A Crisis in Midwifery

With her first child due in August, Kelly Morris always dreamed of giving birth in her own home. She decided against it, however, because she didn't feel it was safe. It wasn't that she was afraid of any risk to herself or her baby, however. Instead she was afraid that she wouldn't receive good care in the hospital if she had to be transported there while in labor. "Midwives who do home births aren't supported by back up doctors and hospitals," she explains. "And I was concerned that my midwife could be arrested."Ironically, the Midwifery Practice Act of 1992 was originally intended to promote the expansion of midwifery and make it an independent profession. Instead it has created a nightmarish situation for direct-entry midwives in New York State. Many have become too scared to practice, fearful that they will be arrested and jailed. And without a trained, experienced midwife to assist them, pregnant women like Morris are not able to exercise their legal choice of deciding where to give birth.What is going on? Why all of a sudden do some midwives fear prosecution? Do they really endanger the health and safety of women and babies, as some claim?Dr. Marsden Wagner, a perinatologist with the World Health Organization, is a specialist in maternity services in industrialized countries. He speaks passionately, addressing what he and others believe is the real threat that midwives pose -- economics. "What is going on in New York State," he explains, "is that the obstetrical monopoly, which has been in place in this country for 75 years, is fighting against any expansion in midwifery. And they're fighting against it by trying to claim that it's dangerous when in fact all of the world-wide experience, as well as good, scientific research, shows that for most women it is not."A closer look at what is going on indicates that his assessment may be right on the money. Poorly written legislation, an antagonistic and uninformed Board of Midwifery and over-zealous investigators are three of the main factors that have given rise to this latest assault on midwifery.To understand what has happened over the past year requires a little background information. A midwife is a primary health care provider, fully qualified to assist healthy women with normal pregnancies and births. While obstetricians are trained to view pregnancy and child birth as medical conditions or sicknesses requiring medical management and treatment, midwives see pregnancy and child birth as natural, healthy and normal physiological events in a woman's life. "With a certain amount of overseeing and guidance," says Linda Schutt, a direct-entry midwife in Trumansburg, "almost every woman can accomplish child birth normally and healthily and be empowered by the experience to then go on and take care of her family in a stronger way."There are two types of midwives: certified nurse-midwives (CNMs) and direct-entry midwives (sometimes referred to as independent or lay-midwives). CNMs are registered nurses with additional education in midwifery. They work predominantly in hospitals and, more recently, birth centers. Direct-entry midwives obtain their training from independent midwifery schools or apprenticeships and do not have a previous nursing background. They tend to have independent practices and attend the majority of home-births. Both kinds of midwives are trained to recognize problems that require the consultation or care of a physician and both demonstrate competency in midwifery skills, practice in accordance with professional standards and are represented by professional organizations -- CNMs by the American College of Nurse-Midwives and direct-entry midwives by MANA, the Midwives's Alliance of North America.Until 1992, New York State only recognized certified nurse-midwives. Direct-entry midwives carried out their work illegally, though prosecution was rare. Believing that the Midwifery Practice Act would give them the legal recognition and respect that they desired, direct-entry midwives worked hard to get the bill passed, even hiring lobbyists to assist them. So far, their efforts have backfired, driving home birth attendants further underground.In June of 1992 the New York State Assembly and Senate passed the Midwifery Practice Act (MPA). This act changed the regulation and official status of midwifery. It took midwifery out of the nursing field and recognized it as its own profession; it created a board that was to oversee both branches of midwifery; and it stated that women no longer had to be nurses to legally practice midwifery, but could become licensed through educational equivalencies."I think the bill struck a balance between state oversight of non-nurse midwives and expanding the field to allow them to enter it," says Assemblyman Marty Luster. "In rural areas and under-served areas, once certification starts coming through we can start to expand the availability of prenatal and obstetrical care." Certification of non-nurse midwives, though, seems a long way off.CHANGING THE RULESIn February of 1995, all midwives were invited to apply for licensure. CNMs previously recognized by the state were immediately eligible. Direct-entry midwives were encouraged to apply. Thirteen did. They heard nothing for 10 months until December, when the Board denied all of their applications. Meanwhile, the Department of Education's Office of Professional Discipline began to investigate many of them, including Hilary Schlinger, an Ithaca resident, for practicing midwifery without a license. These investigations began to occur before licenses had been denied. And because midwifery is now legally recognized as a profession, under the auspices of the Department of Education, anyone caught practicing without a license commits not a misdemeanor, but a felony, carrying with it the possibility of jail time.Why were licenses denied? The Board's position is that direct-entry midwives failed to meet the educational requirements, says Lawrence Mokhiber, Executive Secretary of the New York State Board of Midwifery. But in April, board members publicly admitted that they did not understand direct-entry midwifery in it's entirety; that they did not understand midwifery education through "non-traditional" routes; that they did not consider apprenticeship; and that they had no mechanism in place to evaluate the applications of midwives who gained their training and experience through non-traditional routes. They also admitted they were premature in inviting direct-entry midwives to submit applications for licensure and that they did not have a thorough understanding of the North American Registry of Midwives (NARM), a national certifying agency for direct-entry midwives that offers a competency-based certification process and an examination that evaluates direct-entry midwives' qualifications for licensure. The Board even offered to give back $210 of an individual's $300 application fee."The State has come back and said that there are no standards for the profession of direct-entry midwifery and there is no way to evaluate direct-entry midwives," says Schlinger, a representative of The Midwives Alliance of North America (MANA). "But there is. There is an evaluative process and a certification process. There are standards, there are core competencies for what we consider to be midwifery. They haven't given us any good reasons why they won't recognize it."The Board's limitations have left direct-entry midwives frustrated and angry. They are willing to take additional course work to fulfill any educational gaps and are willing to take an examination to assess their competency. So far, the state has only offered them the nurse-midwifery exam and has not recognized the NARM exam which is used in nineteen other states. Moreover, the Board has been unable to tell midwives what they lack in education. "People thought the gaps would be spelled out, but they weren't. The Board just isn't equipped to do it," explains Linda Schutt, a European-educated midwife in Trumansburg."I don't have a problem going back and completing any course work that they ask me to complete," says Roberta Devers-Scott, President of the Midwives Alliance of New York, who was arrested in a sting operation when two members of the Office of Professional Discipline disguised themselves as an expectant couple seeking her services. "But don't arrest me in the meantime, before you've even told me what to do."Much of the controversy centers around the alleged difficulty of how to evaluate and assess non-academic and apprenticeship learning and how to equate them with credit-bearing academic programs. Schutt explains that although direct-entry midwives had been encouraged to attend a registered midwifery program, the Board has not approved a single one. And apprenticeship training is considered to be inferior to an academically-accredited program. Wagner offers an analogy to illustrate the poor understanding of apprenticeship training and to shatter the mystique often associated with academic degrees: "I sometimes say that I am a "lay doctor," he explains. "My first two years of medical school I was only required to take examinations. As long as I passed the exams, I didn't have to go to class. My second two years of medical school, I spent the entire time on wards at hospitals or clinics, actually practicing under the direction of somebody else. What is an internship? An apprenticeship. What is a residency? An apprenticeship. So I am apprenticeship trained," he says.The upshot of all this is that licensure through educational equivalencies has not happened because equivalence is being defined as "the same as," says Devers-Scott. "When you look at what they say you have to do, you might as well have gone through nursing training," explains Monica Daniel, a sympathetic CNM and Director of September Hill Birth Center.NO RESPECTOne of the Board's responsibilities is to oversee the education and qualifications that a person must have to become a licensed practitioner of midwifery. A direct-entry midwife's ability to obtain licensure and practice midwifery is now being determined by a board composed of CNMs and physicians. Mokhiber, the Board's executive secretary, is a pharmacist. The issue is not only why direct-entry midwives are not represented, but why physicians are on the board in the first place, says Wagner.Moreover, the Board is dominated by CNMs and physicians who are unsympathetic and hostile to direct-entry midwifery and home births. Applications of individuals who had expressed support for direct-entry midwifery were turned down. Board Chair, Elaine Mielcarski, a CNM in Syracuse, NY, has given false information to the media and she and her husband, Dr. Richard Waldman, an obstetrician in private practice, circulated a petition urging the New York Board of Regents not to "yield to the emotional pleas of apprenticeship-trained lay midwives" by expanding the scope of the bill. One of its signatories, Dr. John Choate, is on the Midwifery Board and only one of its signatories has ever worked with a direct-entry midwife. Those who have, did not sign it.According to Devers-Scott, the petition has no factual basis. "Even when midwives make good and appropriate diagnoses, those get unheard of and instead they write untruthful petitions," says Devers-Scott. "To say that a midwife doesn't care enough - which they stated in the petition - is a complete antitheses of who we are as women and midwives." In a letter to the New York State Board of Midwifery and the Board of Regents, Wagner, the perinatologist with the World Health Organization, called for Mielcarski's resignation.Not all board members are as hostile as Mielcarski. "I think it's critical that we have more than nurse-midwives on the Board of Midwifery," says board member Patricia Burkhardt, director of the nurse-midwifery program at New York University, "in order to validate and make clear that we are not in this in order to keep people out. We are in this to facilitate being part and parcel of the process, but they have to meet a standard."Still, there is no standard outside of nursing that meets the Board's criteria. And when all is said and done, the only currently viable path for midwives to follow is through nursing.A PROFESSIONAL PARADOXDr. Robert Tatelbaum, Chairman of the OB-GYN Department at Genesee Hospital in Rochester, reflects what is probably the dominant point of view in this country on midwifery. "I think nurse-midwives have a lot to offer providers of obstetrical care," he says.But while he and others see midwifery as fitting into and being part of obstetrical care, others are adamant that midwifery and obstetrics are distinct and separate fields. Wagner is one such voice. "There is a serious misunderstanding in this country about what midwifery is. Midwifery is not part of obstetrics. It's a completely separate, parallel profession, both of which are essential to good midwifery care."Wagner adds: "I am a doctor. We are trained to diagnose and treat problems. That works beautifully for illnesses and diseases, but pregnancy is not a disease and birth is not a surgical procedure." It is the system that is at fault, he explains. "The U.S. and Canada are the only countries in the entire world," he says, "where you have fully qualified surgeons, obstetricians, taking care of the majority of healthy pregnant and birthing women. It is insane to get a fully board-qualified surgeon to take care of you if you've had no complications during pregnancy and birth.""I think highly of obstetricians says Devers-Scott. "I just think that they have their place. We need to save those scholarly people for those high risk situations that need their expertise."Rhetoric notwithstanding, the medical establishment does not view midwives as professional equals. Lawrence Mokhiber, Executive Secretary of the New York State Board of Midwifery, disputes this. "I think the fact that we now have over 550 licensed midwives with a full range of authority for prescribing, dispensing and ordering laboratory tests for deliveries -- in collaboration and not supervision -- with physicians, is a wonderful step forward for the profession of midwifery," he says.But midwives do not legally or philosophically work in collaboration with physicians. Although the bill specifically states that midwifery is a profession, one of the changes inserted at the last minute takes away a midwife's independence. The bill states that all midwives must have a written agreement with a physician, "providing for physician consultation, collaboration, referral and emergency medical obstetrical coverage." This means that unless a midwife can find a physician -- a direct competitor -- willing to enter into such an agreement, she is prohibited from practicing. Despite the rhetoric of working side by side, the bill reinserts medical authority.At the same time, because of the reluctance to view midwifery as an autonomous profession, a doctor who agrees to participate in a practice agreement would have his or her malpractice insurance affected. Schutt explains, "If a midwife were viewed separately and liable for her own care, a physician would only be responsible once he or she assumed care-giving responsibilities."While all midwives need to be able to consult with an obstetrician, this subordinate relationship is not preordained. As Schlinger explains: "In Europe, midwifery works best when midwives are not subordinate to doctors, but are on par as experts in their own field, much as dentists and doctors are in this country." In fact, a nurse-midwife is a distinctly North American construction and outside of the U.S. and Canada nurses and midwives are separate but equal professions, with different laws and regulations.INVESTIGATIONS AND MISPERCEPTIONSAt the same time that direct-entry midwives are unable to become licensed, they continue to be investigated. In an April 8 editorial in the Syracuse Herald Journal, Elaine Mielcarski, Chairperson of the Board, wrote: "After the Board reviewed the circumstances leading to current investigations of some lay midwives, the board took the unanimous position that the State Education Department and its agencies were undertaking these investigations for valid and appropriate reasons."Mokhiber insists that the timing of the investigations was coincidental and that the licensure review and investigation processes are independent of each other. "All of our investigations were initiated by complaints." he says. The majority of complaints, however, have not been filed by the midwives' clients. Burkhardt, a less hostile Board Member, states that many complaints arise when a woman laboring at home must be transferred to the hospital. Complaints get filed "by disgruntled hospital staff who just think it's a bad thing to do home births in the first place." Thus, many complaints arise precisely when a midwife is providing appropriate care, have no basis in fact or misrepresent what actually occurred.This is what happened to Maggie Kern, for example, a direct-entry midwife with eight years of experience. Working in the capacity of a labor assistant for a woman planning a hospital birth, Kern correctly identified a "critical situation for mother and child" and took the woman to the hospital two weeks before she was due. The hospital staff misdiagnosed her and refused her admission. By the next day the baby had died in-utero. Had she been admitted and properly treated, the baby may have survived.Kern explains that after a complaint was filed against the hospital, the nurses signed an affidavit that an illegal lay midwife had been involved. The investigator told Kern's lawyer that she had done nothing wrong and Kern concludes that had she been legal, the woman would have been admitted. Wanting to protect the families with whom she has worked and not wanting to financially devastate her family, Kern stopped the investigation by signing a cease and desist order.Assemblyman Luster claimed unfamiliarity with the investigations. "If it is true that people who are applying are being investigated," he said, "that runs totally contrary to the purpose of the law. The purpose was to invite people into a process that is licensed and controlled. By investigating their past acts, we chill that very process."POWER AND CONTROLMany argue that fear of economic competition continues to be the primary motivation for today's political climate as the propaganda that was unleashed in earlier decades creeps back into official rhetoric. Bringing CNMs into an already existing obstetrical practice lets physicians increase the number of providers at a reduced cost. But independent midwives constitute a threat. As Schutt explains, "If obstetricians assume that all of the child birth dollars spent should be going into their pockets, then midwives who want to establish independent practices or who are doing home births are immediately seen as taking away from that potential pool of child birth dollars."Independent midwifery may also be threatening because it represents a potentially non-subservient role for women in a field characterized by hierarchies and deference to male authority. Many CNMs must find ways to accommodate their own philosophical and practical orientation within a medical, obstetrical framework that imposes institutional constraints. Direct-entry midwives believe that compared to CNMs, they have more freedom and autonomy in managing the labor and birthing processes because they work outside of medical institutions and have not been trained in the medical, hierarchical model. "I see it as a male-female power issue," says Dr. Susan Soboroff, a family physician in Trumansburg. "These are women who are practicing independently of the traditional medical community. CNMs work under the jurisdiction of a physician, often male, whereas direct-entry midwives are independent."THE FUTURE OF HOME BIRTHDespite Mielcarski's public contention that the "law does not, in any way, inhibit home birth," Schutt explains the reality: "The biggest effect that the MPA is having on women's child birth choices is that it's made midwives who choose to do home births unable to practice without the practice agreement, or afraid to practice without it, for fear of being investigated and arrested. Home birth is much less available than it was before." In Ithaca alone, four independent midwifery practices have been virtually shut down.To be sure, the current inability for direct-entry midwives to becomes licensed is not the only barrier to home birthing. Lack of third-party reimbursement, insufficient medical back-up and concerns about liability and malpractice issues are among the other barriers. Dr. Steve Gelber, at OB-GYN Associates in Ithaca, says that he would welcome the opportunity to participate in a home birth but is held to certain ACOG standards that prevent it. He explains, for example, that ACOG insists that one must be able to proceed to a c-section within 30 minutes and this is not possible in a home birth. Still, providing for the licensure and legality of direct-entry midwives is an important step in lowering the cost of maternity care, reducing unnecessary c-sections and guaranteeing women their legal right to choose the location of their birth."Midwives want to be licensed," says Schlinger. "We want to be legitimate. But instead we are being shut down and options are closing."To maintain the home birth option, the legislature must resist the pressure of the medical community and acknowledge the scientific literature that proves home birth to be at least as safe as a hospital birth; the Board must find ways to validate the experience and training of direct-entry midwives and put mechanisms in place to enable them to become licensed; and the Office of Professional Discipline must stop what many midwives believe is a witch hunt.Giving birth at home is clearly not a choice that is right for everyone. But even Burkhardt, a member of the Board of Midwifery, recognizes it as a valid choice. "I think it is a legitimate barometer of consumer's unwillingness to take the risk of going to a hospital," she says, "because hospitals have done bad things to women in birthing situations."Consumer voices are urgently needed to demonstrate support for midwifery and home birth. Public outcries in many states have made a difference. Write to your local legislators demanding an end to the arrests and investigations and calling for the legalization of direct-entry midwives.SIDEBAR ONEEvidence Supports Safety of Midwifery-Attended Home BirthsObstetricians are quick to point out the risks associated with birthing at home, but they are less likely to discuss those associated with hospitalization. Increased hospitalization and medical intervention have not increased the safety of childbirth. Numerous studies in scientific and medical journals conclude that for low-risk women, home births are associated with fewer interventions, lower costs and equally safe, if not safer, outcomes than those of physician-attended, hospital births. According to the 1994 World Fact Book, the U.S. ranks 36th in infant mortality rate. And in the 8th ranking Netherlands, non-nurse midwives attend the majority of births, both at home and in hospitals.Hospital policies and practices can actually undermine a woman's ability to give birth naturally. For example, in 1992, 77 percent of women who gave birth received electronic fetal monitoring (EFM) which measures their contractions and the baby's heart beat. Randomized studies, however, have shown that for low-risk labors, EFM increases obstetric interventions with no apparent benefit for the baby. EFM, for example, often restricts a woman's movement which may impede her ability to labor effectively, and slow down the entire process. She may then be given pitocin to speed things up, which, in turn, can produce more painful contractions, increasing the need for pain medication and epidurals. This may make it harder for a woman to push effectively, increasing the likelihood of an episiotomy, use of forceps or a cesarean-section.Such interventions have become more prevalent in recent years. Barbara Katz Rothman, a sociologist and author at City University of New York calls the 25 percent c-section rate an "epidemic." Wagner points out that in New York State alone, between 15,000 and 30,000 women have unnecessary c-sections each year, costing the state $100 million dollars annually.A HISTORY OF FALSE ACCUSATIONSThe current political nightmare in New York is only the latest attack on our nation's midwives. Although midwives once delivered the majority of babies in this country, physicians waged a long and vociferous attack against them that began in the mid-nineteenth century. Ignorant, dirty, dangerous and "inveterate quacks" were just some of the epithets used to describe them.Reasons for this earlier attack shed an interesting light on contemporary politics. It had little to do with poor birth outcomes and much to do with the economic threat that midwives posed to physicians. Midwives in the early 20th century were blamed for reducing the number of women who would serve as clinical material and for keeping the field of obstetrics overcrowded and thus not as well-compensated in money or status as the other medical professions. Said one obstetrician, for example: "...as long as women untrained in the medical sciences continued to attend one-half of all births, the obstetrician would never receive his due recognition....under no circumstances should the midwife be granted a permanent place within the American medical hierarchy."While midwives in Europe were trained and respected as responsible birth attendants, those in the U.S. were explicitly denied access to new information and technologies. Empirical studies carried out in the early 1900s, however, failed to vilify direct-entry midwives. Once in the hospital, the mortality rates of women and infants increased relative to those under the care of midwives. This was due to such factors as misuse of forceps, dangers associated with infection, and careless use of anesthesia.Nonetheless, the campaign to eradicate midwifery was so effective that by 1968 midwives attended only 1.5 percent of births in the U.S. The public became convinced that child birth was inherently dangerous and complicated and only the male obstetrician was qualified to manage it. Along the way, child birth was reconceptualized from a normal, home-based event to a hospital-based "pathological process" from which "only a small minority of women escape damage during labor."It has only been in the past 25 years that midwifery has begun to make a comeback. Beginning in the 1960s, women began to regain confidence in their bodies' ability to birth naturally and began to question and challenge the dominant obstetrical model. This spawned a resurgent interest in midwifery, both within and outside of the medical model and a growing number of women began to choose to have their babies at home, among family and friends.