonatologist's dire predictions, however, the baby was just fine, and was soon discharged from the hospital.

Happy ending? No, the trouble was just beginning. The hospital staff reported the family to the local social services agency as a case of child abuse, and the family was investigated and interrogated—for no other reason than that they had chosen a home birth. Where did the doctors get such a bizarre idea? Perhaps it was from two of the past presidents of the American College of Obstetrics and Gynecology, who made public statements equating planned home birth with child abuse.
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Then the authorities began an investigation of the midwife, which led to an outcry from the midwifery community across the country. Letters from scientists, women's organizations, midwives, and clients poured in and were published in the Las Vegas press. The public discussion that took place in the press recognized that the central issue was not the safety of the baby, since the baby was fine and there is no law against home birth in Nevada and no scientific data proving home birth to be dangerous. The protesting citizens
were concerned about the freedom and sanctity of the family. Eventually, the social services investigation was ended and the case was closed. The obstetricians and neonatologists of Las Vegas took a gamble and lost. But the emotional toll on the family and on the midwife was considerable.

Similar attempts to put midwives out of business go on all over the United States. Another common tactic is to question a midwife's qualifications. It is common to hear direct-entry midwives called “lay” midwives when they are being attacked, a clearly pejorative label that implies that they are not trained. Ironically, direct-entry midwives aren't even eligible to take the standardized national midwifery examination until they have attended at least fifty births, but there is no requirement for a labor and delivery nurse to have experience as a birth attendant before a hospital assigns her to monitor women in labor, and doctors who do not become obstetricians often finish medical school having attended, if they are lucky, maybe one or two births, but any M.D. is licensed to attend births.

In 1995, in Connecticut, a direct-entry midwife attending home births was arrested for practicing medicine without a license—a test case that ended up in a state hearing at which a hearing officer would decide whether or not she should be able to practice.
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At the hearing, the director of the state's health department insisted that this midwife should not be allowed to practice because she was a “lay” midwife, trained in an apprenticeship.

When it was my turn to testify, I said that I have a license to practice medicine in California even though by the director's definition, I am a “lay” doctor. I explained: My first two years in medical school at UCLA, I was not required to attend classes; I just had to show up for and pass examinations. The next two years in medical school, I was rotating on various hospital wards and clinics where my teaching was “bedside” teaching, that is, an apprenticeship. My internship was pure apprenticeship—there was no classroom teaching and there weren't even examinations to pass. And my specialty training in neonatology and obstetrics was an apprenticeship with no classes, as all I had to do was pass the final specialty examination. So I pointed out that my training as a physician was also by apprenticeship and examination, just like the midwife's.

In the United States, we tend to believe that the “formal” classroom is the only legitimate place to learn. But for one hundred years, the apprenticeship model has been the foundation of all medical education. Direct-entry midwifery training uses the apprenticeship model as well, with midwives gaining experience in prenatal care and assisting births together with a midwife mentor. Then, after documenting the minimum experience required, midwives
take standard examinations. This training has now been officially approved by the U.S. Department of Education.
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The renaissance of direct-entry midwifery in the United States over the past two decades is largely due to the development of the North American Registry of Midwives (NARM) standardized national examination required for the certified professional midwife (CPM) training and certification process. Educators see the NARM examination and the CPM certification process as exemplary, progressive programs because they combine apprenticeship and distance learning, an approach most see as the wave of the future for educating health professionals.

The WHO's definition of a midwife is one who has successfully completed the educational program recognized by the government that licenses the midwife to practice. The definition does not specify the length or type of education or training or mention specific academic degrees, as these matters are decided by individual governments. In the United States, most of those states that license direct-entry midwives use CPM certification as the official definition.

Some American obstetricians believe that they are responsible for supervising midwives (a belief that has been used to keep midwives from practicing freely). But this is a misunderstanding. Midwives are not supervised by doctors. A midwife is an independent professional, separate from other maternity care providers. Note that the WHO's definition of midwifery does not contain the words
nurse, obstetrician
, or
supervision
, because in most of the world midwives are not trained first as nurses and they are not supervised by obstetricians.

The evaluation and standardization of the NARM examination has been extremely thorough—perhaps even more thorough than most medical or nursing examinations. There can be no doubt that someone who passes the NARM examination and is a CPM is competent to assist during normal births and can carry out all necessary procedures, including administering oxygen or drugs, performing neonatal resuscitation, and so on. An apprenticeship includes formal and informal instruction in all scientific and clinical topics necessary to practice competent midwifery.

In recent years, around half of the states have passed legislation legalizing direct-entry midwives to attend planned out-of-hospital birth. In approximately sixteen states, the legislation refers to the NARM examination and CPM certification. In several states that have such legislation, when it was up for consideration in the state legislatures, medical and obstetrical societies testified against it in an attempt to protect their monopoly.
They usually took the position that midwives and planned out-of-hospital births are “not safe,” but, as there are no data to back up such claims, after careful consideration of the scientific evidence, every one of the legislatures determined that these are safe options for their citizens, and the laws were passed.

In the Connecticut case, the hearing officer ruled that the practice of midwifery is not the same as the practice of nurse-midwifery, and that the direct-entry midwife was legally providing midwifery services. The hearing officer further advised the Department of Public Health in Connecticut that if it wanted to regulate the practice of midwifery, it would have to pursue it through the legislature.

The Connecticut Department of Health has yet to do so, but, six years later, in 2002, it again attacked direct-entry midwives who had passed the NARM exam and were CPMs.
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First, the Department of Health sued two CPMs who refused to release the records of a client who did not want her records disclosed. The client had had a home birth the previous year that ended in a timely transfer to a hospital when medical assistance appeared to be needed. The woman and baby recovered with no problems, but the state Department of Public Health threatened to charge the two CPMs with practicing “outside the scope of their nursing licenses” or “practicing nurse-midwifery without a license” if they did not release the records—rehashing the arguments that were thrown out in the hearing six years earlier.

Around the same time, two Connecticut CPMs were charged with “practicing medicine without a license”—again, because they had transferred their home birth client to the hospital.
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In this case as well, the woman and the baby were fine. It is important to note that, in both cases, the birthing families were pleased with their care and felt that the transfer from midwifery care to medical care was appropriate. Both families continue to support their midwives and have had no part in instigating the charges brought against them, so it is likely that the charges were brought by the hospital. These cases illustrate again that it is doctors and their allies, not families, who go after midwives in legal cases, whereas when obstetricians are sued, it is usually by families who are looking for answers.