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Midwives’ role expands, to some controversy, under new rules

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LAVEEN – Seven years ago, Kim Aiello had a bad experience when she gave birth to her first child in a hospital. She said no one listened to her – the doctors insisted on breaking her water and giving her Pitocin, a drug that induces labor.

“I felt very dehumanized and disempowered by the experience at the hospital,” she said. “I was so emotionally traumatized by that experience, I promised myself never to go back to the hospital unless medically necessary.”

With her second and third children, she opted out of the hospital and into using midwives. She decided to have her second child at a birthing center in Tucson, aided by two certified nurse midwives.

Then, two years ago, Aiello gave birth to her third child in her own bed, surrounded by her husband and kids and a licensed home birth midwife, miles away from a hospital, without any pain medications.

“After I did that I felt like I could do anything, like I could conquer the world,” she said. “Just giving birth my way, feeling like I was totally empowered during the process … I felt invincible.”

Aiello’s experience is part of a growing trend in Arizona of women seeking birthing care from midwives, both at home and in hospital settings. From 2002 to 2012 the number of home births in the state increased more than 80 percent, according to an analysis of vital statistics from the Arizona Department of Health Services. Still, less than 1 percent of births in Arizona happen at home.

More women opt for certified nurse midwives, primary care providers who usually work in hospitals or birthing centers and are regulated by the Arizona State Board of Nursing. Nurse midwives attended more than 5 percent of births in the state in 2007, the most recent year numbers were available from the American College of Nurse-Midwives, and experts say their use has grown rapidly since.

Rules and regulations surrounding home births have also been changing. Starting July 1 the state will allow higher-risk births to be attended by licensed midwives at home, specifically vaginal births after cesarean sections.

Home-birth advocates are celebrating the move as a way to allow women more autonomy.

“When we look to model countries with healthy mothers and healthy babies, they use midwives,” said Marinah Farrell, president of the Midwives Alliance of North America and a practicing licensed midwife in Phoenix. “As midwives, we don’t turn to pharmaceuticals, we don’t do six-minute visits, we tend to spend longer time with clients – these things help women feel like they’re getting attention and they’re being heard.”

But the allowance for expanding licensed midwives’ scope of practice is troubling for some OB-GYNs who say doing complicated births at home is just too risky.

“I don’t want to be a harbinger of doom, but I promise you that in the six months after this law goes into effect, we will read about disasters of a kind that will make us uncomfortable,” said Dr. Hugh Miller, an obstetrician who works with high-risk pregnancies at Tucson Medical Center.

Changing rules

Allyson Fernstrom of Mesa gave birth to her daughter at home in 2009, but she never intended to become so involved in home birth advocacy. She had never done any community organizing. But she set to work organizing as the Rights for Homebirth consumer group, trying to open up the rules for licensed midwives, in late 2011.

“We got a bill passed, which is huge and hard to do,” Fernstrom said. “We did it on our first try.”

The bill triggered stakeholder meetings with midwives, doctors, state officials and consumers. After months of deliberation, the rules were ultimately changed to allow licensed midwives to do vaginal births after C-sections starting July 1.

The rule change also affects breech births. At present, licensed midwives may attend to breech births if they consult a doctor, but as of July 1 the rules will define different types of breech births, allowing licensed midwives to attend only in certain cases.

“It was a long, hard process, but I do believe the department did a really good job and took everybody’s opinions in, which I thought was really great,” Fernstrom said. “The medical community didn’t get everything they wanted, we didn’t get everything we wanted, but we all got a little bit.”

Dr. Patricia Graham, an OB-GYN and director of the Women’s Care Clinic at Maricopa Integrated Health System, said the end result of the stakeholder process isn’t a good thing, citing midwives’ lack of training with higher-risk births.

If a woman gives birth vaginally after a C-section, there’s a small risk the uterine scar can rupture. That risk increases if a woman has had more than one C-section, Graham said.

With breeches, the umbilical cord can prolapse – slip out of position and potentially cut off blood flow to the baby – or the baby’s head can be trapped, both dangerous situations even in a hospital, she said.

“It seems like the state has taken a totally irresponsible stand on that,” Graham said. “It’s placing the public at a much higher risk … I can’t even begin to understand why the state would sanction that because it is a public hazard.”

The Arizona Department of Health Services has required licensed midwives to send in quarterly reports on births they’ve attended and any bad outcomes from these births. But the department hasn’t analyzed this data and doesn’t know how many home births attended by midwives have resulted in bad outcomes for the mother or child.

“We were upfront and honest about that with the group – yes, you’ve been doing quarterly reports, but we haven’t been analyzing them,” said Thomas Salow, branch chief for non-healthcare institutions, who oversees licensed midwives.

The department changed the reporting process to an online format and committed to analyzing the data and releasing reports, but officials want a bigger sample size before releasing the first set of numbers, Salow said.

“We can start looking at trends and see that, if there’s a bad outcome, what led to the bad outcome,” he said. “We stressed that we’re really trying to get people to comply. The quarterly reports, I don’t think we were getting 100 percent submitted. So we told them we’d streamline it and put it online, but we were going to hold them accountable.”

This legislative session, a bill authored by Sen. Kelli Ward, R-Lake Havasu City, sought to ban breech births and vaginal births after C-sections from licensed midwives’ scope of practice before the new rules went into effect. The bill passed the Senate Health and Human Services committee on a 4-3 vote but was never taken up in the Rules Committee.

“I’m a pro-life legislator,” said Ward, herself a physician, said during the bill’s committee hearing. “I see the mom and the baby as two separate entities.”

Licensed midwives and clients showed up at the health committee hearing to oppose the bill in what Fernstrom, the home-birth advocate, characterized as a “huge outcry.”

“It’s interesting, this whole legislative process,” Fernstrom said. “You work on something for two years to get it passed, then the next year there’s another bill to just undo it all.”

Rising trend

Arizona was one of the first states to recognize midwives, allowing them to be present at childbirth in place of a physician and establishing regulations for the practice in 1957.

Licensed midwives, who typically attend to home births, are still not allowed to get credentials in 23 states, making their practice more or less illegal, said Marinah Farrell, the Midwives Association of North America president.

“But compared to states where it is legal, Arizona is doing OK,” Farrell said. “It could always be better. One of the things about living in a conservative state, conservatives usually support autonomous birth, whether it’s for religious reasons or whatever.”

As a licensed midwife, Wendi Cleckner of Chandler said she sees both ends of the spectrum from her clients.

“It’s usually very liberal, progressive, hippie all the way or very conservative Christians, LDS, very religious,” Cleckner said.

Cleckner runs her practice, Freedom and the Seed, out of her home. She does routine blood draws for clients, which Sonora Quest labs will pick up from the box that hangs on her front door. She doesn’t do ultrasounds or any major genetic testing, but she spends an hour with her clients at every visit to talk about all the changes happening in their lives.

“Our medical system is very against natural and normal,” Cleckner said. “Our system is all about reactive and not proactive. It’s all about fixing problems instead of nurturing and sustaining what is natural and normal. That broken system creates the mess we have.”

Rikki Lake, the former daytime TV talk show host, made a 2008 documentary, “The Business of Being Born,” hoping to expose the problems she saw in the system. Many midwives and doctors have said the documentary brought midwifery and home birth more into the mainstream.

The British series “Call the Midwife” also started airing on PBS in 2012, adding to the publicity surrounding midwifery.

In Arizona, licensed midwives first need to become certified professional midwives through the North American Registry of Midwives. To be approved, a midwife needs to observe 10 births, assist on 20 births and be the primary provider on 20 births under the supervision of a certified professional midwife, in addition to prenatal and newborn exams and postpartum visits.

Miller, the Tucson-based OB-GYN, said education home-birth midwives receive isn’t sufficient for them to provide a safe environment for women and babies, especially during higher-risk births.

“At a time in the past when women delivered at home, a significant number of them died and their babies died,” Miller said. “If you really want to go back to that era, as a matter of autonomy, people have that right.”

Kim Aiello, the Laveen mother, said friends and relatives questioned her decision to deliver at home. But she felt she did enough research and talked to enough moms to know what was right for her and her family. And, most importantly, her home birth came with a sense of accomplishment and empowerment, she said.

“I don’t usually get that when I talk to someone about their hospital birth,” Aiello said. “They’re just grateful that they survived and had a healthy baby. It’s like they had to put up with the hospital to have the baby.”

Dr. Maria Manriquez, who delivers babies at Maricopa Integrated Health System and teaches at University of Arizona, said she understands how women feel about births in a hospital.

“I have to look at my profession and ask how did we get here?” Manriquez said. “Why is it so undesirable to deliver in the hospital and what can we do to make it better?”

Nurse midwives

Brahms’ Lullaby echoes through the halls of the maternity ward of Maricopa Integrated Hospital System whenever a baby is born, as happens more than 200 times per month, according to Lucy Hosmer, a certified nurse midwife with Maricopa Integrated Health System.

Hosmer started out as a licensed midwife doing home births in the 1970s but eventually moved into a hospital setting because she felt vulnerable. She didn’t have any backup care or doctors to work with if an emergency arose. But she still felt like the ideals of midwifery were important.

“Midwives tend to have a focus on the emotional, spiritual and psychological well-being of the patient, that we want them to have a sense of wholeness about themselves,” Hosmer said.

Hosmer is one of six certified nurse midwives on the staff at Maricopa Integrated Health System among a team of OB-GYNs, nurses, medical residents, neonatologists and students. She said the team approach means all women’s views and beliefs on birth are respected.

“The effect of midwifery is as much on the residents as it is on the patients,” she said. “We feel that we have kind of permeated the system … We think they have a better chance at more active participation in their births, just because the midwives are on staff.”

Certified nurse midwives must have a graduate degree in nurse midwifery. They usually work in hospitals or birth centers and have more privileges, like the ability to write prescriptions, than licensed midwives. Their practice is legal in all 50 states, and 218 nurse midwives practice in Arizona.

“I have the highest regard for certified nurse midwives and I think they do a wonderful job,” Dr. Miller of Tucson said. “They complement a lot of obstetric care and bring a different approach than physicians.”

Certified nurse midwives working in hospitals and birth centers are now covered by Medicaid under the Affordable Care Act. That has the Arizona Health Care Cost Containment System covering nurse midwives but not home births attended by midwives.

Banner Health added two certified nurse midwives to its staff in 2012, both of whom practice at the Del E. Webb Medical Center in Sun City West. Janelle Drogowski was Banner’s first midwife and said the recognition by Medicaid and the increase in visibility is bringing her more and more women – a far cry from where other medical professionals thought she’d be.

“They all said ‘If you want to be a midwife, you might as well move because you’re never going to get a job anywhere.’ But the whole society is changing and it’s coming back,” Drogowski said.

She said she allows women to dictate the way their birth will go: They can sit, stand, labor in the tub, walk around, sit on an exercise ball, whatever they choose.

“Ideally to me, most uncomplicated births would be attended by midwives,” Drogowski said. “Physicians are there just for the high-risk patients. I dont know that they need to be at every normal birth. I would love to see it be growing more.”

Doctors and certified nurse midwives say their collaboration creates a better, safer experience for women.

“We’ll try to do what your wishes are but please don’t tie my hands, because do you want the perfect delivery or the perfect baby?” said Graham, with Maricopa Integrated Health System. “If you’re looking for the best birth experience but you have a bad outcome with the baby, is that really a good trade-off?”

What’s next?

Allyson Fernstrom of Rights for Homebirth said she expects to see more attempts to undo Arizona’s rule change on vaginal births after C-sections and breeches. But she said she has no doubt that consumers and midwives will continue to show up and speak out against them.

“We really made a stink and so much noise that everybody knew about us,” Fernstrom said. “We stand by 100 percent that it’s our right as women to birth wherever we want.”

Graham said she respects the rights of women to make their own choices and that delivering at home is safe 90 percent of the time. But being able to distinguish between a low- and high-risk patient and recognize the limitations of licensed midwifery is crucial, she said.

“It may take a very public disastrous outcome, which would be unfortunate if it came to that,” Graham said. “I think one thing is that the licensing for them needs to be more rigorous than it has been and they need to be watched. If you’re in the hospital and do something wrong, you get reported. If you’re in someone’s home, it’s not reported.”

Licensed midwives, certified nurse midwives and physicians all said they were interested in finding ways to work together better in order to serve women and babies the best they can.

“I love and respect doctors, I need them, I need hospitals,” said Wendi Cleckner, the Chandler midwife. “Sometimes it’s a struggle to have to transfer because there’s just not the respect, there’s not the knowledge of what a midwife can and can’t do … It’s kind of like, ‘Oh, you’re just a midwife.’”

Kim Aiello said she doesn’t plan to have more children. But if she does, she said she wouldn’t be opposed to delivering in the hospital this time around. Her home birth was fantastic, she said, and she wouldn’t trade the experience for anything – but it was also very physically painful.

“I feel like I’m a veteran mother now, I’m an experienced birther,” she said. “I would feel more confident advocating for myself now … I would voice my concerns, I would try to create the environment I would want to have.”