The Birth Battle:
Doctors, Midwives and the Politics of Pregnancy
By Kim Pleticha
Parent:Wise Magazine, March 2004
Two years ago, Mary Barnett had a thriving career as a certified nurse midwife. She delivered eight babies a month — a lot by midwife standards — while working with Women Partners in Health, a clinic comprised of obstetrician/gynecologists and three midwives.
But that all changed in May of 2002.
That’s when Women Partners in Health followed the lead of Capitol Obstretrics & Gynecology Associates and terminated its midwifery program. By December 2002, only ObGyns could deliver babies in Austin hospitals. Like the other five nurse midwives in town, Mary was out of a job.
“I really didn’t know exactly what I wanted to do…but I knew I wanted to be a midwife,” Barnett says.
Instead of leaving town to find a new job delivering babies in a hospital — which is what several of the other fired nurse midwives had to do — Barnett opened a homebirth practice. The majority of her clients are former patients from Women Partner in Health.
“I have very few options to practice other than at home,” Barnett says. “I could change my career focus, but I am a midwife so my job options are limited.”
So too are the options of pregnant women in Austin. When physicians refused to continue sponsoring midwives at Brackenridge and Seton hospitals in 2002 — citing both the high cost of insuring them and hospital regulations that forced physicians to be present for every midwife birth —Austin became the largest city in Texas without midwives in hospitals. This, at a time when women were — and are — clamoring for the services of midwives. According to the American College of Nurse Midwives, the number of nurse midwife-assisted hospital births nationwide doubled from 1990 to 2000; in Texas, they quadrupled.
The lack of hospital-based nurse midwives in Austin has landed some mothers-to-be in a quandary: do they give up the personal attention and more “natural” approach to childbirth afforded by a midwife or do they give up the security of delivering in a hospital?
As it turns out, those who can afford it are choosing the midwife over the hospital. According to 2003 Texas Department of Health preliminary birth data for Travis, Williamson and Bastrop counties, the number of women delivering babies with nurse midwives in licensed birthing centers increased 64 percent from 2002 to 2003.
“[Our client load] has increased because there’s just not really a lot of options,” says Stacey Jamail, office manager for the Austin Area Birthing Center. “It’s either homebirth or a hospital birth without a midwife to give you that extra TLC.”
Women looking for that extra TLC also drove-up numbers for babies born at home with non-medical midwives: in 2002, 136 women in the Austin-area birthed at home with “lay” midwives; in 2003, that number increased to 157.
“A lot of women would prefer to have their babies in the hospital but the midwifery component is very important to them,” says G.B. Khalsa, a certified professional midwife who has seen an increase in clients coming from Women Partners in Health. “If they can’t get [midwifery] in the hospital they will go someplace else.”
The Battle Begins
But that could change if the Texas Medical Association, a trade organization representing physicians, has its way.
The TMA vehemently opposes out-of-hospital birth and has tried for years to curb it.
“We used to do homebirths. There’s a reason we stopped,” says Joseph Valenti, Chair of the Texas Medical Association’s Committee on Maternal and Perinatal Health. “People forget because they don’t see the bad outcomes.”
Valenti says he and the TMA support certified nurse midwives as long as those midwives are supervised by physicians and delivering babies in hospitals. (Valenti says he employs three nurse midwives in his Houston practice.) However, he and the TMA do not support any midwife who delivers at home or in a birthing center.
The group feels so strongly about this that is it actively working to change the rules that govern those who deliver babies at home or in birthing centers. The proposed change would affect women’s birth options in Austin and throughout the state.
Currently, the Board of Nurse Examiners oversees certified nurse midwives, whether they practice at home or in a hospital. Non-nurse midwives are overseen and regulated by the Midwifery Board at the Department of Public Health. These “direct-entry” midwives have not attended nursing school but rather have completed courses at an approved institution of midwifery, served an apprenticeship, and taken the state midwifery competency test; some are further licensed as “certified professional midwives,” which means they have met the national standards of the North American Registry of Midwives — a process that takes at least three years to complete.
Last session, the TMA asked the legislature to move the regulation of direct-entry midwives to the Board of Nurse Examiners, arguing that direct-entry midwives were practicing nursing. The legislature denied the request.
Now, the TMA wants the regulation of direct-entry midwives moved to the Board of Medical Examiners, saying that midwives are practicing medicine and should be overseen and regulated by doctors.
“We feel that if direct-entry midwives could work within a set parameter and a set group of standards and have mandatory physician collaboration that would create a safer [environment] for patients,” Valenti says.
This alarms midwives, who say it’s a political ruse to put them out of business.
“Every time you see the word ‘supervise’ put in ‘control,’” says Marion McCartney, the director of professional services for the American College of Nurse Midwives. “This is about control and this is about money.”
Money and Power
Midwives — both CNMs and direct-entry — say the push to have physicians oversee out-of-hospital midwives stems from doctors’ concerns about the growing popularity of midwifery and its financial effect on physicians.
“It boils down to money,” says Martha McBride, the Texas representative for the Midwives Alliance of North America. “[Physicians] are not really concerned with the states that have small numbers [of midwives], but when you have [midwifery] schools — more than one — like in Texas that are cranking out midwives,” that worries doctors.
“That’s not it at all, it’s absurd,” Valenti asserts, pointing out that one third of obstetricians in the country have stopped seeing patients because of high malpractice insurance costs. “We are full to the gills with patients,” he says. “We’re not trying to put [midwives] out of business, we’re trying to put rules in there that would enhance patient safety.”
But some Austin physicians say the TMA isn’t being truthful about its push to mandate physician supervision of midwives.
“You know there’s this wise old saying about doctors, which is ‘doctors may appear to be talking about a lot of things but in reality they’re only talking about one thing,’” says Dr. John Day, a family practitioner at Central Family Practice. “The implication is that the ‘one thing’ is the money-power issue.”
Day knows that first-hand: he used to deliver babies at Brackenridge Hospital but says he quit, in part, because of pressure from obstetricians who didn’t like him cutting into their business.
“They really don’t like anyone but ObGyns doing it,” says Dr. Day, whose wife delivered all four of their children with a midwife at home. “They are very, very territorial.”
Studies, Statistics and Safety
The TMA remains adamant that the reason it wants to stop homebirths is because they are unsafe. It bases this assertion on a 2002 Washington University study of birth certificates published in Obstetrics and Gynecology, the monthly journal of the American College of Obstetricians and Gynecologists. The study suggests that women who deliver at home have double the incidence of fetal mortality than women who deliver in the hospital.
The study sounds alarming — until you realize that the numbers for both groups are extremely small: just 0.35 percent of babies died in the homebirth group and 0.17 in the hospital group.
The study also has been heavily criticized by epidemiologists, who say the data do not ascertain whether the births in question were planned homebirths with a competent midwife or simply women who accidentally gave birth at home without proper support.
“If you’re only dealing with birth certificate data, you don’t have any way of verifying the accuracy of it,” says Dr. Patricia Janssen, an epidemiologist with the Department of Health Care and Epidemiology at the University of British Columbia.
Janssen conducted her own study of planned homebirths in British Columbia and found that there was no maternal or neonatal risk associated with them if they were attended by a regulated midwife.
Numerous other studies have come to the same conclusion — in fact, a National Library of Medicine (PubMed) search done by Parent:Wise Austin found more than 100 articles in which the outcomes of planned homebirths with a qualified midwife were as good as or better than hospital births.
“For years midwives have had better birth outcomes than physicians in Texas,” says Beth Overton, president of the Association for Texas Midwives. “That takes into account that physicians take care of high risk women — the fact is, midwifery is safe.”
Dr. Clive Polon, one of the few ObGyns in Austin who provides medical “back-up” to homebirth midwives by seeing their patients when a problem arises, agrees that homebirth can be a safe option for low risk mothers — although he doesn’t think it’s a good idea for women with heart problems, diabetes, multiple fetuses, or those with previous c-sections. Dr. Polon says that while no birth is 100 percent safe, 95 percent of births can take place at home with no problems. When things do go wrong, Dr. Polon says 90 percent of the time patients can transport to the hospital before anything dire happens.
“I think birthing at home is fine, provided you have an experienced midwife who knows what she’s doing and knows enough to know what she doesn’t know — which is just as important for doctors — and will refer a patient to a hospital in a timely fashion,” Dr. Polon says.
Midwives say they want nothing more than reliable physician back-up when they have a client with a problem. At the moment, however, only a few physicians in Austin, like Dr. Polon, will offer such back-up — chiefly because they worry about being sued if something goes wrong. As well, medical malpractice insurance companies don’t look kindly on physicians who willingly provide medical back-up to homebirth midwives. Given that, midwives say the TMA’s proposal for mandatory physician supervision could kill direct-entry midwifery in the same way that mandatory physician supervision ended CNMs in Austin hospitals: ordering physician back-up without ordering physicians to provide it puts midwives out of a job.
It happened in California: The legislature there placed licensed midwives under the direction of the medical board, which required physician supervision. As it stands, no licensed midwife in California currently has physician back-up because physicians can’t — or won’t — assume the liability.
“What is happening is that [birth] choices are being taken out of the hands of individuals — people are being denied their right to a choice,” says Dr. Day. “What we’re working on is the criminalization of a baby coming out of your body unless that happens at a hospital.”
Records and Protocol
The TMA, however, says what is criminal is the lack of protocols and sloppy record-keeping for homebirth midwives in Texas. The group says both of these combine to make it look like homebirth is safe when in reality the numbers are skewed.
“They are going to report that they have really great statistics because their record keeping isn’t great,” says Dr. Valenti of the TMA. “They don’t want people to know that bad things happen and they don’t have the training to recognize when bad things are happening.”
The bookkeeping charge is a serious one: all homebirth midwives are required to fill-out long-form birth certificate data just the same as physicians who deliver babies in hospitals. That data — which includes everything from birth location to birth complications to birth outcome — is filed with the Department of Health. Faking these forms is a crime. When asked by Parent:Wise Austin, representatives at the Bureau of Vital Statistics were astounded then angered that anyone would suggest such tampering was taking place. Midwives echoed that sentiment.
“The Department of Health has nothing but safety in mind — they have no investment in midwives [and] they would not be working for us: I sat on the [Midwifery] Board and I know that for a fact,” says midwife G.B. Khalsa. “The board is composed of physicians, nurses and certified nurse midwives and those people take their jobs very seriously to safeguard births outside of the hospital.”
The other charge, regarding a lack of midwifery protocols, has a involved and contentious history: the Department of Health revised the midwifery protocols in 2002 after a lengthy and livid debate between physicians and midwives. In the end, the midwife-approved version of the protocols passed — much to the chagrin of the TMA, which accused the midwives of dishonesty and foul play. That’s when the TMA went to the legislature and demanded that direct-entry midwives be placed under the jurisdiction of the Board of Nurse Examiners — and lost again.
“We beat them and they didn’t like it,” says Susan Jenkins, an attorney for the Association of Texas Midwives. ”We beat TMA in the senate and the house — and now they’re coming back to do it again.”
Sunset and Supreme Court Rulings
The TMA is “coming back” because the Texas Midwifery Board is in “sunset” right now: a period of review that will culminate in 2005 when the legislature must decide whether to continue the Texas Midwifery Board in its current state or make changes. The TMA is lobbying for serious change — putting direct-entry midwives under the jurisdiction of the Board of Medical Examiners — and this time around they could get it. That’s because the state is trying to consolidate various departments and boards to save money.
At the same time, Dr. Valenti says the TMA is “looking into” challenging the Texas Supreme Court ruling that legalized homebirth. That ruling, Banti v. State, occurred in 1956: it found that “childbirth is a normal function of womanhood” and that midwifery “is outside the realm of the medical practice act” — but only because the legislature failed to include pregnancy in the definition of “practicing medicine.” The ruling has never been challenged, according to representatives at the Texas Supreme Court. Doing that could be difficult — but asking the legislature to re-consider the definition of “practicing medicine” might not be, at least not for a group with as much lobbying power as the TMA.
Some midwives don’t believe that could ever happen—primarily because lawmakers have supported midwifery since the days of the Republic.
“They are not going to be able to overturn it — there’s too much water under the bridge,” says midwife G.B. Khalsa. “There are too many of us: we’re in all of the metropolitan cities, we have a lot of clients, there is a lot of support out there for us.”
But the threat sends shudders down the spines of others, who fear the TMA will not stop until it gets its way.
“They want us gone,” says Melanie Henderson, a certified professional midwife in Austin. “They’re playing hard ball and I don’t know when it’s going to stop.”
Future Birth Choices
For women in Austin, the bottom line is that birth choices could become even more limited. It is unlikely that certified nurse midwives will return to hospitals here anytime soon: although the University of Texas Medical Branch, which runs the Austin Women’s Hospital, says it supports employing certified nurse midwives, it is leaving the final decision up to Austin doctors — none of whom will agree to do back-up for CNMs. The TMA says physicians must be willing to do such back-up, but it cannot require them to do so.
That means birth centers and homebirth will continue to increase in popularity among women who want midwife-assisted birth. If the TMA succeeds in tightening the regulations on homebirth midwives, however, they too could disappear.
Midwives and their advocates say, if women don’t want to see that happen, they have to act now.
“Women and midwives need to work together, as they have been in Austin, to bring public attention to the problems and public pressure to rectify the situation,” says Susan Hodges, president of Citizens for Midwifery.
Hodges and others suggest that women join organizations that support midwifery, write to lawmakers and even involve their own ObGyns in the discussion — because it is going to take physicians who support midwifery to keep it accessible to women. Involving physicians in midwifery is no easy task, since the two philosophies are so different. Still, it can be done — as evidenced by physicians like Dr. Day, Dr. Polon and others who support midwifery despite the legal and insurance ramifications of doing so.
In the meantime, midwives like Mary Barnett say they plan to continue assisting women in birthing babies in a natural, supportive environment. Barnett even hopes to open her own birthing center in the future — a future she hopes will not mirror her past by being controlled by physicians.
“If physicians control midwifery then midwifery is not its own profession,” Barnett says. “You will lose the art of midwifery if physicians control midwifery.”