Lexington, KY - To some, the term "midwife" automatically conjures the antiquated image of a counterculture witch-healer type, with little clinical knowledge, traveling from village to village with a mysterious birth bag that might contain anything from a needle and thread to a bottle of vinegar.
Fast forward to perhaps the most common image associated with modern childbirth: a woman on her back in a hospital bed, stainless steel, feet in stirrups, a doctor standing between her legs telling her to push.
Both of these media-propagated stereotypes provide an incomplete and misleading picture of modern-day options regarding childbirth and midwifery. A growing profession that has adapted to modern medical practices on many facets, nurse-midwifery is incorporated in an increasing number of hospitals, many of which offer the services of Certified Nurse-Midwives (CNMs) as an alternative or supplement to obstetrician care throughout a woman's pregnancy and labor. While contemporary American midwives are diverse on a number of levels - from their belief system to their certification, training and the places where they are legally allowed or willing to assist in births - overall, the practice of midwifery retains a common core mission: to provide individualized care, options and assistance to mothers throughout pregnancy and delivery.
At the heart of this mission is minimizing unnecessary medical and technological intervention, particularly Cesarean sections, which have come to encompass over 30 percent of births in the United States. Even though widespread research has shown that the ideal Cesarean rate is somewhere between 5 and 10 percent, C-sections in the United States have been rising steadily over the past 40 years - in 1965, when it was first measured, Cesareans made up less than 5 percent of births in the United States; by 1989, it had risen to over 20 percent.
Knowing Your Options
The rise in C-sections to a rate that even the Center for Disease Control and Prevention says is more than 20 percent higher than it should be is an epidemic, according to Lauren Faye Howard, a certified pregnancy therapist who lives and practices in Lexington.
"There's this whole feeling that we shouldn't question medical authority," said Howard, who utilized the services of a midwife for the births of both of her children, the first in a hospital and the second at home. After the birth of her first son, which was assisted by the late nurse-midwife Beth Broderson at St. Joseph's, Howard trained to become a doula - a professional labor support specialist who provides physical, emotional and educational support throughout a pregnancy and birth, and often during post-partum as well. A key aspect to a happy and healthy pregnancy and childbirth, most doulas maintain, is knowing your options and exercising your right to personal choice.
"Many women aren't taking the time to educate themselves or empower themselves and recognize that that they do have choices - even if they are going to the hospital," Howard said.
Among the first and most important choices a woman must make in pregnancy is choosing a caregiver for her primary prenatal, labor and postpartum care - be it an OB/GYN, a Certified Nurse Midwife (CNM) or a Certified Professional Midwife (CPM). While many elements of the certification processes for nurse-midwives and CPMs are comparable, there are a number of differences between the certifications, among the most defining being that CPMs do not have nursing degrees and are therefore not licensed to practice in many states (including Kentucky). Almost exclusively, CNMs practice in hospitals, clinics and birthing centers, while CPMs, having only the midwife certification that requires extensive training in out-of-hospital births, tend to specialize in at-home births.
Presence of Nurse-midwives in Lexington
Two practices in Lexington offer the option of nurse-midwives: Lexington Women's Health at Central Baptist Hospital and Associates for Women's Care at Saint Joseph East.
According to Melissa Courtney, the first CNM hired by Lexington Women's Health, the pre-natal and labor care that you would receive with a nurse-midwife at their practice, which currently employs three CNMs as well as four OB/GYNs, is comparable to the care you would receive with a physician.
"The care is essentially the same - you just have a certified nurse-midwife as your provider instead of a physician," Courtney explained. "Basically, (CNMs) offer more time with patients (during their pre-natal visits), more individualized care, more one-on-one ... We try to help advocate and support the patient through the whole process in trying to have the type of experience that they want to have."
As with most midwife care, the thrust of CNM efforts at Lexington Women's Health includes minimizing medical intervention, advocating vaginal birth among low-risk mothers, and letting the process happen as naturally as the mother is comfortable with. The CNMs at Lexington Women's Health maintain a 7 percent C-Section rate, and if it is determined that surgery or other interventions are needed (such as the use of vacuum or forceps), the on-call physician at the time takes over, with the CNM remaining present for emotional support.
"Research has proven that medical intervention in a pregnancy tends to have a snowball effect," Courtney said. "We use medical equipment and technology to our advantage, but we try not to use it to the extreme."
Problems with Medical Intervention
In effect, Lexington Women's Health seeks to address the concerns many women have about the over-medicalization often associated with hospital births. Howard, who worked in a hospital as a massage therapist for five years, has a number of good friends who are OBs and a proclaimed "great appreciation for the medical staff." Yet, despite the positive experience of her first birth, she acknowledges a number of flaws in the system that led her, after witnessing dozens of hospital births as a doula after her own first childbirth, to feeling that if she were to become pregnant again, she would feel more comfortable giving birth at home.
"The issues that I see in a hospital are that it can be intimidating and overwhelming - that alone can cause more pain and anxiety for women," Howard said. She added that even though her hospital birth was a positive experience, she still experienced a degree of pain and trauma. Looking back and comparing it to her home birth experience (which she describes as "magical" and "out-of-body"), she now relates that pain to the intense stimuli around her. "That (pain and anxiety) heightens the need, or perceived need, for drugs or intervention, because it's not looking the way the doctor feels it should. And then it just snowballs."
Medical intervention during labor can include efforts to induce or speed up labor, such as amniotomy (breaking the amniotic sac) or labor-inducing drugs like Pitocin; fetal heart monitoring and IV use; and ultimately, unplanned surgery (Cesarean section or episiotomy). To provide a hypothetical example of the potential snowball effect that both Courtney and Howard referred to: A woman elects for an epidural, likely because she is terrified of the perceived pain of childbirth. Because epidurals can actually inhibit labor, the doctor may choose to administer Pitocin, a synthetic drug commonly used to induce or speed up labor by increasing the strength, duration and frequency of contractions. After taking Pitocin, the strength of the epidural might be increased because the pain is more intense, which may eventually cause fetal distress and thus increase the perceived need for a Cesarean operation.
A Fear of Pain and the Unknown
"As Americans, we are terrified of pain and the unknown," said Katherine Shaw, a Lexington mother of three who opted for natural childbirth. Shaw believes that that fear, accompanied with a widespread blind trust of the medical establishment, results in many unwanted and unnecessary surgeries during childbirth.
Pregnant with twins, Shaw opted for a hospital birth for her first delivery. Twenty-one years old in 1986, she recalls standing out during the tour of the first Lexington hospital she considered, being the youngest woman and the only one who was unmarried.
After being told she could not use the hospital's birthing room, which provided a more personal, comfortable and home-like environment compared to a typical labor room (because there would not be enough space for the medical equipment to deliver twins), Shaw opted to seek a different hospital and a different doctor. She feels fortunate to have come across Dr. Fisher at the Woodford Hospital, whom some women have called the "equivalent to a male midwife." Fisher understood and respected her wishes for a natural childbirth with as little intervention as possible.
"I wanted to be awake and aware, to actually feel what was going on, to be trusting of my healthy body," Shaw explained, "and to have a professional available if I need them."
Thanks to the efforts of her doctor, Shaw delivered the twins with a natural, vaginal childbirth, even though her son Tevis was breeched - a fact that she is confident would have ensured C-section if she had been in a different hospital. Regardless of her positive experience with hospital birth, when Shaw became pregnant a second time, she knew she wanted to opt for a natural at-home birth. At the time (1988), the Bluegrass Family Birthing Center, a facility that briefly provided women in Lexington with an alternative to home births or hospital births, had recently shut down, and local midwife resources were scarce. Shaw eventually came in contact with Sandy Tucker, a midwife from Casey County. She delivered her second daughter safely in the comfort of her home with Tucker, along with Shaw's partner and her twins, who were over 2 years old by then, all by her side. She describes the process as empowering and beautiful. (Due to the increasing hassle Tucker was getting from authorities opposed to her practice, it was the last home birth she performed.)
Home Births
"Birth is a natural, healthy process, and it works best when you don't interfere with it," said Sarah Hood, a home-birth advocate living in Lexington. "Interfering with it can include as small of a thing as going to the hospital in the first place - it takes you out of your own environment where you feel comfortable, and adds stress, which can change labor. Your body works best when it's not stressed."
Research, including a 2005 landmark study by the British Medical Journal, has shown that home-births attended by midwives are just as safe or safer than hospital births for low-risk women. Even hospital professionals agree: the only danger of home-births, according to Courtney, the CNM with Lexington Women's Health, lies in the time that elapses before medical assistance can take place if something happens emergently during the birth.
"Our stance on home birth is that women should definitely have options, but we don't participate in home births," Courtney explained. "And so if a patient chooses to do a home birth, that's not something we can be a part of."
Despite the strong history of midwifery in Kentucky, local options for out-of-hospital births are extremely limited today. While it is not illegal to give birth outside of a hospital, it is virtually impossible to find a doctor who will perform home births. Thus, with no freestanding birthing centers, the caregiver options for providing a safe, out-of-hospital birth in Lexington are essentially restricted to two choices - a Certified Nurse Midwife or a Certified Professional Midwife. And both face considerable challenges.
Finding a CNM who will attend home births as a caregiver is virtually an impossible task - an estimated less than 2 percent of CNMs nationwide (and none this magazine could identify in Kentucky) do so. The reasons are basically the same reasons doctors won't do it: liability concerns, and the enormous cost of malpractice insurance.
While there are a handful of CPMs in the state who perform at-home births under the radar, Kentucky is one of 11 states that does not license CPMs to practice legally in the state. The conundrum leaves by the wayside the needs of women wishing for a safe, comfortable and legal birthing experience outside of a hospital, according to the home-birth advocates who have joined forces to create Kentucky Midwifery Taskforce, an organization that has advocated for a change in legislature that would license CPMs to assist in births in Kentucky.
"If women want to have their babies at home, they should be allowed to have a competent caregiver who can provide that," said Hood, who has worked with the task force in the past, but became frustrated with the slow pace of the movement. Hood received her CPM certification, a post-Bachelor degree that took three years -
including three semesters of academic work, an apprenticeship that lasted about a year, and five months at a birth center in Texas -
from Birthwise Midwifery in Maine in 2006. She didn't think at the time that she would end up back in her home state of Kentucky. But now, realizing she is here to stay, Hood is making plans to go back to school to get her CNM certification - another four-year, multi-thousand dollar process.
While disparity exists among doctors, nurse-midwives, CPMs and legislators about whether professional midwives should be licensed to practice, it is essentially agreed across the board that women have the right to a safe, legal alternative to hospital birth. According to Howard, a local freestanding birthing center is the missing link between what she calls the "two extremes" of home birth and hospital birth.
"When talking to clients who have moved here from out of town, they just are shocked that there isn't one here in the area," Howard said. A freestanding birthing center would create a comfortable, home-like environment in a facility where there would be more life-saving devices and medical staff on hand in case of emergency, Howard said. Midwives would be carried through a physician, but it would be "a stand-alone facility where women could feel a lot more at ease."
A number of hospitals have operated birth centers within their facility, but they historically haven't been as different from a typical hospital room as many women would prefer. The Bluegrass Birthing Center, a freestanding facility located on South Limestone, closed down after less than two years of operation in 1985, after having its malpractice insurance dropped (the insurance company dropped a number of similar clients across the country at the same time; no malpractice suit had ever been filed against the birthing center in Lexington).
Despite the limited options on a local level, options do exist, and local birth experts stress the importance of educating yourself about them before encountering what most parents agree is one of the most life-changing events you will experience.
"If you're educated and wise, you can go out and get everything you need," Howard added.
Baby Moon Birth Resource Center is a resource for more information on local birthing options that comes highly recommended from all of the sources mentioned in this article. You can reach them by calling 859-420-MAMA (6262) or visiting www.baby-moon.org.