Born in the USA (24 page)

This increasing unity among midwives is at least partly due to the fact that although direct-entry midwives were the original victims of the witchhunt, more nurse-midwives have felt the heat in recent years. Earlier in this chapter we saw that in the past several years, groups of nurse-midwives in Texas, Ohio, New York, and Washington, D.C., have been fired. American midwives now understand that unity is critical in their fight to expand and legitimize midwifery as the primary health profession for normal pregnancy and birth.

Another key strategy for midwives must be to push for autonomy—recognition that midwifery is an independent health care profession with its own certification, licensure, and state boards—and for an egalitarian relationship with doctors. From the beginning, nurse-midwives elected to join the nursing and physician camps in order to survive, though midwifery is not the practice of nursing or medicine. They did survive, so they can't be faulted, but now they're faced with the hard task of extricating themselves from both camps. Direct-entry midwives have taken a lot more heat for being out-of-hospital independent practitioners, but, in their position, achieving autonomy, though not easy, is less difficult.

One of the strongest tools available to all midwives as they work toward autonomy is scientific evidence. The data are in: midwives are safe, midwifery practice is far closer to evidence-based practice than obstetric practice is, and midwives don't need “supervision” any more than other primary care workers, such as family physicians, need supervision. For this reason, it would behoove midwives to insist on accountability and transparency in maternity care. Their results are excellent, with very low rates of mortality for both women and babies, even though they often work with families who are at higher risk, such as families living in poverty. Fortunately, transparency and accountability are becoming ever more popular in the United States, in all areas, from education to business to health care.

Home birth is child abuse in its earliest form.

KEITH RUSSELL, PAST PRESIDENT OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, 1992

Discussions of home birth usually generate much more heat than light.

WORLD HEALTH ORGANIZATION, 1985

Women in the United States have the right to choose who they want to attend the birth of their child, and they also have a choice regarding where the birth will take place—in a hospital, in an alternative birth center, or at home. These are two different choices, though if an American woman chooses a doctor as her birth attendant, she cannot choose a home birth, since doctors in the United States no longer attend home births. Home births are attended only by midwives, and since that represents a loss of business for doctors, doctors attack home births with zeal.

In
chapter 5
, I told a story about a direct-entry midwife in upstate New York who was entrapped by the “obstetric police” masquerading as a couple expecting a baby. The midwife was fully trained and had experience, and there was no evidence of malpractice. She could have been licensed in many states without difficulty, but it was unclear whether she was licensed in New York State because it had an ambiguous new midwifery law. A passionate turf battle has been taking place in New York State since the 1980s between direct-entry midwives and obstetricians, with most nurse-midwives taking the side of obstetricians. This particular midwife was caught in the middle.

Such battles are by no means limited to New York State. A California midwife, Ms. S, was at home with two of her three children, ages five and
eleven, when she heard loud banging at the front door and someone shouting “Open up! Police!”
¹
Before she could get to the door, six armed policemen burst in (the door was unlocked), one of them wearing a bulletproof vest. They ordered the midwife and her children to stay in the living room while they ransacked the house. Ms. S was not permitted to leave the living room to see what the police were doing.

“Why?” she asked.

“Because you might have a gun,” the man in charge replied.

While this was going on, the midwife's nine-year-old son arrived home from school and was upset to find armed police going through his home. The three children became hysterical. Ms. S told the policeman in charge that she intended to phone her mother to come and get the children. She was prevented from doing so. In time the police got tired of the sound of screaming children, however, and relented. When the grandmother arrived, the police demanded to see her I.D. before “turning over” the children to her. The midwife told the police, “These are not your children, they're mine. This is my house.” She won that round; the children left with their grandmother.

The police spent three hours searching and packed up thirty-eight boxes of Ms. S's possessions—a strange miscellany that included not only midwifery equipment and client records, but also books and magazines about childcare, toiletries, even a hair curling iron. The items were impounded and turned over to the district attorney. Imagine some young assistant district attorney painstakingly sorting through the boxes, scratching his head and wondering what the devil that curling iron was used for—possibly a baby born with straight hair?

This midwife's only crime was that she had attended home births. There had been no adverse outcomes to precipitate a malpractice complaint. A local obstetrician who was against home birth simply reported her to the California State Board of Medical Quality Assurance because he “thought she might be dangerous.” He offered no specific charges, and no charges were needed. The board was willing to investigate. As part of the investigation, the board wanted to search the midwife's patient charts for possible malpractice, and, without providing a shred of evidence beyond the obstetrician's vague complaint, they were awarded a search warrant.

One hundred of Ms. S's friends and supporters, many of them families whose births she had attended, rallied to her defense in a demonstration at the state capitol. The demonstration received considerable media coverage. One TV channel ran a call-in poll on whether home birth midwifery
should be legal. The poll recorded 88 percent in favor. Ultimately, no charges were brought against Ms. S.

In another case, the California State Board of Medical Quality Assurance instigated an entrapment operation that led to local police arresting a breast-feeding midwife. They took away her infant and threw the midwife in jail—for no other reason than that a young obstetrician practicing in the same area accused her of practicing medicine without a license. (He was trying to build his practice and the midwife was formidable competition.) This midwife had had no bad outcomes from her home births that might have raised concern among doctors.

California midwives were outraged. They raised money, secured an excellent lawyer, and located outside medical experts to testify. Then, suddenly, just as the court case got started, the district attorney dropped the charges. Perhaps he had not expected such serious opposition. In any case, the suit had already achieved its purpose: the midwife had been harassed.

In another California case, a midwife's thirteen-year-old daughter was held on the floor at gunpoint while the police searched their home for evidence.

Nurse-midwives in California have not escaped police either. Three nurse-midwives were handcuffed and jailed after a home birth.

Although it is usually a doctor or hospital who makes the original complaint against a midwife, it is medical boards that initiate and pursue these cases and order police investigations, and a representative of the board usually accompanies the police. These aggressive police actions—bursting through the door, holding a child down on the floor, handcuffing, taking midwives off to jail—are inexplicable. None of these women resisted arrest. No one can think there was any real danger of life and limb. The only reasonable explanation is police harassment.

The “obstetric police” (state medical boards that order police investigations) don't limit their harassment to midwives; they also do everything they can to intimidate home birth families. In New York State, an orthodox Jewish family had a home birth with a midwife. The state medical board got wind of it and started an investigation. When the authorities asked the family who the midwife was, the family replied that the birth of their child was guided by religious customs and was no business of the government. The parents were summoned before a grand jury and told that if they didn't name the midwife, they would be found in contempt of court and could go to jail. They refused.

One final real-life story from the obstetric police files: In 2002, a woman
in California having her fourth baby in a planned home birth developed a possible minor problem during labor, and her midwife transferred her to a large HMO hospital. The hospital staff attempted to scare the woman by telling her that she had put the life of her baby in serious jeopardy by attempting a home birth. They irresponsibly told her that research has found that twice as many babies die in home births as in hospital births, mentioning a study in Washington State that, as we will see later in this chapter, has been discredited for gross misclassification. The birth proceeded normally, and after both mother and newborn had been checked by a doctor and found to be fine, the woman asked to be discharged. The pediatrician said no, terrified that a baby born after the mother had labored at home might develop serious medical problems. When the mother insisted, the pediatrician called the police to file a complaint to force her and her baby to stay in the hospital until he said that it was okay to go home.

These stories, like the story in
chapter 5
of a woman having a home birth who was taken to the hospital against her will and given a forced C-section, illustrate human rights abuses that we might expect to see in a police state but not in our free country.
²
Why is it happening? Where does all this medical anger toward planned home birth come from? Let's trace it back.

The technological era that followed World War II touched all aspects of life in the United States, including medicine and health care, and shaped our attitudes in profound and subtle ways. If we can put a man on the moon, the thinking went, then surely we can make sure that every baby is born healthy: the answer is to have all women give birth in hospitals, where the latest technology is available. There were no studies done to investigate the validity of this thinking. It was simply assumed that hospitals were safer for births, whether or not the birth involved complications. Inside the hospitals, the practice of using interventions in maternity care and assuming that they were safe before any scientific evaluation became the norm. As far as most health care professionals were concerned, high-tech birth was the wave of the future.

In 1975, the American College of Obstetricians and Gynecologists (ACOG) made its position official and published a recommendation against home birth: “Labor and delivery, while a physiological process, clearly presents potential hazards to both mother and fetus before and after birth. These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation.”
³
ACOG cited no studies to back up this statement, apparently assuming that everyone would simply take the organization's word.

At that time, what little research had been done on out-of-hospital birth failed to separate planned and unplanned out-of-hospital births. But then scientists showed that the findings in these studies were seriously faulty. There were more babies dying in out-of-hospital births because the studies put all out-of-hospital births in one category. When out-of-hospital births were separated into two categories—planned home births and unplanned out-of-hospital births (those that never made it to the hospital and took place, for example, in a taxi cab)—then the rate of babies dying in planned home births was no higher than the rate of babies dying in hospital births, while the mortality rate in unplanned out-of-hospital births was fifty times higher.
⁴

In the quarter century since this separation and clarification, ACOG has never changed its policy against home birth. In fact, in 2002 it reissued its recommendation against home birth—still with no references to back up its position.
⁵

Over time, other events contributed to the mounting distrust of hightech hospital birth. Doctors insisted that moving birth to the hospital was the reason for the falling rate of perinatal mortality (babies dying around the time of birth) in the United States in the 1950s to 1990s. But epidemiologists corrected them, explaining that this perspective was a case of two things happening at the same time and falsely assuming cause and effect. Gradually an understanding evolved in the scientific community that the fall in perinatal mortality was due largely to social factors, such as better housing, better nutrition, and family planning. To the extent that doctors and hospitals played a role in saving babies, it was the introduction of general medical advances such as antibiotics and safe blood transfusion that were responsible, not women giving birth in hospitals or any of the hightech interventions. Then, in the 1950s and 1970s, two of the drugs that were frequently given to pregnant women, thalidomide and diethylstilbestrol (DES), were found to cause birth defects. The women's movement became aware of how doctors were imposing their will on women's reproductive lives and maternity care, and a reaction against the medicalization and dehumanization of birth began.

In the 1980s, two quite different approaches to maternity care evolved: the medical model advocated by doctors, and the social or humanized model advocated by most midwives, perinatal scientists, and many public health professionals and women's groups. Humanized birth means putting the woman giving birth in the center and in control so that she, not the doctors or anyone else, makes all the decisions about what will happen.
Humanized birth means that the focus of maternity services is community-based (out-of-hospital) primary care, not hospital-based tertiary (specialist) care, with midwives, nurses, and doctors all working together in harmony as equals. Humanized birth means maternity services that are based on good scientific evidence, including evidence-based use of technology and drugs.
⁶