Midwives in Legal Limbo

The closing of birth centers in Takoma Park and Bethesda, Md., demonstrated the challenges facing midwives. Kate Bauer and Kitty Ernst, of the American Association of Birth Centers, took your questions about how malpractice insurance and other strains are leaving those interested in natural childbirth with fewer options.

Bauer and Ernst were online Friday, May 18 at noon ET.

A transcript follows.

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Alexandria, Va.: Besides insurance premiums, do you think that not enough people are aware of birth centers in order to generate enough revenue? Also, will this have any effect on the number of CNMs who do assisted home deliveries?

Kate Bauer: It is important for women to realize how empowering the birth experience can be. We should not try to escape this experience but rather embrace it. I think more women need to be educated about their options for childbirth and make informed decisions based on their needs - not society's expectations.

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Kitty Ernst: and expanding exponentially the number of midwives trained. This will require reallocating the monies, some of it tax dollars, to establishing a proper ratio of midwives to obstetricians. . Midwifery education programs have enormous problems finding the clinical sites for training because they are all controlled by medicine and allocated to medical students who will probably never use the training and the obstetrical residency programs. For the past few years the OB residency programs have had trouble recruiting qualified applicants and instead of opening the arena to midwives to teach these providers how to work together they have been recruiting foreign trained physicians to be surgeons - more of the same. Last year Britain trained 2700 midwives while we trained 3-400. And they feel they are not training enough.

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Warrenton, Va.: The closing of The Maternity Center in Bethesda is a real tragedy. Mothers wishing to avoid hospital births and unnecessary interventions are left with fewer and fewer choices. In 1989, I had an unnecessary cesarean at Holy Cross Hospital because of alleged cephalo-pelvic disproportion. Fortunately, I'd been warned ahead of time to be sure they used the small, transverse incision if such a surgery became necessary. Two years later, I was able to have a VBAC in the wonderful, quiet, warm and supportive atmosphere of The Maternity Center attended by Marian McCartney. I had two more vbacs there; then I had to switch practices because the Maternity Center had become affiliated with Shady Grove Hospital, and hospital policy REQUIRED that any mother who had EVER had a c-section would have to deliver in the hospital, even one who had three subsequent vbacs without complications.

And so we started driving down to Alexandria, Va., to BirthCare. I had two home births, and one transfer (which turned out just to be for safety's sake -- the outcome was good for me and baby).

I knew that if I stayed with a traditional ob/gyn practice after that first c-section, odds were that subsequent c-sections would be a foregone conclusion for me. I knew I had to go to the midwives to have a really good chance for a vbac.

What difference does it make that women have this choice? At a time when health care costs are out of control, midwives provide excellent care at a fraction of the cost of ob/gyns. The care is far superior to what a doctor is able to deliver- your midwife and birth assistant are with you only for the duration of your labor, deliver and immediate post-partum hours. I only had one delivery when one other woman was also present at the center. Of course, when you give birth at home, you and your baby are the only ones your mid-wife has to care for.

It is my belief that my health and the health of my children was enhanced by the care of our midwives at The Maternity Center and BirthCare. The responsibility a woman is given for her own health, awareness of what is going on pre-natally (you get to read your chart at every visit and fill in some info yourself), give you a sense of being on a team with your mid-wife. The support they give during labor is quietly assuring and fills a laboring mom with confidence. I can't praise them enough, nor say enough how very thankful I am that they were available to me when I had my babies. I can only hope my daughters will be able to receive the same excellent care and will not be forced to use hospitals when they have their children.

Kitty Ernst: You are correct that there seems to be no rational for some of the policies that are implemented and interfere with a woman's choice for birth. I think most providers try to base their practice on evidence but the liability climate pushes them in other directions. Until this is addressed we will not only lose quality services and providers because the care becomes unaffordable, we ill continue to see medical intervention rise.

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Northeast Washington, D.C.: Wow. I'm saddened by this because I've always envisioned using a midwife when I had my children (though my mother says, one contraction and I would have them rushing me to the hospital faster than greased lightening). I have had several friends use midwives with no problems and it has seemed to help their families bond. Is there any solution to this problem they are facing?

Kate Bauer: I firmly believe that the personal care provided by midwives and birth centers does enhance the bonding experience for families.

There are no easy solutions but we can all work to promote midwifery and birth centers. A simple thing such as sharing your positive experiences helps balance out the horror stories that women hear when they are pregnant. In the media, we hear how women love their c-sections... we need to balance that with women talking about how empowering their birth experiences were. We are beginning to see this in books like "Birth" by Tina Cassidy and the new documentary film "The Business of Being Born" by Ricki Lake and Abby Epstein. We are approaching a "tipping point".

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Washington, D.C.: Isn't the AMA somehow responsible for all of this since its members stand to make that much money?

Kitty Ernst: Perhaps it is money but more important is control. the AMA really believes that only doctors are qualified to provide care and has directed all state organizations to monitor regulations that give "midlevel " providers independence. this include midwives both nurse and direct entry midwives, nurse practitioners, PAs etc. However, I do not believe all doctors agree with this .

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Seattle: What are some resources for those of us interested in having a midwife for childbirth? My husband and I are planning on having a child next year. My family has always done natural childbirth and I hope to continue the tradition. My husband, however, is scared that it's too risky. I'd like to convince him otherwise (provided I have a healthy pregnancy, of course).

Kate Bauer: Resources on the web include:

www.BirthCenters.org

www.childbirthconnection.org

www.waterbirth.org

www.midwivesofwa.org

www.washingtonmidwives.org

It is important to have the support of your family. The safety of birth centers has been documented in the National Birth Center Study (published in the New England Journal of Medicine - 12/31/89). I invite you to visit AABC's Web site - www.birthcenters.org - where we have information on the safety of birth centers, as well as stories from consumers, midwives and obstetricians. Also, most birth centers offer a free orientation where you can go and learn more about the birth center and their program of care. This would be an excellent opportunity for your husband to talk with the midwives about his concerns/fears.

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Re MD vs Midwife: As the son of a former OB (foreign medical grad) and friend of a midwife, I've heard both sides of this debate. I've also recently heard in the med center where I work the antipathy that some docs have for midwives.

Some of the day-to-day reality is related to state laws on the subject which are of course the product of lobbying by the medical establishment. Its fairly clear from what I understand that physicians used the medicalization of child birth to severely limit midwifery in the past. What is the context now? Can you elucidate how different localities treat this issue?

Kitty Ernst: AH you are getting at the core of one of the problems. Remember we are all products of our education so if we want to change the relationship between midwives and doctors we have to change the education. We can only improve care when providers work as a team for the benefit of the client. OBs and midwives in birth centers and home birth work as a team and it takes work to learn to do that. We could remedy this by training midwives and doctors together in the residency programs - each learning and sharing the individual talents that bring to the mother baby and family. I see us getting to that point as the only real solution to bring about change. I think it may even go a long way to solve the liability problem if you look at why people sue.

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Burke, Va.: How well are birthing centers prepared for emergencies such as the mother hemorrhaging?

Kate Bauer: The birth center is prepared for all types of emergencies. Because emergencies occur infrequently, the staff conducts drills. When an emergency does occur, the birth center staff and receiving hospital know exactly what to do.

The birth center providers will initiate emergency procedures and transfer the mom to the hospital.

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Athens, Ga.: What do you think about the free-birth movement? No mid-wives or any other medical professional, just the mother delivering the baby alone. I don't trust doctors or hospital at all. I think they're only out to charge you as much money as they can, without any regard to your health, so the free-birth idea appeals to me.

Kitty Ernst: I just read an article from Canada about this. Actually it has been going on for some time. I think we should have a system where women are not pumped up with fear and that would cover her no matter where she chose to give birth or with whom she chose or did not choose to be with her. I would counsel her that we are here if she needs us and educate her to the infrequent complications that may require medical intervention and then be available. There are few women in the U. S. that could or would take this leap.

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Washington, D.C.: Ms Bauer, you say we're "approaching a tipping point". You must mean that we're heading towards universal medical deliveries, regardless of need or prudence. I think we're headed for more cases of drug-resistant staph, more c-sections and all their attendant horrors, more forceps and vacuum deliveries, and higher and higher expenses.

I'm expecting in September, and other women in my discussion groups are all PLANNING on epidurals, inductions and even c-sections. Natural birth is on its way OUT.

Kate Bauer: I don't agree. By "tipping point" I mean that women are becoming more dissatisfied with the status quo and the care they are receiving in the hospital, and are searching for alternatives.

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Warrenton, Va.: I am concerned about the future of midwifery in the U.S. for the sake of my daughters. I want them to have the choices I've had, (and my sons, as well). What can we do to support midwives and birth options?

Kitty Ernst: I think the viability of midwives and birth centers will be up to women and families. I have been a nurse-midwife for half a century and have never seen the activity that id emerging now. there are three new books discussing the problems with maternity care in the U.S. by Marsden Wagner, MD (formerly with WHO, Jennifer Block (former editor of MS magazine and Tina Cassidy. They are all available form Amazon. I would suggest that women read at least one of these books to become fully informed and form or join existing organizations to keep abreast of the efforts of those who are working for a solution. You can become a member of AABC, Friends of ACNM, Citizens for midwifery, and a number of other groups already working for a solution. Keep Googling for the niche in which you want to put your effort.

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Washington, D.C.: If malpractice costs are higher for midwives, then that means that there are either more problems at birth centers, or that people are more likely to file claims against birth centers. Why is that?

Kate Bauer: Malpractice costs in relation to revenue are higher for midwives. Midwives spend more time with women during pregnancy and birth, and therefore do not have the volume that an OB/GYN has. In fact, there are fewer claims filed against midwives and birth centers.

One of the factors influencing the cost of malpractice insurance for birth providers is the length of time after the birth (18-21 years) that they may be sued.

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Washington, D.C.: I'm sorry, but I have no idea how the whole concept of midwives has survived this long without being closed down by lawsuits or lack of interest.

I know some women want a "natural childbirth," but given everything (and anything) that can go wrong, there is no way in hell I'd delivery anywhere than a hospital. For me, it's just a question of where myself and my baby are safest.

Kate Bauer: If we were to follow this logic for all things in life, we would not drive down the street without an ambulance in tow.

Birth is not a catastrophe waiting to happen. It is a normal, natural life event. Humans are exquisitely designed, and our ability to give birth is no exception.

For women anticipating a normal birth, the hospital may not be the safest place for you or your baby. A hospital designed to care for the sick. You will increase your chances of unnecessary intervention, cesarean section, separation from your baby, and staph infections. I urge to learn about your options before dismissing them.

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Maryland: What is the difference between midwives who deliver at home or at birth centers? Do they generally have the same skills/training/experience for avoiding c-sections, etc.? I am very troubled by the closings of the TP and Bethesda centers, and am trying to learn about home birth vs. birth center births.

Kate Bauer: Nurse-Midwives who attend births out of the hospital (at home or in a birth center) have the same education as nurse-midwives who deliver in the hospital. I invite you to learn more about birth centers at www.birthcenters.org and more about nurse-midwives at www.acnm.org

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RE: training midwives and doctors : I don't see this ever happening unless midwives attend medical school. Seriously.

Kitty Ernst: I respectfully disagree. The last thing a midwife needs to do is attend medical school. That is part of the problem. Do you know anything about the education of a nurse-midwife? Does medical school teach you anything about normal birth? Most of the obstetricians I have provided consultation services to over the years say that they were never taught anything about normal birth. It is not on their exams. You have to listen to women prenatally, stay with them in labor and birth, listen to them again for the weeks following birth to understand. Five minute belly palps do not do it. Leaving nurses (who also have not been educated to normal birth) to manage labor and run in at just the right moment to "deliver" won't do it. Repeated offering of escape from birth rather than experiencing birth won't do it. It might help you to understand if you could work with a midwife, attend a birth center or home birth or read the books previously recommended. If you are unable to do any of these things. try to see the Ricki Lake's film coming out this summer, "The business of being born". According to the evidence provided by the Cochran Database, Midwives should attend all normal births and the mother should choose her palace of birth. This is what the countries off that have significantly better outcomes than the United States.

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Kate Bauer: Thank you for the opportunity discuss birth centers and midwives.

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