Midwives At Center Of Controversy

Thousands of American women give birth at home each year aided by unlicensed midwives whose assistance violates state laws governing medical practice.

In the last decade, more than 300 midwives have been disciplined by state medical boards, sued in civil court or charged with committing crimes. Many have been forced to give up their practices.

About 50, mostly women who charge small fees to assist at home births, have been sentenced to prison.

Most of these cases, court records show, begin when a baby born at home dies or is disabled after complications during delivery. Criminal charges against the midwives range from practicing medicine without a license to child endangerment.

Sometimes, the parents are also charged.

Midwife advocates say the prosecutions are part of a systematic attack on home-birthing. Most of the medical establishment vigorously opposes the practice, saying it compromises safety, and insurance companies often refuse to cover patients and professionals who participate in it.

The prosecutions are a witch-hunt prompted by a "struggle for control of maternity services, the key underlying issues being money, power, sex, and choice," says Dr. Marsden Wagner, a midwifery advocate and neonatologist who worked for the World Health Organization for 14 years.

The American College of Obstetricians and Gynecologists disagrees, saying the issue is safety. Unpredictable hazards to both mother and child "require standards of safety which are provided in the hospital setting and cannot be matched in the home," academy policy states.

Prosecutors who handle the cases say there is no attempt to force women to accept expensive hospital care. They say they are merely enforcing the law. No organization keeps track of midwife prosecutions; The Associated Press compiled the numbers by examining court records, news reports and data from organizations representing midwives.

"The state has an interest in making sure the mother and baby are safe," says prosecutor Joan Risse of Sonoma County, Calif., who brought child endangerment charges against a midwife in a pending case involving a brain-damaged infant.

Risse, a former nurse, says women should be able to give birth how and where they choose, but that attendants must follow rules or suffer penalties. "It's a preventative measure in my mind," she says.

The controversy over the prosecutions raises anew fundamental questions that policy makers, medical professionals and families have wrestled with for years:

Is giving birth a natural process or a medical procedure? What rights do women have in choosing where they give birth and who assists them? And when does a woman's choice become the government's business?

Some midwifery advocates say the forces arrayed against home birth are succeeding only in driving the practice underground - making it more dangerous than it needs to be.

Only about 1 percent of the 4 million babies born each year in the United States are delivered at home, according to the National Center for Health Statistics. But that's still a lot of home births - about 40,000 a year.

Women choose home birth for many reasons: They want to avoid anesthesia or Caesarean sections; they favor home birth for religious reasons; or they simply view birth as a natural process best done at home.

"When a baby is born, the universe is opening up to let a new soul into the world and everybody feels that new energy," says Pamela Hunt, a Summertown, Tenn., midwife who had her six children at home. "That energy is allowed to flow easier at home."

Bettina Zastrow of Nyack, N.Y., had her first baby, Karl, in 1999 in a hospital and her second son, Wilhelm, a year ago in her bedroom.

"The big difference," she says, "was that at home it just seemed like a normal part of life instead of a medical crisis."

But San Francisco writer Susan Gerhard, who raced to a hospital "with my legs crossed in a hilarious attempt to keep the baby inside me" after her home birth became complicated, said that in hindsight she welcomed the crisp sheets, the night nurses and the caretakers who took her new baby so she could get a few hours' sleep.

Nearly all home births are attended by midwives, who come in two varieties.

Certified nurse midwives have medical training; all 50 states license them, though with varying requirements on insurance and obstetrician backups.

So-called "direct-entry" or lay midwives learn through apprenticeships and non-medical training. Only 19 states issue licenses or permits for them; nine states and the District of Columbia forbid them to practice. In the other states, regulations are evolving or nonexistent.

There are about 8,500 certified nurse midwives in the United States, mostly working in hospitals and clinics, according to the American College of Nurse-Midwives in Washington, D.C.

There may be as many as 2,000 direct-entry midwives, according to the Lilburn, Ga.-based Midwives Alliance of North America. The exact number is unknown because in many states they are practicing illegally.

Certified nurse midwives attend only 3,000 of the country's 40,000 annual home births, according to the National Center for Health Statistics.

Nearly all the remaining 37,000 - excluding rare "emergency" home births and deliberately unassisted births - are attended by direct-entry midwives, many in violation of state requirements. That breaks down to scores of unlawful deliveries daily.

"Being a direct-entry midwife is actually a radical and political thing to do," says Susan Moray, a midwife and spokeswoman for the Midwives Alliance.

Political statements are not their primary aim, she says. "Their focus is attending women and babies. But there's no denying that there's a broad struggle with money at stake and issues about who has the authority to define how birth is managed."

The number of home births attended by certified nurse midwives is not only small but believed to be on the decline. It's not that certified nurse midwives don't want to assist with home births; it's because of insurance.

Most states require that certified nurse midwives have obstetricians on call to back them up when complications arise. However, few obstetricians will provide this service because doing so results in astronomical malpractice insurance premiums or cancellation of their policies, according to officials at the American College of Nurse Midwives.

"It's a game," said Diane Polan, a Connecticut lawyer representing four midwives in separate cases related to home births.

Even in places where certified nurse midwives offer home births with doctors backing them, another insurance complication exists: Women's own medical insurance usually won't cover home births.

"Insurance companies rely on their medical directors and the medical directors say, 'Oh, this idea of home birth is crazy,' and they don't want to deal with it," said Dr. Mayer Eisenstein in Chicago, who runs one of the approximately 50 home birth physician practices left in the United States.

Larry Akey, spokesman for the Washington D.C.-based Health Insurance Association of America that represents 300 health insurance companies, said insurers believe mothers and babies are safer in hospitals.

Furthermore, Akey said, lawmakers in many states have made it impossible for midwives not under a doctor's supervision to bill for maternity services.

"That's the real stickler even for insurers who would like to support this," he said.

All of this, midwifery advocates say, leads women who want to give birth at home to turn increasingly to uninsurable and often unlicensed direct-entry midwives, making home births more risky.

Dr. Thomas Purdon, former president of the American College of Obstetricians and Gynecologists, said unlicensed midwives who assist with home births are "unethical, immoral and in cases where babies die, deserve to be criminally prosecuted."

About 20 percent of seemingly normal pregnancies become high-risk or complicated during labor, Purdon said. "If there's not appropriate medical help available at that point, things can get going down the slippery slope too fast and too far."

The group discourages home births even with a certified midwife present.

What are the risks of home birth compared to hospital delivery?

More than 50 studies since the mid-1980s have looked at the question, and many have concluded that home births involving a low risk mother, good prenatal care, a trained delivery assistant and a nearby hospital are as safe as hospital births. Some studies, however, contradict this.

Dr. Michael Speer of Baylor College of Medicine, who chairs the American Academy of Pediatrics' perinatal section, says he doesn't have a problem with home births as long as proper procedures are followed, including having someone available who can quickly resuscitate a baby.

However, he says, midwives should be held as accountable as doctors - with regulations and legal consequences.

"I've been involved at the receiving end of home birth babies where the hospital gets sued instead of the person who assisted the home birth, and I don't think that's fair." he said.

Home birth advocates offer an array of ideas to reduce risks. Some would like to see their practice legal and unregulated while others favor certification and licensing systems. American College of Nurse Midwives spokesman Eric Dyson says that medical complications and occasional prosecutions could be largely avoided if all midwives were trained and certified.

Prosecutors say the last thing they want to do is get involved in the debate, but they must enforce laws.

In Mansfield, Mo., earlier this year, unlicensed, direct-entry midwife Victoria Kocher was charged with child endangerment after attending the birth of Ethan Criswell, who died a week after he was born at home seven weeks premature. The infant's parents, William and Cheryl Criswell, were charged with involuntary manslaughter.

Authorities said Ethan, who weighed 3 pounds at birth, suffered from multiple birth defects, but no one took the child to see a doctor until the day he died.

Larry Tyrrell, prosecutor in the pending case, said he believes the Criswells were criminally negligent and "failed to provide medical care, nourishment and liquid to sustain life."

Kocher "created a substantial risk by not advising the parents to seek medical attention for the child," court documents charge.

In Holmes County, Ohio, Frieda Miller, an unlicensed midwife, was prosecuted this year for administering a prescription drug, Pitocin, to stop a new mother's bleeding.

"Before God and all of you present, I would like to apologize for the wrong I have committed to possess those drugs that are not legal for me to have," Miller said as she pleaded guilty to the charge.

Miller was placed on probation but remains in jail on a contempt charge because she refused to tell a judge who gave her the drugs.

In San Luis Obispo, Calif., Abigail Odam, a direct-entry midwife, was charged in 1997 after a baby she delivered was not breathing at birth and later diagnosed with cerebral palsy. Odam had lost her nursing license almost 10 years earlier after one baby died following a home birth and another was stillborn.

In the 1997 case, she was convicted of six felonies, including practicing medicine without a license and child endangerment, and spent two years in state prison.

"I had this sort of blind faith that I was doing such good work, that I was helping humanity and there was such a demand for my services," said Odam. "I loved it, I was good at it, it was addictive, it was a passionate joy."

Odam was released in 1999, and said she would never go back to assisting childbirth.

"I was trying to please two models of care, the medical model and the midwifery model. I was walking a line trying to please both," she said. "I wouldn't practice midwifery again in California or the United States because we aren't in a culture of accepting responsibility. We're in a culture where if something goes wrong, it's someone's fault."

Midwife advocates argue that prosecutions are not just about promoting responsibility and safety. Many midwives who have been criminally charged are high-profile home-birth advocates who have trained other midwives, says Katherine Prown, who works as an advocate for midwives facing legal challenges.

"Prosecutors and state medical boards are trying to send a message," says Prown, a Wisconsin mother of three children, all born at home. "I think this comes down to an issue of authority. Who has the authority to define how birth is managed?"

By Martha Mendoza