Born in the USA (23 page)

Another common strategy in the witch-hunt (which was used in all three Connecticut cases) is to accuse a midwife of practicing medicine without a license, a charge that reveals a fundamental misunderstanding of midwifery. Midwifery is not the practice of medicine; it is a professional practice in its own right. The cases in Connecticut are similar to other cases
in Vermont and Kansas in the 1980s and 1990s in which a legal determination was made that practicing midwifery is not the same as practicing medicine.
²⁹
In December 1999, the same charge was raised in California. In the decision, J. R. Roman, an administrative law judge on California's Medical Quality Hearing Panel, wrote:

But the witch-hunt continues. In the last several years in many states, including Illinois, Utah, California, Vermont, Virginia, Nevada, Oregon, Indiana, and Ohio, police have arrested direct-entry midwives for practicing nursing or medicine without a license.

One can't help but wonder why someone would choose a career as a midwife or a doula. Midwives and doulas are harassed by doctors, nurses, hospitals, and sometimes even local newspapers. They're on call 24/7, and when a client goes into labor they may be away from home, attending the
birthing woman, for hours or days. The pay is not good and often uncertain. To choose that life, someone must really want it. When I talk to midwives and doulas, there is no doubt in my mind that it is more than a job, it is a vocation—for some, even a “calling.” Midwives and doulas love the one-on-one with women, the hands-on experience of assisting at many (beautiful) births. For some, it is an ideal career to start later in life, after raising children. Most important, a midwife or doula knows that she is playing a part in the historical struggle for equality for women.

To understand the source of a midwife's deep commitment, it helps to observe or read about home births. Juliana van Olphen-Fehr, the director of the School of Midwifery at the University of Shenandoah in Virginia and the author of
Diary of a Midwife
, wrote of her own home birth: “This was my strength . . . if I could have a baby on my own and with all my dignity, I could do anything in the world. . . . No one could take away my competence, my knowledge, my compassion and my integrity as a midwife.”
³¹

Maternity care in the United States is changing, and one of the most important changes still in progress involves who will catch the three and a half million babies a year whose mothers have had normal pregnancies. That is, who will be the primary birth attendant for low-risk births? In the past decade, the percentage of births attended by midwives has gone from 5 percent to 10 percent, and, as mentioned earlier, there are a few places where it is closer to 25 percent. HMOs are hiring more and more midwives. Kaiser Permanente, one of the largest HMOs in the country, has many midwives on its staff and the largest HMO in New Mexico has more staff midwives than staff obstetricians. There are several reasons for the growth of midwifery in the United States, and a big one is money.

Midwifery is far cheaper than obstetrics for two reasons. On average, obstetricians take home a
net
income in the neighborhood of two hundred thousand dollars a year, whereas midwives earn about one-quarter of that. Equally important, the cost of the obstetric interventions, such as induction and C-section, performed
unnecessarily
can easily be cut in half by having midwives, rather than obstetricians, assist at normal births. Health care in the United States is very much driven by the bottom line, and slowly but surely the insurance companies, managed health care organizations, HMOs, and even state and federal government agencies are realizing that the obstetric monopoly is wasting enormous amounts of money. The day that truth fully sinks in will be the day the obstetric monopoly is on its way out. For a detailed discussion of cost saving by using midwives, see
chapter 9
.

As midwifery becomes better established in the United States, it becomes
more difficult for the obstetric establishment to perpetuate the myth that midwives are not as safe as doctors. Pushing the “safety” issue has backfired as a way for obstetricians to protect their territory. Because there is such a campaign by American obstetricians to convince the public that planned home births attended by midwives are dangerous, it is necessary to carefully review the scientific evidence. This is done in
chapter 6
, where a review of the research leaves no doubt that a planned home birth attended by a nurse-midwife or direct-entry midwife is a perfectly safe option for the 80 to 90 percent of women who have had normal pregnancies. As more state legislatures look carefully at the data and realize that they have been denying families a safe maternity care option, momentum will grow and laws that support and protect midwives will spread to other states.

Another reason midwifery is going to grow: Americans believe in a free market economy with open competition. Obstetricians and midwives both offer primary maternity care. They compete for clients. In those states where doctors are still regulating midwives, we can expect that eventually a midwife who has had her license revoked will sue the state medical board for restraint of trade as it becomes clear that doctors are using their power unlawfully to eliminate their competition.

Finally, midwifery will continue to grow as more women come to appreciate that maternity care is not primarily a health issue but a women's issue. Midwifery plays an important role in strengthening women's control over their own bodies and reproductive systems. The following story illustrates the degree to which fundamental human rights are now at stake in the realm of maternity care.

A woman in northern Florida we will call Ms. P had a normal vaginal birth with her first pregnancy.
³²
Her second birth, however, ended with a C-section that she believed was unnecessary, so when she got pregnant a third time, she sought a local midwife and signed on for a planned home birth.

Ms. P had a normal pregnancy, and when she went into labor, her midwife came to her home to attend the birth. The labor progressed nicely, but after some hours Ms. P was having a hard time keeping fluids down. Since the local hospital was only a couple of blocks away, her midwife suggested that they go over to the emergency room for a short time to get an intravenous drip (IV) to hydrate her, and then return home.

In the ER, Ms. P told the staff that she was giving birth at home and would like an IV for a short time. She was put in a room and told to wait for a doctor. When the doctor arrived, he asked if she had had a previous
C-section, and when she replied yes, the doctor said that he wanted to admit her for an immediate C-section. Ms. P said, “No thank you, I just want the IV, and then I'm going home.” The doctor became adamant, telling her that she “must” have a C-section, and said that he would consent to give her the IV only if she consented to the C-section. When she refused his attempt to coerce her, the doctor said that if she did not consent to the C-section, the hospital would get a court order to do the C-section. The doctor then asked her to wait, and left the room.

As is typical in any hospital, word of what was going on in the ER spread among the staff. After a few minutes, a nurse ducked into the room where Ms. P was waiting and whispered, “If you don't want to have a cesarean section by force, you better get out of here quick. There is a back entrance to the ER if you go out and turn right.”

Ms. P escaped by the back entrance and went home, where she continued her labor without the benefit of an IV. (Note that the hospital never offered Ms. P the option of having a vaginal birth in the hospital with a staff doctor handy.)

Meanwhile, the chief of obstetrics called an emergency meeting with the hospital administrator and told him that the woman's baby was in grave danger of dying due to a ruptured uterus if an emergency C-section was not done quickly. What he said is not true. Studies have shown that Ms. P's C-section meant that she had a slightly higher chance of uterine rupture than a woman who had never had a cesarean, but the risk was still small—especially since labor was not being induced with drugs—and the chance that the baby would die was even smaller. The hospital administrator, however, was not an obstetrician and had no idea whether or not the information was accurate. He called a local judge and told him to rush over, as it was a life-and-death situation. The judge came to the hospital and was told the same story by the obstetrician. He signed a court order for an immediate C-section—by force, if necessary.

Ms. P was continuing her labor at home when there was a knock on the door. She opened the door to the local sheriff, who was a friend of hers and a member of her church. The sheriff said, “I'm really terribly sorry, Ms. P, but I have here a warrant for your arrest.” Shocked, Ms. P said, “What on earth for?” The sheriff answered, “I'm terribly sorry. I don't know what the hell is going on. My orders are to take you to the hospital, in handcuffs if necessary.”

Against her wishes and the repeated objections of her husband, Ms. P was taken to the hospital, taken to the surgery ward, tied down on an operating
table, and given a forced C-section. The story doesn't end here. Ms. P and her husband sued the doctors and the hospital. However, in Florida a judge must decide if a case deserves to go to trial, and another local judge decided that Ms. P's case was not worthy of proceeding, so her case never went to trial—a shocking miscarriage of justice, given the serious violation of Ms. P's basic rights. Since then, Ms. P has had another baby, born vaginally at home with no problems. Needless to say, there was no visit to the hospital during the labor.

It is important that women in this country become aware of the danger to birthing women and join the movement to protect them. Ms. P's family's wishes were not honored, and her body was invaded against her will. Her human rights were violated. In another recent case, a woman in Utah who refused a C-section and had a stillborn was accused by the district attorney of murder. She was able to avoid the homicide charge by pleading guilty to lesser child endangerment charges, but the case raises important and troubling issues regarding the autonomy rights of pregnant women and whether a disparity exists between the rights of pregnant women and other persons.
³³
Treating pregnant women in this manner goes against the Nuremberg Code and the Helsinki Accord, which explicitly state an individual has absolute rights over her or his own body and no medical treatment can ever be forced. Cases like this indicate a dangerous trend in U.S. maternity care toward totalitarian control of a woman's reproductive life by doctors.

Midwives have been fighting to protect the rights of birthing women for a long time. They have not always presented a united front, however, and the divisions among them have hurt the cause. Midwives of every stripe have been oppressed in the United States for more than a hundred years, and, as often happens in oppressed cultures, the oppressed fight among themselves rather than taking on the oppressor. In the 1960s and 1970s, nurse-midwives were the only midwives practicing in the United States, with the exception of a small number of underground home birth midwives. As direct-entry midwifery began to flourish in the 1980s and 1990s, a tragic struggle evolved. In some states, when legislation to legalize direct-entry midwifery was proposed, nurse-midwifery organizations joined with medical and nursing associations and testified against it. In the 1990s in New York, a new state midwifery board was formed, but only nurse-midwives were included on the board, and when the police came to arrest the direct-entry midwife in upstate New York in the story recounted earlier in this chapter, the state midwifery board took no action to stop it.

Early in the 1990s, a group of certified nurse-midwives (CNMs) who had roots in direct-entry midwifery and home birth formed a “bridge club” with the goal of bridging the gap between CNMs and direct-entry midwives in the United States. Some dialogue took place, but after a short effort, the discussions ended badly. Now change is in the air. Younger graduates of nurse-midwifery schools have a better understanding of direct-entry midwifery and are more willing to work with their counterparts in that profession. In states such as Virginia and California, state nurse-midwifery organizations have worked to pass legislation to legalize direct-entry midwifery.