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reproductive health

When Midwives are Considered Criminals

Despite the proven safety of midwifery and home births, why is the practice still being treated like an illegal, underground economy?

Noah Berlatsky

Noah Berlatsky

Photo by Xunbin Pan via Stocksy

In 2007, certified professional midwife Mary Walsh almost watched a friend die due to Missouri's restrictive and unnecessarily complex laws against midwives.

Walsh was present at her friend's home birth to provide support; another midwife managed the labor. The baby was born without incident, but then the mother started bleeding. The midwife decided they should transfer to a hospital. At that time, however, it was a felony for a midwife to attend a home birth in Missouri. At the hospital, therefore, the midwife couldn't identify herself as a medical professional; she just said she was a friend, while the father tried to explain that there had been excessive bleeding.

Bleeding had slowed, though, and "the doctor did not take them seriously for a long time," Walsh told me. By the time the hospital realized something was seriously wrong, the mother's blood had stopped clotting. She almost died on the operating table as the OB tried to remove the remaining placenta, which was causing the bleeding. "That was one of my early experiences, just realizing how bad it could get because nobody at the hospital was going to believe the parents, or even the midwife, even if she had spoken up," Walsh said. Doctors in Missouri didn't perceive midwives as legitimate; as a result, they couldn't draw on their knowledge, and a dangerous but treatable condition became a massive medical emergency.

She almost died on the operating table.

In many parts of the world, midwife-supervised home births are an accepted, and unremarkable part of the medical system. As just one example, the British National Health Service recently recommended home birth over hospital birth for women with uncomplicated pregnancies.

In the U.S., though, many states still see home birth as dangerous and illegitimate. Illinois, where I live, is one of the most restrictive states. Only certified nurse midwives—professionals who are trained both as midwives and as nurses—are legally allowed to attend home births, and then only if they have a written agreement with a physician. Due to these restrictions, and because the vast majority of CNM work is in hospitals, not in homebirth settings, it is effectively impossible to have a legally attending midwife for a home birth in large sections of Illinois. Women who want a home birth either have to find a midwife willing to risk operating illegally—or they have to deliver their babies without professional help.

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Illinois is particularly restrictive, but it's not alone, according to Susan Jenkins, legal counsel for the Big Push for Midwives, a national umbrella organizaiton that works to legalize and license Certified Professional Midwives (CPMs). Jenkins pointed to North Carolina and Alabama as states with particularly restrictive environments. Other states like Massachusetts don't license midwives, but aren't actively prosecuting them. However, Jenkins said, "our experience has been that all it takes is one complaint, one prosecutor who wants to make a name for themselves, and all of a sudden a midwife has been arrested." Over all, Certified Professional Midwives are licensed to practice in 28 states; in 22 others, home birth midwifery remains largely illegal. (A complete list of midwifery regulations by state is available here.)

States that restrict home birth midwifery generally do so on the grounds that home birth is unsafe. The American College of Obstetricians and Gynecologists (ACOG) says that women should be allowed to choose home birth, but that it leads to substantial risks to the fetus. However, the research on safety for mothers and children in home birth is not as certain as ACOG suggests. The reason that the UK recommended home birth for many women is because they found "that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital," according to Dr. Neel Shah.

Alison Winterroth/Stocksy United

This is because, Shah says, "obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them." Unnecessary interventions, with attendant risk of infection, complications, or simple discomfort, go up substantially in a hospital setting. In large part because hospitals dominate care in the US, Cesarean rates are around 33 percent, much higher than WHO's recommended safe rate of 5-10 percent. "It is important to acknowledge the very compelling reasons why home birth is attractive to many childbearing families and why more and more are choosing to give birth at home, "Carol Sakala, Director of Childbirth Connection Programs, National Partnership for Women & Families, told me. "Healthy low-risk women who give birth in US hospitals today are vulnerable to cesarean birth and other major interventions that they do not need and many restrictions. For example on hydration, movement, positioning, and care options)."

It is true that home birth can entail some risks. According to Katy B. Kozhimannil, Associate Professor at the University of Minnesota School of Public Health, home birth and hospital birth in the UK seem to be about equally safe for babies. But home birth in the United States has slightly more risk.

Women who want a home birth either have to find a midwife willing to risk operating illegally—or they have to deliver their babies without professional help.

The reason for this increased risk in the US is not entirely clear. Studies are difficult to design, Kozhimannil told me, and opposition to home birth in the United States makes it hard to fund research projects. But one reasonable explanation, for the danger is that "the health care system is set up differently," Kozzhimannil explained. "In Great Britain, home birth is part of the continuity of maternity care; it's part of the system, it's not outside of the system. Whereas in the U.S. it's outside of the system."

In other words, as Susan Jenkins of the Big Push told me, "It's not good for women and babies to have their health professionals be in an underground economy. Where you don't have any chance of getting your health insurance to pay for it, you don't know if your midwife is going to be there the next day because she might be getting arrested, and when you try to hire her, you don't really know for sure if she's certified, if she has the required education and credentials." If you force home birth into the shadows, it becomes less secure, and less safe, for any number of reasons.

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Criminalizing midwives makes it difficult for women to find qualified and reliable midwifery care for home birth. It can have dangerous, and even catastrophic consequences in an emergency situation. And it can have other painful effects as well. Midwife and birth activist, Alicia Kaye, who had a home birth in 2006 in Hampton Virginia, went to Mary Immaculate Hospital afterwards for a laceration repair to her labia. The doctor attending "made snide comments about not waiting for anesthesia since I could deliver a baby in my own home without anesthesia." More, the hospital contacted Child Protective Services, and her husband's military commander.

The CPS case was eventually dismissed. But the hospital couldn't have made it clearer that mothers who had home births were not welcome. And that puts mothers and children at risk, both when they go to the hospital, and when, through fear of mistreatment, they stay away.

The doctor attending "made snide comments about not waiting for anesthesia since I could deliver a baby in my own home without anesthesia."

In contrast, Mary Walsh told me, when home birth is legalized and regulated, hospital transfers become a simple routine. Missouri began to license Certified Professional Midwives in 2008; Walsh is now the founder and President of Family Birth & Wellness in Springfield, Missouri, a midwifery practice that includes a birthing center and home birth services. Just before she got on the phone with me, she said, she transferred a patient to the hospital. "It was a totally smooth seamless, respectful transfer just as you would hope would happen when a medical professional says there's something wrong with this person and I need to send them in."

There's still some resistance among some Missouri hospitals to working with home birth midwives, Walsh told me. But the more time doctors have to become accustomed to legal midwifery, the better the working relationship becomes. Home birth occurs at home, but "home" doesn't need to be some sort of secret quasi-illicit bunker walled off from the rest of the health-care system. There shouldn't be a barrier for mothers and babies erected between the home and the hospital. In Missouri, there isn't any more. Illinois, and the rest of the country, should follow suit.