Belly Tales

The New York Times has been turning out a lot of articles on birth, pregnancy and midwifery, lately—seems like there’s been at least one major article a month for a few months now. Here’s the latest one, from last week, which centers around the prosecution of Jennifer Williams, a CPM practicing homebirth in Indiana. Because CPMs aren’t licensed or recognized by the state of Indiana, Jennifer is being prosecuted for the practice of midwifery without a license—Indiana being one of eight remaining states which still doesn’t recognize CPMs certified by NARM.

By and large, the article is pretty fair and objective, but I think the case against the hospital—how dangerous and damaging the overmedicalization of birth can be—and the reasons why a woman might choose NOT to have her baby in a hospital, is missing from this article, or else given very short shrift. There’s still a small hint of “those crazy midwives who deliver babies at home without any medical knowledge at all!” to this article, and it always saddens me when midwives get press like this.

“No one complains until a baby dies or a mom dies,” Professor Tovino said. But once the issue arises, she said, legislatures often become involved as well, with doctors and midwives engaging in a bitter struggle over the proper regulation of midwives, one driven by a mix of motives that are difficult to disentangle.”There has always been a tension between true quality-of-care concerns and anticompetitive concerns,” Professor Tovino said.

Around the nation, there are some 3,000 midwives without formal medical training, according to the Midwives Alliance of North America. About 1,100 of them, including Ms. Williams, have been certified by the North American Registry of Midwives, a private agency whose evaluations are recognized in some 20 states. In Indiana, though, only doctors and nurses may deliver babies.

[...]

Mr. Apsley said his decision to prosecute Ms. Williams was driven solely by the law as it currently stood. “We can all have different opinions about the speed limit or the age of consent or whether drugs should be legalized,” he said. “Those decisions are for the legislature.”

He added that the evidence against Ms. Williams was strong.

According to an affidavit filed by Rick Isgrigg, an investigator with the Shelby County Sheriff’s Department, Ms. Williams conducted a dozen prenatal examinations on Oliver’s mother, Kristi Jo Meredith; monitored the fetal heart rate during labor; made a surgical incision known as an episiotomy when she detected fetal distress; performed frantic CPR on the baby when he emerged; and sutured the incision afterward.

I love the use of the word “frantic” there. When is CPR not frantic? I assure you, it’s frantic in the hospital. I’ve never seen resuscitation done at a homebirth before, but I’m sure the midwife had oxygen and the proper equiptment, was certified in Neonatal Resuscitation, and probably knew what she was doing…albeit frantically. (In theory I know what I’m doing, but I’m still frantic every time a baby comes out blue and I’m the one who needs to begin the bagging).

Where’s the other side to this? Where are the statistics regarding how many babies die every day in hospitals all over this country, or how many doctors are sued for negligence or malpractice? And of course, the excuse given is that more babies die in hospitals because hospitals always manage the dangerous, high-risk births, which is true—hospitals do handle the high risk births, but mistakes are made in hospitals just like they’re made in homes. And then, where are the statistics depicting the number of unecessary invertions performed in hospitals that damage the mother and baby (or both)? The number of unecessary episiotomies cut, the number of baby’s bruised by forceps, scalped by vacuums, the number of women who no longer enjoy sex because their pelvic floor is toast after a pair of forceps made their vagina look like a fire-cracker had gone off inside of it, the number of totally unecessary cesareans, the number of spinal headaches, uteruses ruptured by pitocin, postpartum hemorrhages caused by impatient doctors tugging on the cord or manually removing the placenta?

I could go on and on, but this isn’t really about the safety of homebirth (which many studies have verified, including last year’s large prospective cohort study in the BMJ). This is about choice.

“It is not illegal to have a home birth,” Ms. Welch said, noting that about 1,000 Indiana families had their children at home each year. “But doctors and nurses are choosing not to do home births.”The current law, Ms. Welch said, drives midwives underground. “I don’t want to have a midwife hesitate to take a woman to the hospital because she is afraid she will be arrested,” she said.

If a woman wants to have a homebirth, who is she supposed to turn to? If doctors and CNMs aren’t performing homebirth (for whatever reason), a woman’s choices and options are severely curtailed—either she succombs to the system, and has her baby at a hospital or birthing center with a legal practitioner, or she has a homebirth anyway, though not necessarily with a legal practitioner. Even in states where homebirth is legal, practical barriers are in place which limit the number of practitioners who can offer homebirth as an option. A perfect example of this is what’s going on in the capital region of New York right now: homebirth is legal in New York State, and it’s legal for CNMs/CMs to offer homebirth, so long as they have a signed practice agreement with a collaborating physician. However, doctors in the capital region are refusing to sign collaborative agreements with homebirth midwives, so these board certified, legal CNMs/CMs are forced to work underground, illegally…or else, no longer offer homebirth services to women in the capital region. What kind of choice is that?

If a state does nothing but put up barriers to homebirth so that it’s virtually impossible to have a homebirth legally, and then continues to punish women and midwives for choosing to have a hombirth illegally (because that’s the only way to have a homebirth in that state), women are caught in a no-win situation. While the midwife is the one being prosecuted here, it’s really homebirth itself that’s indirectly under attack.

This reminds me of the prosecution of another midwife in Pennsylvania, Judith Wilson, a CPM with over 20 years of experience who is being charged with Involuntary Manslaughter, Endangering the Welfare of a Minor and Unauthorized Practice of Midwifery after the death of Isaac Daley, a footling breech baby she delivered in 2002. When it became clear to Judith that the baby was in the footling breech position, she explained the risks to the parents, John and Healther Daley, and recommended that they transfer to the hospital immediately. However, John and Heather, weighing all of their options, made an informed decision and chose to stay at home, willing to bear whatever consequences occurred. This is called CHOICE. Now Judith is being prosecuted by the state, even though John and Heather Daley do not blame Judy, continue to support her, and refuse to press charges. More information on this case can be found at The Mommy Blawg.

When the state steps in to prosecute a midwife for continuing to help and support a couple who has made the informed decision to give birth at home, despite the known risks, what is really under attack here? And what else was Judy supposed to do in the situation above, after explaining to the family about the footling breech, and recommending that they go to the hospital? If the family refuses, what more can she do? Abandon John and Heather Daley in the middle of their birth, in order to legally save her own skin? As Barron H. Lerner pointed out in his essay in the NY Times yesterday (Saying No Is a Patient’s Choice, However Risky), the choice to turn down medical options or interventions is always a choice.

Women choosing to give birth at home are taking a big risk, said Dr. Kevin R. Burke, president of the Indiana State Medical Association.

Well, that’s your opinion, Mr. Burke. But they should still be allowed to take that risk, if they so choose. Just like people should be allowed to have an abortion, if they so choose, or refuse a life-saving blood transfusion, or choose to die at home, forgoing all of the drips and transplants and procedures that could prolong their life for another 10 months. For some reason, though, birth, and homebirth in particular, triggers gut reactions in people which have absolutely no basis in reality. Personally, I think it has everything to do with what Robbie Davis-Floyd discusses in her book Birth As An American Rite of Passage: birth, as one of the major rites of passage in our society, is something that needs to be controlled by our society so that it upholds our cultural beliefs and values (i.e. the trancendence and dominance of technology). Choosing to give birth beyond the bounds of these controls necessitates the need for even tighter controls, hence the prosecution, and the barriers in place which restrict homebirth, and all of the hew and cry which arises whenever a story like this comes out. Call it a fantastical theory, if you like, but it rings true ot me.