Post Magazine: A Labor Without End

Ruth Lubic defied doctors to champion midwifery and change the way American women give birth. In the last four decades, she has been determined to make sure poor and minority women are given that same care and nurturing during pregnancy and labor.

But, as Phuong Ly discovers in this week's issue of The Washington Post Magazine, this 80-year-old isn't done working, as she struggles to keep her D.C. birthing center going.

Phuong Ly is a freelance writer. Ruth Lubic is founder of the Family Health and Birth Center in Northeast Washington.

The transcript follows.

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Washington, DC: Ruth you are amazing. Thank you for all that you have done and our doing for women's and children's rights! As a mother who birthed with a midwife eight months ago I can attest to the empowering and amazing experience it is to have a midwife by your side. I am terribly saddened by all of the closings of birthing centers in the DC area as well as all over. What can individuals do to make sure that we can birth babies with midwives in the location of our chosing? I feel so frustrated that we have to fight to have children in natural ways and I want to be an advocate for natural birthing and secure my rights to have my next child the same way. Unfortunately health insurance regulations, birth center closings and strict laws are slowly taking away my freedom of choice. Thank you Ruth for your sage wisdom.

Ruth Lubic: Thank you for your testimony!! The thing that will be most helpful now is to let your Congresspersons know of your experience and of the shrinking options for families. I will be working to try to expand the services we provide to other populations in other parts of the country especially to the undersrved. Actually, according to survey material collected by the American Association of Birth Centers, there are 42 centers in 19 states serving greater than 50 percent medically underserved populations, so there is an infrastructure there already in place if we can get federal support. We birth centers particularly need recognition by Medicare as facilities, so that Medicaid will be required to reimburse. Just have to be political! I am hoping that our cost savings as well as disparity reductions will "wake up" the congress. Thanks again!

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Farmington, CT: Hi Ruth,

I thoroughly enjoyed the Post article. I'm wondering if you've ever talked with Bill and Melinda Gates about funding through the Gates Foundation? Mir and I are so glad that we had a chance to visit the clinic early on.

Pauly Topazian, classmate and old friend

Ruth Lubic: Dear Pauly,

Thanks for your chat! I'm glad you liked the article--especially recall how our experience as student nurses was so medicalized!

I would love to have the opportunity to talk to someone at the Gates Foundation, especially because there is a birth center infrastructure already in place--42 centers in 19 statews are serving greater than 50 percent medically underserved families. we are in a position to set up a national system--to say nothing of the national and overseas visitors we have had visit us and recognize that we need to set health care in its social context! Thanks again, Pauly

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Washington, DC: I am a well educated, middle class woman who knew nothing about midwife care when I had my first child. It seemed so far out of the mainstream. I've now had two babies -- one difficult delivery and recovery with an epidural and a doctor and an easy, uplifting delivery with one of the wonderful Takoma Park midwives.

Why is midwife care not considred more mainstream, and what can be done about it?

Phuong Ly: I knew nothing about midwife care before I started researching the article. I found out about Ruth through a friend of a friend.

Midwife-attended births account for just a small percentage of births -- 8 percent in Maryland, 3 percent in the District and 7 percent in Virginia, according to the American College of Nurse-Midwives.

Midwife care might not be considered mainstream because society's view of modern medicine has emphasized doctors and hospitals. However, that attitude appears to be changing among some women. With the internet and listservs, women are doing a lot of research before they decide how they are going to deliver. Unfortunately, even though they may have a specific type of delivery in mind, their options are limited as birth centers around the country are forced to close.

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Bethesda MD: I had my child at the Maternity Center and was so sad to hear it is not an option for mothers anymore. Do you think we'll ever see more freestanding birth centers in the area, given the recent setbacks?

Phuong Ly: Financially, it is extremely difficult to make the numbers of a free-standing birth clinic work. Even obstetricians, who receive higher insurance reimbursement rates than midwives, are finding it harder to survive financially because of the burden of high malpractice premiums. Many OB/GYNs in the area have closed their OB practices in recent years.

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Crystal City: Hey Ruth!

It is Keith, Rachelle's husband. I just want to thank you for all that you do and have done for my family and lots of others as well.

I hope the additional press helps the birth center get the funding it needs. It is truly a great place full of great people.

As a someone who has been blessed to know Ruth personally, I am here to tell the audience that you all should only HOPE to be as full of life at age 50 as Ruth and her husband are at age 80. I don't know if this really came across in the article as well as it should have. For lack of a better term, they are ROCKIN'.

PS--My son is Avery, the first boy born in the facility and the kid sitting with Ruth in the picture in the magazine.

Ruth Lubic: Dear Keith,

And to be mentioned is your eloquence when you "testified" at the visit of Justice Ginsburg. it is parents like you and Rachelle who will make it happen, so keep talking and to your Congresspersons when you can. They need to know about our reduction of the disparities suffered by particularly African American families once thought to intractable and the cost savings associated with that reduction! We do appreciate your board service too Rachelle. Keep hammering away!

Love, Ruth

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Bowie, Maryland: I am appalled that insurance companies are dictating to American women where they can give birth, and that birthing centers are so financially strapped that they are either closing or in danger or closing due to premium costs. Kudos to Mrs. Lubic for her heart and courage for her work. It is a sad, sad day in America when profits are placed over the well-being of people. Who knows where this is going to end, even tho I have read about women taking birth into their own hands, i.e. unassisted births, home births, etc. I don't know if these activities are on the rise, or that I agree with them, but I certainly understand why they are happening.

Ruth Lubic: Dear Bowie,

I agree with your plaint! It should follow that the lawmakers will respond to the cost savings of our service (in 2005, we saved more for the system than it cost us to operate, but we saw none of the savings!) if not to the increased quality of life of the families we serve! We need you to drum that into your Congresspersons! I know you will help!

Thanks, Ruth Lubic

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Philly, PA: First of all, I just want to say how wonderful it was to read this article on Ms. Lubic's work and struggle for better, quality care for DC's poorer families. In particular, I believe midwifery care is the ONLY form of prenatal care that should exist for low risk pregnany women and the fact that all pregnant women are essentially caught in the OB snare simply on the basis of it making more money is abominable (not to mention the fear that is propagated in women who think pregnancy and birth are disease states that require a doctor's expertise!). Birthing babies is big business for hospitals, and it's no wonder the c-section rates are so high. They provide more money for hospitals and doctors so it's no wonder birth centers across the country are feeling the heat from OBs, area hospitals and insurance companies--closing its doors due to rising malpractice premiums and little recognition for the wonderful work they do.

I think midwifery care needs more PR! So many women seem unaware still that such low-intervention, high-touch care even exists! Or how safe it really is.

I am 8 months pregnant and will give birth at The Birth Center at Bryn Mawr, PA and I am so happy such a place exists for women like myself who know my options and exercise my right to birth as I see fit. Women nowadays are denied their most human right to give birth as they choose and it certainly seems like things are not getting better. (Of course, women have been long denied the right to trust their own bodies and minds with what the recent setbacks in abortion rigths. But I digress.)

We need high profile, big PR--we need more studies done on the safety of midwifery care and on nonhospital birth options!! We need more people like Ms. Lubic! Thank you for all your hard work. You not only make a difference locally but on a global scale.

Ruth Lubic: Dear Philly, PA,

Thanks for your great comments! You recall I am a graduate of Penn! Now what I would suggest you do is get in touch with Bill McCool, CNM, the Director of the nurse-midwifery educational program at the School of Nursing at Penn. He and a group of faculty and students were here last week to see how they might apply our success to a similar venture in West Philly! I'm sure you can be of assistance to them!

I know the Bryn Mawr birth Center very well--am a peer of Edith Wonnell who established it and know Sherley Hollis as well. It was good to hear from you--good things are worth working for!

Ruth Lubic

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Washington, DC: I know firsthand how great midwives can be. But many first-time mothers just go to their doctors, who refer them to hospitals, and that's that. How do you help change the minds of physicians to embrace midwives?

Phuong Ly: Times have changed since Ruth Lubic first started work in New York in the 1970s. Some doctors now include midwives in their practice, and some hospitals have midwives on staff. This has happened as more women have asked about midwifery care.

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Baltimore, MD: Ms. Lubic, thank you for your work to bring back the midwife. And Ms. Ly, thank you for the article.

My husband and I are about to start trying for a baby, and while I would prefer a birthing center and midwife he is very frightened of having me deliver outside of a hospital. Are there birthing centers attached to hospitals that you know of, or hospitals that will allow me to use a midwife? How would I go about finding a decent place?

I've also heard bad stories from people who were told they would have a private room with attentive nurses and whirlpools, but when it came time to deliver they were stashed in large recovery rooms and ignored for long periods of time. How can I avoid that type of experience?

Ruth Lubic: Dear Baltimore, Thanks for your communication! It would be good for your to get started with a midwife or a midwifery service now in your preconceptual period. The American College of Nurse Midwives (Silver Spring, MD) can help you with individuals and the American Association of Birth Centers can help you locate a birth center near you.

And do come to visit us to see how we do it, if you think that would help! Actually, one of our staff midwives, Lisa Uncles, lives in Baltimore and I'm sure could help you to find someone. but it is very smart for you to be looking now! thanks for your kind words!

Ruth L.

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Alexandria VA: Dear Ruth, I'm curious to know your opinion of the practices that have both doctors and midwives on staff. That seems like a good compromise solution for women who want the security of having a doctor available but the care and attention of a midwife.

Ruth Lubic: Dear Alexandria, Yes of course you are right, but that's a given with nurse-midwifery practice. We are specialists in normal birth and need obstetrical colleagues to work with if and when needed. You might want to talk to Alice Bailes or Marsha Jackson of Birth and Women's Health Care there in Alexandria. I'm sure they would be happy to discuss your concerns. For our part the Washington Hospital Center and its obstetricians have been great partners!

Ruth L.

Do visit us if you'd like!

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Washington, DC: Can you explain the difference between a midwife and a doula?

Phuong Ly: A doula is a birthing assistant who helps support the mother emotionally and makes as comfortable as possible during the experience. Doulas do not give medical care.

Nurse-midwives are registered nurses who have completed a midwifery training program. They can give gynecological exams, prenatal care and supervise the birth. All nurse-midwives are required to have a physician or a hospital on-call that is available for backup in case of emergencies. Nurse-midwives are not authorized to perform a C-section or other surgeries.

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Arlington, Va.: How do men react to midwives? Or are most of the women who use them at the birth center single moms?

Ruth Lubic: Dear Arlington,

Thank you for your question. We actually encourage fathers to attend prenatal visits and to be present at the birth. Pull out your copy of the Post and you will see in one photo, Travis Ally holding his new daughter while the midwives are attending to Nubia Jones, his wife. I have always found men to be very interested in information about women's reproductive processes including menstruation and the "change of life" as well as pregnancy and birth. Often they have been excluded from information, I have found. In sum--"No Problem!"

thanks again, Ruth

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Washington DC: Ruth,

You are truly an inspiration. I delivered my first child at Birth Care, the birthing center in Alexandria, and had an absolutely, amazing, empowering experience. Given the fact I had 24 hours of exruciating back labor, I'm sure that in a hospital setting with a doctor presiding I would have been a prime candidate for a c-section. Instead, I delivered vaginally, fully coherent and surrounded by two nurse-midwives cheering me on at every step. My question is: as a DC resident with limited representation in Congress, what is the next best thing besides writing my congressial rep to help drum up support for birthing centers? I'm so grateful for your advocacy and want to help other women experience the type of childbirth experience I had.

Ruth Lubic: Washington, DC

Even tho she has no vote, Representative Norton is a very articulate advocate. if you can visit the FHBC, we can show you a video in which she appears and is very effective. We need her as well, to take up the banner for us even more! And we need you!!

Ruth

How lucky you are to have known Marsha and Alice at Birth Care!

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Alexandria, VA: In the article, when Ms. Jolles talks about bringing the center into the federal system, Ms. Lubic opposes it, saying that "the system is broken." But Ms. Lubic is pursuing Medicaid reimbursements and other arms of that same, broken system. What's the difference between the two in Ms. Lubic's eyes? Why is it okay to take federal money but not federal control?

Ruth Lubic: Hi Alexandria! Thanks for your very cogent question--

Let's start with the outcomes we have achieved--virtually a 50 percent reduction of the disparities suffered most by African American families. The big question is why do we get those outcomes? My hunch, and that of many other people, is that it is the relationships formed with the families by the midwives. The time spent with a given mother depends upon her needs, not only physical, but ewmotional and social, so that often an hour is spent in a prenatal visit. In the FQHC world, x number of women must be seen in y number of minutes--resulting in prenatal visits of 10 minutes. That's what the conventional system allows. Medicaid pays for care, but doesn't have the time requirements (as a usual matter) In addition FQHC has been around for decades and hasn't come up with the outcomes which we have seen. In my opinion, we need not be "more of the same". this is a new model and it is working!

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MD: I enjoyed the article very much and wish I'd had the option.

But I have to ask if you also talk to the women about birth control.

Ruth Lubic: Oh, yes, midwives include birth control in their care. they are instructed in that important aspect of women's health. Actually the midwives at the FHBC do gynecologic visits on women of all ages.

Thanks, MD

Ruth

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Columbia MD: Hi,

I work in the area as a childbirth educator and a home birth birth assistant. How do you feel about the fact that as the nurse-midwives are losing ground and closing up shop, women are choosing certified professional midwives and home births? In some states both types of midwives can operate with licensure. In Maryland where CPMs are not recognized and we have had 7 CNM practices close including 3 birth centers in the last 8 years, the CPMs who committ to holding the options for Maryland women open are busier and busier every year. Do you support CNM and CPM joining forces as they have in Massachusetts, New Mexico and other states that enjoy more access to midwives than we do in the Maryland/DC area?

Ruth Lubic: Of course; in fact the American College of Nurse-Midwives includes CPM's in its membership. My caveat is that midwives be given a course of instruction which is based in science as much as is possible.

Ruth

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Southern Maryland: I used the Maternity Center and had a wonderful birthing experience. I was healthier and became informed about health and medicine that impacts me and my family today. Ironically, after sharing my pregnancy story with other women, they wished they had considered the option of a not using a hospital. Midwives provide health care services in the most efficient and cost-effective manner. I can't say enough good things about midwives and birthing centers.

Phuong Ly: That's terrific! Thank you for sharing your thoughts.

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Phuong Ly: Thank you for your comments and for reading the story!

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Insurance: I think we have the right to have our babies at home if we want. However, IF we expect our insurance to pay for it, they do have to right to require certain conditions, since we'll surely expect them to pay if there are any problems. I don't blame them, they're just trying to cover potential losses.

Ruth Lubic: Dear Insurance,

Of course insurance companies are trying to cover potential losses, but in raising premiums the way they have, both midwives and doctors are being driven out of practice. Women without professional assistance will be even more likely to have complications--back in 1975, when our first birth center was opened, there was a movement to father assisted birth without any professional monitoring. To me that is patently unsafe, even though I am an advocate of as little intervention as possible amd that is why we opened the first childbearing Center. Keep in mind that insurance companies are businesses and must pay stockholders. We are not privy to that information.

thanks, Ruth

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Damascus, MD: I. too, just want to thank you for the work you do. I was a patient at the Maternity Center in Bethesda, though I wound up with a c/s due to breech. I hated being in the hospital, and my son wound up in the NICU for 48 hours due to some slight trouble breathing (not uncommon in c/s babies).

I'm dreading having to fight for a vbac the next time around. Some hospitals in the area don't even allow them! It makes me so angry that women in this country have fewer and fewer choices when it comes to childbirth. Not due to any evidence-based medicine, but due to malpractice insurance costs and fears of lawsuits.

Midwifery is so much more women and child-centered. It should be the standard of care - obstetricians should only be seen for high-risk and/or complicated births and deliveries, in my opinion.

Ruth Lubic: Dear Damascus,

You make a good point--in Sweden, 85 percent of the materrnity care providers are nurse-midwives and 15 percent obstetricians- it is that way because that reflects the needs of women rather than the needs of any other business or profession.

Thanks, Ruth

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DC: I was struck by the contrast between your article and the article on the building of the Pentagon in the same issue of the Post Magazine. Nothing better sums up our national priorities. Your important project project is suffering for modest funing while the Pentagon was built in a year. I think you should lobby the Defense Department for funding. Your project is doing more our nation that they are.

Ruth Lubic: Dear DC,

A very interesting observation! Thanks!

Ruth

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Washington, DC: Getting the word out is key -- I probably wouldn't have considered a midwife-assisted birth had the nurse at our fertility clinic not said, "You're not high-risk -- why not look into using a midwife?" And so we went on to have an absolutely wonderful natural birth with a midwife at Georgetown Hospital. I know the doctors there mean well, but because my water broke at 35 weeks, they really hounded me about having a C-section. My blood pressure started ro rise, which only convinced them that they needed to cut me open right away. My midwife intervened, moved me to a quiet room, and my blood pressure dropped right back to normal. We had a perfect, unmedicated, noninduced birth, and my daughter was completely healthy -- Apgars of 9. We went with the Takoma midwives when the Georgetown midwives were disbanded, and had another fantastic natural birth (premature, even). We're lucky we've already had our two kids -- the non-medical options are really dwindling in this region.

Are OBs open to collaborating with birthing centers on policy initiatives that would ease malpractice insurance premiums for all, or is that a completely antagonistic relationship? I read in another article about community health centers that private practice physicians were insisting that hospitals close such facilities to eliminate competition. I find that so sad when the end goal -- better health for all -- is a shared one.

Ruth Lubic: Dear Washington,

Nothing would please me more than to have the organizations representing medicine, nursing and midwifery working together on a solution, so that we are not falling victim to the "divide and conquer" potential.

I'll keep at it!

Thanks for sharing your experience.

Ruth

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