NURSEWEEK: Midwifery still illegal in some states

Efforts continue to legalize midwifery nationwide

By Tanya O'Connor
Health24 News
October 31, 2000


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Since the beginning of human history, women have been delivering babies, and usually with the help of other women, making midwifery the oldest profession in the world. Today, the likelihood that midwife-assisted home-births can occur without surgical intervention, with low infant mortality rate and at much lower cost is as good or better as in hospitals. The concept that the birthing process is a medical procedure and that pregnancy itself is an illness has been challenged for decades by midwives.

Now, activists around the country are trying to get state legislatures to acknowledge pregnancy as a normal physiological event so that professionally certified midwives may acquire state licensing to practice.

Currently, it is illegal to practice midwifery in the District of Columbia and 15 states: Alabama, Delaware, Georgia, Hawaii, Indiana, Iowa, Kentucky, Maryland, Mississippi, New Jersey, New York, North Carolina, Rhode Island, Virginia and Wisconsin.

In some states, statutes require midwives to have nursing degrees in order to practice, while in others, licensure is unavailable, indirectly preventing midwives from practicing legally. As a result, there are cases pending in courts around the country prosecuting midwives for practicing medicine without a license.

A midwife was arrested in North Carolina two years ago, and another based in Stafford County, Va., is being charged with manslaughter in addition to practicing medicine without a license. Blamed with the death of Julia Peters, who apparently hemorrhaged 11 hours after giving birth in September 1997, midwife Cynthia Caillagh reported seeing no signs of hemorrhage during or even a few hours after the birth.

Although midwives are trained for medical complications, hemorrhages normally happen sooner, often during the labor process itself. While there are many other instances of midwives' being prosecuted, there is also wealth of scientific evidence that supports the midwife-assisted process.

First of all, midwife-attended births have been found to have the lowest rates of cesarean section. The risk of maternal death associated with cesarean section is two to four times that associated with vaginal births. Many women are turning to natural birthing methods to avoid unnecessary surgical intervention. Researchers have also found that roughly "half of the cesareans done in the U.S. in 1991 were unnecessary and that the women having cesarean sections are the ones least likely to need them.

Despite the high risk of caesarean births for mothers, cesarean section is now considered the most common major operation performed in the United States. According to 1994 statistics, 16 U.S. hospitals had cesarean section rates at 45 percent or higher, while 106 U.S. hospitals maintained rates of 37 percent or higher. The World Health Organization (WHO) has issued a statement saying, "There is no justification for having a cesarean rate higher than 10-15 percent" and that "countries with some of the lowest perinatal mortality rates in the world have cesarean rates under 10 percent."

Only 4 percent of births in the United States were assisted by midwives in 1994. Steve Cochran, president and founder of the Virginia Birthing Freedom Organization, who has been working on midwife legislation for the past three years, says doctors are quicker to resort to surgery when the baby is in a difficult birthing position, like a breech situation, when the baby's buttocks present first.

Midwives will work through external manipulation to reposition the baby, while many doctors will perform a cesarean. Greg Phillips, communications specialist from the American College of Obstetricians and Gynecologists (ACOG), said that for external manipulation to be performed by doctors, "it would have to be done weeks in advance." He said that breech birth is the second most common reason for cesarean births, citing recent Centers for Disease Control and Prevention (CDC) statistics.

The CDC reports that more than 80 percent of all breech situations result in cesareans. The most common reason for cesarean is a situation in which the baby's head is too large to pass through the mother's pelvic area, according to the CDC. Some doctors will perform a cesarean if the length of labor exceeds the 12-hour standard that many doctors follow. Additionally, Cochran said that the birthing position of the mother affects the position of the baby.

According to midwives, having the feet up in stirrups is not ideal for pushing a baby out, given the physiological and muscular makeup of the human body. Bearing in mind that midwives do not accept high-risk pregnancy cases, infant mortality rates with midwife-assisted births also compare favorably with other types of births, according to the American Journal of Health. The journal reports that the infant mortality rate is 10 per 1,000 hospital births, 30 per 1,000 of unattended home-births and three per 1,000 midwife-attended births.

Although the infant deaths in hospitals may occur from a number of causes, according to Cochran, they are primarily due to the presence of foreign and super-resistance bacteria found in the hospital otherwise not present in one's home. The American Journal of Public Health writes "physician-attended hospital birth has never been shown to be safer than midwife-attended home birth for women with normal pregnancies."

Some studies have even shown that routine obstetric management may increase risks to the pregnancy. The most recent study to date was conducted by Peter F. Schlenzka, for his doctoral dissertation at Stanford University. He looked at perinatal outcomes in out-of-hospital and in-hospital births totaling more than 800,000, and found that "the medicalization of childbirth and the move of childbirth from home to the hospital might not have improved the outcomes for these low-risk pregnancies," which constitute 60-80 percent of all pregnancies."

ACOG has issued several statements indicating that labor and delivery are hazardous events and therefore require "standards of safety which are provided in the hospital setting and cannot be matched in the home situation."

In a joint statement issued with the American College of Nurse-Midwives (ACNM), ACOG says that the ideal model of practice is where a qualified obstetrician-gynecologist directs the maternity care team.

However, the World Health Organization has declared, "The preferred location for most births is outside the hospital, either at home or in a birthing center."

Supporting this statement is the fact that in Denmark, Sweden, Norway, and Finland, where 70 percent of births have a midwife "as the only birth attendant," there is a lower perinatal mortality rate than in any other European or North American country, according to Wagner M. Pursuing, author of "The Birthing Machine".

Cost is another positive factor in midwife-assisted births. According to Frank A. Oski, MD, professor and director, Department of Pediatrics, Johns Hopkins University School of Medicine in Baltimore, $13 billion to $20 billion can be saved every year in health care costs by developing midwifery care, making childbirth less of a medical procedure and by encouraging breastfeeding. The cost of all the unnecessary cesareans alone done in 1991 added up to more than $1.3 billion, he said. Schlenzka agrees with this cost analysis, writing that "a shared maternity care system would lower the cost for childbirth by roughly 40 percent, or $13.143 billion."

With the cost of a normal hospital birth averaging around $6,000, advocates of midwifery say that such expenses are unnecessary for a normal life event.

Today the effort continues to legalize non-nurse midwives across America so that the midwife-attended home births can occur legally. Referring to the statistics provided by the WHO and others, professional (non-nurse) midwives carry better credentials, according to Cochran. The biggest difference, he says, is that most nurse midwives practice in hospitals. Those who do attend to out-of-hospital births lack the clinical training that non-nurse midwives have received. Certified Professional Midwives (CPM) are given 1,300 clinical hours in home and birthing center births. Out-of-hospital clinical hours for Certified Nurse Midwives (CNM) are not part of the standard curriculum.

There are many programs that offer out-of-hospital experience, usually through internship opportunities, according to Marion McCourtney, director of Professional Services for the ACNM.

Another difference that Cochran cites is that non-nurse-midwives do not rely on medical supervision or physician collaboration, while McCourtney says that collaboration with a group of physicians is necessary for nurse-midwives. McCourtney did not rule out the ability of non-nurse-midwives to fill a need and said that there are no data to support the idea that midwives have to have a nursing background to perform successfully.

"We should be looking at what works," McCourtney said. "The needs of the people should come first. People should not have to fit into some model of care that doesn't suit their needs. Direct-entry (non-nurse) midwives practice successfully worldwide," she said.

Some of the benefits that a nurse-midwife might offer include an ability to call for prescription drugs and to perform episiotomies (incision in the vaginal area). The nurse-midwives also work as part of a medical team and are in constant collaboration with a physician, which is, in some cases, required if the life of the baby or mother is at risk.

The ideal model, according to both McCourtney and Cochran is a shared maternity system, where both nurse and non-nurse-midwives, who are trained to recognize complications, provide referrals to physicians during the pre-natal process if complications are noticed, and who have written backup plans for medical transport in case complications do arise.

This way, the woman receives attentive pre-natal care (average visit with a midwife tends to be longer than with an obstetrician), a potentially safer birthing environment and access to medical intervention if needed.

Of the fifteen states that outlaw non-nurse-midwifery, Indiana and Virginia are currently looking at legislation to make it legal.