Call the midwife?

As a nervous first-time mother, Lisa Bass reached the hospital “a little too soon,” she says.

“I guess they just wanted to speed things up. They gave me Pitocin to induce labor, and they broke my water, and then the baby was in distress; her heart rate was plummeting, and they had to give me an episiotomy and pull her out with forceps.”

No drugs, she told the hospital the next time. Don’t rush me.

By the time she had her third baby, Bass had found a midwife and studied the Bradley method, mastering such deep relaxation that she waited too long to leave home.

Then, because her husband was driving “like a maniac” (her shrieked words), a cop pulled them over. He took one look at Bass and waved them on. She did her darnedest to hold on as she jounced in the front
seat, cell phone in one hand and her midwife’s voice floating out, urging her to hold on as long as she could. Finally the urge to push was too strong. Bass gave up, climbed into the backseat, and announced, “I’m having this baby.”

After a rush of fluid, her son’s head appeared. When his body slid out, she grabbed him and brought him up to her chest, cord still attached.

“I had my third child in the back of our van, at 75 mph,” is now a line on Bass’ popular blog, Farmhouse on Boone. It’s a good conversation starter, but it made up her mind: She wasn’t taking any more chances with the timing. Next time, she’d stay home to have her baby.

The Birth and Wellness Center, in O’Fallon—Missouri’s only licensed freestanding birth center—gave Bass a list of what to have ready: 10 towels and washcloths; swaddle blankets; two fitted sheets with a vinyl shower curtain sandwiched between them, so the top sheet and shower curtain could be peeled back and her bed made clean and ready for her right after childbirth. Her midwife, center founder and director Jessica Henman, suggested soft or dimmed lights: “For a low-risk, healthy birth, we don’t need the bright lights that are standard at hospitals. So much of delivering a baby is in your ears and your hands.”

When Henman arrived at the family’s home, in Troy, Bass looked like she was sound asleep—that’s how she gets through contractions—so Henman waited until she opened her eyes, then checked her blood pressure and the baby’s heart rate. Mainly, though, she let Bass sink into privacy. (She doesn’t even want her husband around when she’s in labor.) As the contractions got closer together, Henman did just a little coaching, murmuring, “Slow down, be gentle,” so Bass didn’t tear. And when instinct propelled Bass out of bed and down on her hands and knees, Henman moved to stand behind her and catch the baby. Momentous as the experience was, it felt relaxed.

A woman in North County was eager to have her baby at home, too. She wanted to give birth on her own terms, in the intimate comfort of her own home. But unlike Lisa, she was using Medicaid. She was crushed to learn that her policy wouldn’t cover the cost of a home birth.

She continued receiving regular prenatal care, though, and even checked in with her midwife at the first hint of contractions. She promised to call as soon as she entered active labor.

Her next call was to say she’d gone ahead and given birth at home. By herself. Could somebody come check on the baby?

It was an awkward situation. “Do we say, ‘You’ve chosen to leave our care, so we’re no longer responsible’?” asks Henman. “Or do we assume responsibility for this baby whose birth we had no control over? It’s this ridiculous bind, and it never should have happened.”

As a country, we’re not very practiced at home birth yet. It’s taken us more than a decade—the change taking place slowly, state by state—to even acknowledge midwives.

For 15 years, advocates tried and failed to legalize midwifery in Missouri. Then, in 2007, State Senator John Loudon (R-Chesterfield)—whose wife had been helped by a midwife’s advice—cannily inserted wording about “tocological certification” into a bland insurance bill for low-income workers.

Tocology is a synonym for midwifery or obstetrics.

Nobody reached for a dictionary.

Clueless, the lawmakers voted yea on the bill. Afterward, Loudon was stripped of his committee chairmanship but expressed no regret. The St. Louis Metropolitan Medical Society and Missouri State Medical Association swiftly filed suit to invalidate the, er, tocology section of the new law. The American Medical Association added a brief warning of “profound risks to the health and welfare of Missouri Citizens” and emphasizing the “gravity” of the childbirth process.

The court agreed. But then the Missouri Midwives Association appealed to the Missouri Supreme Court—and won. The court held that the medical associations did not have standing to bring the suit because they could not represent the public health interest they claimed.

Fast-forward a decade. Midwives have gained enough respect to be included in some OB/GYN practices and given admitting privileges at hospitals. Elizabeth Cook, a certified nurse midwife, is the director of the Mercy Birthing Center at Mercy Hospital, which offers a home-like birth experience within the hospital. She says her profession is growing rapidly: Midwives attend almost 12 percent of all vaginal births, and in some states that figure is reaching 25 percent.

In 1900, almost all U.S. births occurred at home. Then women began coming to hospitals, which now had antibiotics for infections and transfusions for blood loss. By 1969, childbirth was far, far safer for both mother and child, and only 1 percent of births happened outside a hospital—many of them probably unplanned.

In 2004, the number of home births began, ever so slightly, to rise again. In 2015, according to the National Center for Health Statistics, it hit 38,542.

The American College of Obstetricians and Gynecologists still maintains that “hospitals and accredited birth centers are the safest settings for birth.” ACOG’s 2017 opinion statement warns of a more than twofold increased risk of the baby dying (one to two deaths per 1,000 home births), as well as an increase in seizures.

But ACOG also notes evidence of “fewer maternal interventions, including labor induction or augmentation, regional analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery,” as well as fewer vaginal lacerations and maternal infections, with home births.

Dr. Eric Strand, an associate professor in the Washington University School of Medicine’s Department of Obstetrics and Gynecology, points out that “overall, women having home births tend to be the lowest of the low-risk patients, and in any setting they’d have fewer interventions.” Unfortunately, he adds, not all home births are to women truly at the lowest possible risk. Most serious problems occur when women at higher risk elect to give birth at home.

“Diabetes, high blood pressure, twins, a breech presentation, delivering preterm, attempting a vaginal birth after a C-section—there are a lot of things that can make you different from the average low-risk patient,” Strand says.

Those women try for home birth?

“Yes. Absolutely.”

Shouldn’t the midwife refuse?

“All midwives are not created equal,” he says. “Certified nurse midwives have very rigorous training and education in childbirth. Other types of midwives do not.”

Two studies published at the end of 2015—one in The New England Journal of Medicine and one in the Canadian Medical Association Journal—compared planned home births and planned hospital births. They reached very different conclusions.

Using Oregon birth certificate data, the U.S. researchers found 3.9 infant deaths per 1,000 planned out-of-hospital births, compared to 1.8 infant deaths per 1,000 planned hospital births.

In Canada, there was no difference in mortality. Their stats showed home birth to be as safe as hospital birth. Why? Because in Canada, midwives are tightly woven into the healthcare system, so a woman or her newborn can be transferred to a hospital at the first hint of complications. There are established uniform criteria for home births. There are no turf battles, no layers of red tape, no illegal underground practices.

As the New England Journal article concluded, “The extent to which midwifery is integrated into a health care system probably explains some of the differences in practice and outcomes.” Studies from Europe have also shown safe outcomes, perhaps because “the European Union defines uniform standards for the education and training of midwives, whereas the United States takes a piecemeal approach.”

Like Lisa Bass, Ciearra Stevens moved closer to the idea of home birth with each pregnancy. Her first time, she reached 41 weeks’ gestation with her baby showing no inclination to emerge. The hospital gave her Pitocin, which not only induces but also intensifies contractions, and broke her amniotic sac. She’d been determined to have a natural birth, but toward the end of a fiercely painful 23-hour labor she broke down and begged for an epidural. It was hard even to get it placed, because she was writhing in pain. But once the shot landed, numbness smoothed over her like a blanket. She couldn’t even feel her legs, let alone the contractions. “Now push!” she heard voices urging. “Now stop!... Now push!”

She had her second baby at The Birth and Wellness Center at 39 weeks. This time she was good and ready, and when it was time to push, nobody needed to tell her so. Soon she stepped into the birthing tub, its water warmed to body temperature so as not to shock the baby, and felt her contractions melt “from a 10 to a 3” as gravity loosed its hold.

The lights were dim, and the room was quiet. Stevens focused on relaxing, breathing, paying attention to what her body needed to do. Her eyes were closed.

“You don’t look good,” she heard.

“Well, geez, I’m having a baby,” she retorted. Then she heard, “Do you want a drink of water?” and her eyes flew open. It was her husband they were talking to. “He needed medical attention more than I did,” she said, giggling, afterward.

Her first baby, Cailynn, had come out screaming. Camrynn emerged quietly, her little face peaceful. Everything necessary was done with her curled against her mother’s chest.

Elated, Stevens decided to try a home birth the next time: “You’re in your own space already, your comfort zone. Everything’s familiar. You don’t have to worry about getting up and leaving to go home.” But when she checked her policy’s manual, it looked like Medicaid wouldn’t cover a home birth. “So I went with what they’d allow me to have,” she says, still disappointed.

Amanda Owens still remembers the relief of switching to a midwife: leaning back, clothed, on a sofa, for the prenatal checks rather than donning tissue paper to sit on a cold, hard table. Weighing herself and telling the midwife; feeling trusted. Not being constantly checked for dilation during labor. “You know your body,” her midwife said. “You’ll know when you need to push.”

“Yeah!” thought Owens. “I do know!’”

When tiny Solomon emerged, she held him close. She was so elated by the experience, she decided that the next time, she’d have a home birth with her midwife. “My husband’s a veteran and self-employed, so we qualified for Medicaid for the pregnancy. But Home State Health [one of the Medicaid managed care programs] wouldn’t cover a home birth. I looked it up in the little booklet and even called to double-check.”

Owens abandoned her plans, but she suspects that her friend Miquilaue Young, who’s had all her children at home, would rather sell her wedding ring first.

Young dances when she’s in labor. She’s not a masochist; she just wants to keep her muscles loose so she can work with the contractions. Her husband’s a schoolteacher, and his insurance paid for two of her home births—then changed its policy and sent her a rejection letter. When her appeal was denied, she picked up the phone. “I’ve never had a hospital birth,” she said. “They’ve all been to term, and they’ve all been safe.” She says the person on the other end just kept repeating, ‘There are suitable OB/GYNs in your area.’”

Her mind flashed to her grandmother, who’d had five children at home and her sixth, reluctantly, in a hospital. Back then—before all the studies emerged showing racial disparities in healthcare—African-Americans were told they were “backward,” and if they wanted to be somebody, they had to do things the mainstream way.

No, thanks.

The Youngs took a deep breath and canceled their traditional insurance, enrolling instead in Samaritan Ministries, a Christian healthcare plan in which members share costs. Milquilaue had her baby at home.

A home birth costs roughly one-third of what an uncomplicated hospital birth does. Why not cover it? And why, when Medicaid pays for nearly half the births in the U.S., was I hearing so many stories of Missouri women threatened with losing their Medicaid forever if they opted for home birth?

Lisa Cohen, a certified nurse midwife in Kansas City, says one client told her that she just wanted to keep Medicaid as a backup and pay out of pocket for delivery—but when she mentioned her plans for a home birth to Medicaid, she received a letter of termination.

Rachel Williston, who’s both a CNM and CPM (certified professional midwife) and has a birth center in Independence, says, “It used to be that Medicaid wouldn’t pay us at all. They were requesting $1 million/$3 million malpractice insurance, and to get that, you’re usually looking at $50,000 a year, and I’m, you know, making $50,000 a year.”

It’s all pretty arbitrary, she adds: “I’ve had people who were told by the Medicaid office, ‘Don’t tell me where you’re having your baby, because if you do, I will have to mark it down and you will lose your Medicaid.’ We are living in an environment where insurance is dictating a patient’s choice of healthcare. I’m pretty sure that’s not how it’s supposed to work.”

A mother who’s now an apprentice midwife herself says she was told quite plainly that if she was planning a home birth, Medicaid would cancel her policy.

“My understanding is that technically Medicaid could cover a home birth with a CNM, as opposed to a CPM,” she says, “but the way the policies are enforced, no one is legal.”

I email the Missouri Department of Social Services.

MO HealthNet, the state’s Medicaid program, does indeed cover home births, replies communications director Rebecca Woelfel. If someone has enrolled in one of the managed care plans for pregnant women and newborns, “the managed care plan would disenroll the participant so she could temporarily enroll in the MO HealthNet fee-for-service program”—which is usually for seniors and people with disabilities.

So is that why women thought their coverage was being terminated? It sounds a little convoluted—and completely contradicts the experiences that moms and midwives have been relaying. I forward the response to Henman.

“WHAT?!?! I have been told by SO many authorities that a woman would be dropped from Medicaid completely,” she zaps back. “Women have been threatened, told they would lose their benefits. Last fall, I was in a visit with a woman who wanted a home birth, and I informed her that she wouldn’t be able to because she had Medicaid. She was very upset and called Medicaid while she was in my office. During the call, she was told that the person on the phone was required to report her to a supervisor, and a note would be put in her file, because she had inquired about home birth.”

Maybe they just forgot to mention the fee-for-service part?

I call the Medicaid managed care programs that cover maternity and ask about home birth. And although I identify myself as a reporter, I think I pretty much get the same answer that a pregnant woman would:

“We do not cover home births,” says Sheronda S., who’s not allowed to give me her last name, “and if you do ask for home birth, we are supposed to take you off the plan. You can be discontinued.”

Forever?

“We can take you off—we are supposed to—and refuse you. If somebody calls and they gave me their information and asked for home birth, we can remove them from coverage.”

What about later, I ask, with another pregnancy?

“Forever. Now, we do have those midwives we cover, but you have to choose one of ours, and it has to be at a regular hospital.”

I tell Henman, who’s been doing a little detective work herself. She’s on the St. Charles County list of approved fee-for-service Medicaid providers, so she called provider services to ask about home birth. “They said, ‘It is up to the enrollment broker to determine if a participant can change from managed care to fee-for-service,’” she reports. “I called, and a very nice gentleman said, ‘I don’t know what fee-for-service is.’ He said as far as he knew, if you were pregnant you had to be on a managed care plan unless you were disabled or planning an adoption.”

He sent her to participant services, which sent her to provider education, where “the woman was very nice but had no idea what I was talking about.”

Henman emailed Woelfel, who reiterated the policy: You can have a home birth on Medicaid if you switch to fee-for-service.

“I told her I have another woman—I’ve had more than a dozen in the past year—who wants a home birth,” Henman reports. “She asked me to wait until next week before the woman calls, so they have some time to educate call centers.”

Henman is both a CNM and a CPM, as well as a childbirth educator, and she’s worked as a cardiac/emergency staff nurse. She has admitting privileges at Missouri Baptist Medical Center and close relationships with the nurses in its NICU, should complications occur. She won’t agree to a home birth if a case involves any of a long list of risk factors, including twins, diabetes, clotting disorders, medications that might have an effect on delivery…

Obstetricians’ wariness of home births is understandable, Henman says, if they’ve seen “the outcomes of unsafe home births. To see a woman whose water has been broken for five days, and now her baby has paid the price…” But those are the rare exceptions, and midwifery has professionalized itself faster than many people realize. When an obstetrician wanted to partner with her on a home birth and was trying to figure out how to get an oxygen tank, Henman had to smile: “Well, you know, I do have an oxygen tank.”

“What about sterile gloves?” the obstetrician asked nervously.

“Anything we have at the birth center, we also have in the home,” Henman said, wondering, Why do you think this is a good idea if you don’t think I carry sterile gloves?

CNMs hold advanced practice degrees in midwifery and are legal in all 50 states (although some—such as Missouri and Illinois—require an agreement with a collaborating physician). CNMs are regulated by licensure boards.

There’s also certification for professional midwives who, though they may not be registered nurses, have studied midwifery—focusing on home birth—and passed the certifying examination of the North American Registry of Midwives.

Thanks to Missouri’s legislative sleight of hand, CPMs are legal in Missouri but not licensed. They’re not allowed to prescribe or order diagnostic procedures from hospitals or get contracts with private insurance or Medicaid. “Missouri law is not even clear on whether it’s legal for them to carry emergency meds and oxygen,” says Henman.

Across the river in Illinois, CPMs are illegal and can be arrested for practicing medicine without a license. But after years of failed attempts, a fresh discussion is in the works. An amended bill called the Home Birth Safety Act would bring midwifery licensure standards up to the level of those set by the International Confederation of Midwives. The standards are endorsed by ACOG.

Similar bills are planned or being actively debated in 10 other states—but Missouri’s not one of them.

“There was a great push,” Henman says—so intent, she misses the pun—“toward midwives and home birth after ’08. But then midwifery became more common, and there were fewer threats to the practice itself. A lot of the momentum for change slowed down, and it became ‘Don’t rock the boat.’” Or the cradle.

The U.S. spends three times as much as any other industrialized nation on obstetric care yet ranks about 37th in outcomes, and our maternal mortality rate is getting worse, not better. Henman blames disparities in healthcare, based on a woman’s race or how much money she has, and “overintervention.” Too often, she says, “women are told that their bodies don’t work. That you can’t do this basic function that is part of your womanhood unless we, the medical establishment, help you. It’s made to seem very difficult and scary and risky.”

One thing leads to another, she adds: Pitocin to an epidural, an epidural to continuous electronic fetal monitoring, IV fluids, a catheter for Mom, and often forceps and an episiotomy.

Not to mention all the C-sections.

Nationwide, the C-section rate was 32 percent in 2015. Internationally, a rate of 10 to 15 percent has long been acknowledged to save lives, but recent studies reported by the World Health Organization note that “when the rate goes above 10 percent, there is no evidence that mortality rates improve.”

“So for more than half the women having C-sections, there’s more risk than benefit,” says Henman. “A woman who has a C-section has five times the risk of dying. The C-section also affects the woman’s next pregnancy, increasing the risk that the placenta will attach abnormally to the uterine wall and cause massive hemorrhaging. Yet in a provider-centric system, the safest thing for a provider to do is a C-section, because standing in court, the provider can say, ‘I did everything I could.’”

At the other end of the continuum, filmmaker Ellen Esling just finished a documentary on underground midwives in Southern Illinois. These women risk felony charges every time they attend a home birth. There are obvious problems with an underground network, Esling says, including accountability and safety. “But they have to hide. So many counties in Southern Illinois don’t even have hospitals with delivery rooms.” Across the country, rural hospitals are shutting down costly delivery rooms at such a rate that a bill’s been introduced in the U.S. Senate to declare maternity care shortage areas. Advocates of licensed midwifery say it could help. “But the people making the laws are up north in the urban areas,” Esling continues, “and it’s all linked to money and turf wars.”

For home birth, the key to safety is the willingness—of both family and midwife—to transfer the woman to a hospital if necessary. Strand says “roughly one-third of women having their first babies will get transferred to the hospital” (a risk that drops to 4 to 9 percent for later babies). “So now they’re getting transported, at the most stressful moment, to a hospital that hasn’t been involved in their care at all.”

And that’s if they make it to the hospital. In Canada and the Netherlands, provision is made ahead of time for emergency transport. In states where midwives practice underground, there’s a risk that they will delay a hospital transfer or try to avoid it altogether.

The Birth and Wellness Center won’t even agree to a home birth if the family lives more than 30 minutes from a hospital with a NICU. In the past two years, 64 of the center’s clients planned home births. Five wound up going to the hospital: three because they had such long labors, one because there was meconium—fetal fecal matter—in the amniotic fluid, and one because her water broke prematurely. All births were vaginal. Everybody’s thriving.

“A lot of the fear of home birth is ‘What if there’s an emergency? There’s no surgeon, no anesthesia, no NICU,’” Henman says. “What we forget, because we live in metro St. Louis, is that there are lots of places where you can give birth in a hospital without having all that. At community hospitals, anesthesiologists and surgeons have to be called in; they have to be able to assemble an OR team within 30 minutes. What’s the difference between that and a home birth?”

About 99 percent of transfers to a hospital are non-urgent, she adds. “The most common reason is that the mother is exhausted and needs pain medication for rest, and maybe her labor needs to be augmented with Pitocin. Or if a mother’s blood pressure is rising to a point where we are no longer comfortable, or her water has been broken long enough that there’s risk of infection.”

Midwives are a quiet presence. They don’t intervene unless they have to, and they don’t take charge so much as watch over, assist, attend—a word that also means to listen. The midwife listens closely to her client and helps her listen to her baby.

Whose timing isn’t always going to be convenient.

“With Pitocin, you can turn it up or down, titrate it, to time the birth around a shift change,” Henman notes. “In the U.S., there’s a huge slant toward weekday, daytime births.” Overall, vaginal births were more likely to occur between 11 p.m. and 6:59 a.m. when they were not induced, noted a 2015 report from The National Center for Health Statistics. “In contrast, induced vaginal deliveries rose in the morning hours, peaked in the 3:00 p.m. hour, and then declined from 6:00 p.m. onward.”

The report also looked at out-of-hospital births (at home or in a birth center). They were “most likely to occur in the early morning hours of 1:00 a.m. through 4:59 a.m. During these same hours, the lowest percentages were observed for in-hospital births.”

From a midwife’s perspective, the medical establishment too often swoops in and ignores the natural timing of a woman’s body.

“Overall, there’s probably been some truth to that,” Strand says, “but there is definitely a movement in the past several years toward a better understanding of the course of labor. I think we have figured out that labor doesn’t progress as rapidly as we thought. We need to be more patient.”

He urges women planning a hospital birth to find out how conservative the obstetrician is with regard to intervention—and also to ask about the call setup. If there’s “24-hour in-house coverage, then you don’t have the incentive to make sure everybody delivers by 6 p.m. It’s not ‘If this patient delivers, I get to go home.’ You are much more inclined to let nature take its course.”

Henman approves wholeheartedly. She’s even assisted at outdoor births, screened by walls and trees for privacy. “We’ve had family members in the water with the mom.” One woman’s 3-year-old son was part of her support team.

A 3-year-old?

“It wasn’t traumatizing,” she assures me. “He’d come to all the appointments. To him, birth wasn’t scary.”

But seeing his mother in that kind of agony?

“You’re assuming that she’s going to be out of control in pain!” Henman says with a smile. “She knew, because it wasn’t her first birth, that she wouldn’t be out of control. We talked to him about times you go ‘Rrrrrrrrr’ really loud and make a funny face, like when you try to lift the couch.” She adds mildly, “Not all women look possessed or scream and curse. Some do, and it’s good to know that about yourself.”

A recent client wanted her kids around, too. “Not in the room, but she was comforted hearing the normal household sounds of her children getting ready for bed. And think about a child in a hospital room: ‘Don’t touch that!’ ‘Get down!’ ‘‘Be quiet!’” Other women want their dogs at their sides, and Henman’s fine with that. “Most animal pathogens don’t transfer to humans, and a woman has already been exposed to all the bacteria in her house—so if they’re not interfering in any way, they can be present.” She pauses. “It’s odd, but animals know. Even animals that are normally on the hyper side become quiet and attentive when a woman is in labor.”

One of Henman’s favorite phrases is “What gets the baby in gets the baby out.” “The hormonal processes of birth are the same as those of enjoyable lovemaking,” she explains. “I tell college students, ‘Imagine making love in a hospital room, with all the accoutrements of electronics and tubes and straps and plastic and metal and bright lights.’ There is a vast body of research that supports a woman’s need to be in a protected space to give birth without intervention. There’s a certain hormone mix that’s required—oxytocin and norepinephrine. The stress hormones that spike in an unfamiliar setting, with strangers and intrusion and intervention, reverse those hormones. So it’s not surprising that 70 percent of women who walk into a hospital need help getting their babies out.” She grins. “The same woman probably wouldn’t be able to have an orgasm there, either.”

Now, though, a quiet shift has begun.

A hospital delivery suite won’t ever feel like your bedroom, but it’s designed, these days, to look a lot more soothing and a lot less clinical. Even as midwives work to win the full trust of the established healthcare system, setting higher standards and working toward licensure, that system is learning from them, becoming more patient and slower to intervene.

“In the early 20th century, we saw a trend toward more medical management of birth—all well-intended—to create a much safer experience,” says Cook, “and I think we became so medicalized, we lost the art of birth. The pendulum is swinging back.”