It's your birth -- show up for it!
Women are increasingly at the center of their own health care and many argue that they particularly need to be their own advocates about how and where they will give birth. One thing to remember while pregnant and planning the birth of a baby is that the care provider a woman chooses can have a lot to do with her birth experience and ultimately, how she will feel about it.
Although certified nurse-midwifery got it start in this country in the 1920s, women have been helping other women deliver their babies since the beginning of time. The word “midwife” means simply “with woman.”
The midwifery model of birth is completely different from the medical model, in that it sees birth as a natural physiological event, not an “accident waiting to happen,” said Kathleen McCarthy, CNM, MSN, and co-owner of The Birth Center in Wilmington.
According to ChildBirthConnection.org, a national not-for-profit organization that has aimed to use research, education and advocacy to improve maternity care for all women and their families since 1918, views of the childbearing process and of appropriate care for childbearing women vary.
“Two contrasting perspectives are often called the ‘midwifery model of care’ and the ‘medical model of care.’ There are striking differences in the two models. These differences can have a great impact on your experience and outcomes,” notes on the Web site.
Some contrasts between the two models include: The midwifery model of care focuses on health, wellness and prevention; views labor/birth is a normal/physiological processes; has lower rates of using interventions; the mother gives birth, and care is individualized. The medical model of care is noted as focusing on managing problems and complications; views labor/birth as dependent on technology; has higher rates of using interventions; the doctor delivers the baby; and care is routinized.
The models are not black and white, of course, as some OBs might lean more toward a midwifery-type model and some midwives lean more toward the medical model.
In a report in Midwifery Today magazine, “Technology: First do no Harm,” Dr. Marsden Wagner analyzed the use of obstetricians as primary birth attendants for women.
“While midwives trust women’s bodies, use such low-tech assistance as the skilled use of their hands, and understand the importance of preserving normalcy, doctors, in general, do not trust women but trust drugs and machines, use high-tech assistance, and focus on the pursuit of abnormality,” he said.
“So having a highly trained surgeon obstetrician assist at your birth is about as sensible as hiring a pediatric surgeon as a baby sitter for your healthy 2-year-old when you go out in the evening,” he continued. “Like the obstetric surgeon who gives the normal woman a shot to hurry her labor, the pediatric surgeon baby-sitting your normal child will focus on medical management: when your robust 2-year-old gets tired and fussy, the pediatric surgeon will give him or her a shot to hurry the child to sleep.
“The result? In the one case you get the medicalization of birth (remember, birth is not an illness), with a lot of unnecessary risky interventions and very expensive medical care, and in the other case you get the medicalization of childhood (being 2 years old is also not an illness), with unnecessary risky interventions and very expensive baby-sitting.”
For women who are interested in having a midwife-attended birth in Sussex County, there are three main options: drive to The Birth Center in Wilmington, the state’s only free-standing birth center; pick a private practice that employs midwives as well as physicians for a hospital birth; or give birth at home.
Freestanding birth center
The Birth Center, Holistic Women’s Health Care LLC, has provided maternity and gynecological care for 22 years as Delaware’s only freestanding birth center. Freestanding means that although it is less than a block away from a hospital, it is not owned or operated by one. It has a staff of seven registered nurses, an OB/GYN consultant, and a pediatric consultant.
The Birth Center in Wilmington (www.thebirthcenter.com) got its start as an extension to The Birth Center is Bryn Mawr, Pa., because many women from Delaware would travel there to give birth. It is now independently owned by two certified nurse midwives (CNM)s.
According to McCarthy, one of the main differences between receiving routine pregnancy care in a doctor’s office and receiving it at the center is the time spent with each patient.
“A typical first office visit in a doctor’s office is 20 minutes, whereas here it is an hour. And a typical subsequent visit in a doctor’s office is seven minutes, and here it is around 20 to 30.”
Another one of the differences women might see at The Birth Center is the fact that they can wear their own clothes, have as many support people as they need or want, and can eat and drink throughout labor — something not encouraged in hospital births because of the chance they would need surgery should their labor not progress. These are all areas in which differences between the two school of thoughts can be seen. In a hospital, a laboring woman might get fluids through an IV and labor without eating anything for hours.
“Labor is like running a marathon, and you wouldn’t run a marathon without eating or drinking,” explained McCarthy.
McCarthy said The Birth Center sees patients of varying socio-economic and education levels. The Birth Center also sees women regardless of their age or number of pregnancies.
There are certain types of situations the birth center views as inappropriate for the out-of-hospital birth provides: it does not accept clients carrying twins and, although women with breech pregnancies and those planning a vaginal birth after Cesearean, or VBAC, can go to the center for pre-natal care, The Birth Center does not attend those deliveries.
“We can do your care, but have agreements with an OB should we need to ‘risk out’ patients,” said McCarthy. “Also, although we are a freestanding center, we are located less than a block away from the hospital and in times of need of neonatal transportation, it flows effortlessly. We are all part of the same system.”
McCarthy added that, even though a woman that ends up being ‘risked out’ of delivery at The Birth Center might not have met with the OB consultant beforehand, that situation is not unlike many of the larger OB practices where a woman might not have met the person who ends up attending her birth. Women at The Birth Center see each of the CNMs there during her pre-natal care, to ensure they’re familiar with the one who will end up attending their birth.
McCarthy said that, at The Birth Center, women are like family, because the extra time and support given to them surrounding the pregnancy and birth lends itself to really connecting with the women and their extended families.
“Not only do we see the women as families, but the other families connect to each other as well. We are having a barbecue next week for everybody, and we’ll be having a showing of ‘The Business of Being Born’ in the coming weeks,” said McCarthy.
“The Business of Being Born” is a documentary produced by actress and television host Ricki Lake to support out-of-hospital births after her experience with the birth of her first baby, directed by Abby Epstein. It is now available on DVD (www.thebusinessofbeingborn.com).
Midwife in hospital setting
Carrie S. Keane, CNM, MSN, is one of the area midwives with privileges at Beebe Hospital in Lewes.
“It’s a balance of science and nature,” said Keane of the midwifery model of care versus the medical model. “You respect the science of it, and they [the doctors] respect the art of it. A midwife and a doctor are like a carpenter and a plumber. You very much respect each other’s role, but it’s a whole different job.”
Keane works at Bayside Health (a practice made up of four doctors and three nurse-midwives), where pregnant women rotate to see each of the seven providers throughout their pregnancies, much like other large practices in the area. A pregnant woman could end up with any one of the four doctors or three midwives attending their births.
“How it works, usually, is a midwife is on first call, so that would be the first person they would see [in labor]” offered Keane.
The challenge with a large practice is that there is not one universal philosophy. Advocates for women’s birth choices say that a pregnant woman must be diligent in her quest for knowledge and ask each and every one of the members their opinions on things that are important to her and will likely affect her birth experience.
What one person might think is old-fashioned or outdated, another might think is the best route for that situation. It is up to the woman, the consumer, to decipher and to make sure that her goals mesh with the person who ends up attending her birth.
Although midwives in general see birth as a natural event, even midwives in the same practice have different approaches and personalities, something women have to think about and be aware of when the time comes to have their baby.
“There’s not one philosophy for the practice,” said Keane. She explained that because Bayside Health practitioners are often coming on shift after someone else in the practice, a woman in labor might already be started on pitcoin and IV and an epidural — things she said Keane can’t reverse once she gets there, even if her recommendations to the patient would have been different.
Also, in working with four doctors and two other midwives in the practice, Keane admitted that, in such a situation, even midwife-attended births tend to be become more medicalized than in the birth center experience.
“It’s a really hard job, especially in the hospital, where we spread ourselves thin. Just think, when you are working 9 to 4 in the office all day and then you are on call at the hospital, and the reality is you have to get up and go to work the next day, and you haven’t seen your family in days, are you going to have a woman in labor all night or give pitocin to get things moving along? You almost have to.
“Is it wrong? Definitely,” she said. “And I don’t do it all that often, but I have done it. I think everybody can admit to having done it. It’s brutal, but it’s a fact of the matter. We care about women, but we care about our own family too.”
That fact that the natural, physiological event of birth is becoming more and more medicalized with more inductions, more interventions and ultimately more Cesarean sections cannot entirely be blamed on the doctors and midwives, according to Keane. She stresses that patients are at the center of their care and need to be educated and be their own advocates.
“There are entirely too many C-sections — unnecessarily so, but it is a matter of liability,” said Keane. “It’s absolutely terrible — horrific. We are taking the nature out of birth.
“But it is not entirely our fault. Elective inductions are up, even though your chances of having a C-section go up with them,” she noted. “People beg us to induce them, and people insist on having C-sections, and insist on coming to the hospital too early. It is not a matter of the doctors doing it to the patients. The patients do it to themselves. It is a sad situation.”
According to a 2006 press release from Citizens for Midwifery, results from a Listening to Mothers survey done by childbirthconnection.org indicate the extreme rarity of a woman asking for a Cesarean section. According to the survey, “Only 1 (0.08 percent) out of 1,300 women who could have asked for a primary (first) Cesarean section actually requested it.”
“In other words, ‘patient choice’ Cesarean section is a myth,” pointed out Citizens for Midwifery Board Member Nasima Pfaffl. “Until recently, no one actually asked women if they were requesting Cesareans, it was just assumed that Cesarean sections for no medical reason equaled ‘patient choice’ Cesareans. Today, we know this assumption is wrong; birth certificates and hospital discharge data do not include any information about women’s intentions or decision-making.”
Citizens for Midwifery goes on to say that there were significant discrepancies in what women understood the reasons for the surgery to be and what was indicated in the birth certificate and hospital discharge data.
“Most significantly, results of the Childbirth Connection survey (of births in 2005) (http://www.childbirthconnection.org/article.asp?ck=10372) show that there is a serious discrepancy between what women understand as the reason for their Cesareans and what the birth certificate data says. Birth certificate and hospital discharge data show that Cesarean sections performed for no medical reason have been increasing, amounting to about 2 percent of all births in 2001. In contrast, of the women surveyed, 99.2 percent of those who had primary Cesarean sections believed that there was, in fact, a medical reason, presumably based on what their doctors told them.”
Keane offered that many times the patients will have family members present who influence their decision-making, which doesn’t always help the situation.
“Patients need information. People will have their family in there, and they’ll ask, ‘Why is it taking so long?’ And women bring their husbands in, and, often, they don’t know what to do. Sometimes it is their only support person. Women should bring other women — their girlfriends — to bring it back to a female-centered approach.”
“I’m making it sound all bad,” said Keane. “But it’s not. I just came off a weekend of five glorious deliveries where the patients were joyous and happy with the choices they made, even if that meant a C-section. A joyous birth is when it happens on the patient’s terms and when the patient is happy with the choices they make. They feel like they triumphed.”
When asked what she would choose for a birth setting if she herself were to become pregnant, Keane answered that she would have the baby at home.
“It is safe to do a home birth,” she emphasized. “There are always foreshadowing events where you could ‘risk out.’ You always keep an eye out for those events and signs. I would stay at home. I’d have tons of people there, and they’d all be baking cookies in the kitchen: my family, my sisters, my mother, and I hope my midwife friends would come, and my husband would catch the baby…
“But, with that said, I would have a back-up plan. At the first sign of anything, high blood pressure or a baby in a funky position, I would not take the risk and I’d change the plan.”
Midwife-attended home birth
Many women wish to explore the idea of giving birth at home, attended by a midwife. It is something Sheila Pritchett of Bridgeville has been trying to achieve for 23 years.
Pritchett has five children and is currently pregnant with her sixth. Her first two children were born at The Birth Center in Wilmington. But she knew that for the third she wanted to have the baby at home, because of her history of short labors — and the long trip to Wilmington.
“For our third, we were going to a Mennonite Church, and there’s one midwife in Delaware than can legally assist the Amish and Mennonite with home births, and we had planned to use her. But the baby ending up being born in the car, in front of the Dover Air Force Base,” said Pritchett.
For the fourth child, they used a midwife that had been helping some families, but, despite a positive experience with that birth, using her was not an option for the fifth baby.
“We found a homebirth midwife, and it was wonderful. But she was contacted by the medical board and asked not to come back to the area,” Pritchett noted. “For the fifth baby, we were no longer attending a Mennonite church, so we couldn’t go back to that first midwife.
“If I am the same person with the same beliefs, but I just don’t go to church with ‘Mennonite’ in the title anymore, how is that fair to me?” she asked. “So, for the fifth, I felt forced to go to a hospital to give birth.”
Pritchett never made it to the hospital, and that baby was delivered at home as well, although it was not something she was planning.
“I called my husband and three friends, and in the end I had everything I needed. But an unassisted homebirth is nothing I would ever plan for myself,” she said. That circumstance spurred Pritchett to take action. “In 23 years, nothing has changed in Delaware, so I jumped on board with [Delaware Friends of Midwives.]”
Delaware law currently requires direct-entry or non-nurse midwives wishing to assist with births in the state to obtain a permit from the State of Delaware. To get that permit, an applicant must prove completion of an accredited midwifery program and must have a collaborative agreement with an obstetrician for “back-up” coverage, should an emergency arise.
Requirements include that the midwife:
• Demonstrates completion of an accredited midwifery education program and is a Nationally Certified Midwife as demonstrated by possessing a valid certification of Certified Professional Midwives (CPM) from the North American Registry of Midwives or Certified Midwife (CM) from the American College of Nurse–Midwives Certification Council or an equivalent certification (a certified non-nurse midwife).
• Establishes a collaborative agreement with a Delaware-licensed physician with obstetrical hospital privileges which includes at a minimum: a minimum number of medical provider prenatal visits; guidelines and protocols that must include access and use of oxygen, medications (including Intravenous medications), emergency protocols for labor, delivery, and postpartum for both mother and neonate.
• Submits to the Division of Public Health a sample contract between the midwife and the pregnant women, outlining the scope of practice and potential risk factors and complications.
Although Delaware is one of only 20 states that have any licensure available for non-nurse midwives, Pritchett said the idea that a midwife has to have the collaborative agreement is part of what Delaware Friends of Midwives would like dropped in the proposed House Bill 106.
The law, the way it is written, can be seen as a double-edge sword — the midwives need the collaborative agreement to be legally practicing in the state, and yet OBs are reluctant to sign on.
“We’d like to have that part dropped. The way the law is worded now is like telling Shell they can open gas stations in Delaware as long as they have approval from Exxon… or that nail salons can operate as long as they have approval from the full-service salons who do nails as well as hair, make-up and massage,” said Pritchett.
“And I received an e-mail yesterday from a midwife who wrote to 100 OB/GYNs asking for that back-up, and she only received two responses, both of which were negative,” she said.
According to the North American Registry of Midwives (NARM), which was created in 1987 by the Midwives’ Alliance of North America (MANA), the group is an “international certification agency whose mission is to establish and administer certification for the credential Certified Professional Midwife (CPM).
“CPM certification validates entry-level knowledge, skills and experience vital to responsible midwifery practice. This international certification process encompasses multiple educational routes of entry including apprenticeship, self-study, private midwifery schools, college- and university- based midwifery programs, and nurse-midwifery.”
“A lot are regulated under NARM [North American Registry of Midwives], and we want that,” declared Pritchett. “We don’t want just anybody to be able to say, ‘I’m a midwife.’”
Pritchett noted that the differences between midwives’ model of care and doctors’ is great and is often the reason for completely different birth experiences.
“The school of thought behind midwives or nurse-midwives, and doctors, starts in two different places and often ends up in two very different places. It’s when you try to mix the two that conflict comes in.”
“I’m thankful for the medical community and have friends that wouldn’t be here if it wasn’t for the skills of an OB, but it is much nicer to stay at home and let the natural progression of birth take over.”
May 5 was International Midwives Day, and Delaware Friends of Midwives planned to celebrate the event on May 15 (after Coastal Point press time) at Legislative Hall in Dover, with a gathering in support of House Bill 106.
“The purpose of the day was twofold,” said Pritchett. “First, we want to thank and support midwives in each of the three categories [hospital-based, birthing center, homebirth]. We also want to educate the legislators and to help them understand that the birth process — when not intervened with — most of the time has a positive outcome and is not necessarily the dangerous situation that some make it out to be; and, to show them that enough of their constituents want out-of-hospital births.”
Despite the increasing demand for home births and a wider range and availability of midwife care, traditional medical establishments often oppose the kinds of changes that would be seen under House Bill 106.
The American College of Obstetricians and Gynecologists (ACOG) recently reiterated its longstanding opposition to home births, stating that: “While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning, even among women with low-risk pregnancies.”
“ACOG acknowledges a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).
“Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre,” they said.
In response, ChildBirthConnection.org states, “ACOG had put out a previous statement (in 2006) that included all out-of-hospital births citing the hospital as ‘the safest setting for labor, delivery, and the immediate postpartum period.’ However, the statement failed to cite any evidence to support the assertions and failed to acknowledge impressive existing evidence regarding the safety of planned home birth and out-of-hospital birth center birth.”
Some individual ACOG members rejected the ACOG statement opposing out-of-hospital birth, as did numerous other organizations, including the American Association of Birth Centers, American College of Nurse-Midwives, Consumers United for Evidence-based Healthcare, Lamaze International, and White Ribbon Alliance for Safe Motherhood.
“The revised statement concluded by stating that ‘ACOG strongly opposes home births’ and ‘does not support programs or individuals that advocate for or who provide home births.’ Again, no study was cited to support this position, and existing research in support of planned home birth was overlooked,” ChildBirthConnection.org noted.
Katie Prown, PhD, campaign manager of The Big Push for Midwives 2008, said in response to the ACOG statement, “It will certainly come as news to the Amish and other groups in this country who have long chosen homebirth that they’re simply being ‘trendy’ or ‘fashionable.’”
“ACOG has it backwards,” said Steff Hedenkamp, communications coordinator of The Big Push and the mother of two children born at home.
“I delivered my babies with a trained, skilled professional midwife because I wanted the safest out-of-hospital care possible. If every state were to follow ACOG’s recommendations and outlaw CPMs, families who choose home birth will be left with no care providers at all. I think we can all agree that this is an irresponsible policy that puts mothers and babies at risk.”
The Big Push reports the following about the states’ midwife regulations:
“Currently, Certified Nurse-Midwives, who work predominantly in hospital settings, are licensed and regulated in all 50 states, while Certified Professional Midwives, who work in out-of-hospital settings, are licensed and regulated in 24 states, with legislation pending in an additional 20 states.”
Delaware is actually one of 19 states that experienced a drop in the number of births attended by a Certified Nurse Midwife (CNM) between 2000 and 2004, according to the American College of Nurse-Midwives. Delaware was the largest proportional drop —from more than 10 percent of vaginal births attended by CNMs in 2000 to 3.9 percent in 2004. But, officials at The Big Push are hopeful nonetheless, because eight states recorded increases of more than 10 percentage points, including New Mexico, West Virginia, Vermont and New Hampshire.
Supporters for women being at the center of their own healthcare say the bottom line is that women are consumers. As one midwife put it, shopping for a provider is like shopping for a pair of jeans: you rarely buy the first pair you try on. So they advise that women ask questions, make lists, compare notes and do research. And if you don’t like the answers — move on to another provider. The only person truly in charge of your birth and your birth experience is you — so show up for it!
For more information on current licensure and regulatory information regarding midwives of all types, including CNMs, CPMs, CMs, or direct-entry midwives, visit Citizens for Midwifery at www.cfmidwifery.org online and click on FAQ. For more information on the North American Registry of Midwives, visit www.narm.org, and for more information on the American College of Nurse Midwives, visit midwife.org.
For much more information on choosing a caregiver and choosing a place of birth, visit www.childbirthconnection.org.