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license lay midwives
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When it came time for Debbie Fraedrich to bear her fifth child, the Cobden woman found she didn't have many choices outside of giving birth in a hospital — an option she hoped to avoid. She'd had her first child in a hospital but much preferred delivering at home, as she did with her next three children under a midwife's care while living in Texas. "I wanted a midwife so that I could give birth at home again, but this state has made things so difficult for them that I couldn't find one in southern Illinois," Fraedrich says. "I drove two hours to a midwife I found outside the state to get my prenatal care from her. But I wound up delivering my child at home with just help from two friends." It's not unusual for Illinois women to give birth attended by friends — or only their husbands. Whether for financial or philosophical reasons, they decide to have their babies outside of a medical setting, leaving them limited in their choice of attendants. For decades, Illinois licensed lay mid-wives, also known as direct entry mid-wives, who attended to home births regularly. (They shouldn't be confused with nurse midwives, who are registered nurses with advanced training in childbirth.) But in 1963 the state stopped issuing new licenses for this profession. Then, in 1991 the state's Medical Practice Act was broadened to include treatment of conditions along with treatment of ailments, which some have construed as designed to outlaw midwifery. The end result is lay midwives are left in a sort of legal limbo today in Illinois — not listed as illegal in any statute, but not acknowledged either. |
"The law certainly is vague," says Yvonne Cryns, president of the Illinois Alliance of Midwives. "No midwife has ever successfully been charged with practicing medicine without a license. We simply must assume it's an unregulated profession."
With health care reform now a conversational topic of choice — and with several other states outlining specific guidelines for lay midwives — many people say it's time for Illinois to revisit the issue. Some consumer advocates as well as some medical doctors say fear and technology have moved health care standards to the point that pregnancy and birth are treated as an illness. Public policy has been pulled along in the same direction, they say, in a trend that should be stopped.
Advocates in Illinois would like to see passage of a law setting up a licensing procedure for lay midwives, such as those enacted in more than a dozen other states. This would allow women having normal pregnancies the option of choosing a lay midwife's care and giving birth at home — an option that many women prefer and find more affordable.
"Pregnancy is not a medical condition," says Carol Bogard, a consumer advocate in the Chicago area. "But in this country, a pregnant woman is treated as though she is sick." Bogard serves on the board of Chicago Community Midwives, a home birth service directed by a certified nurse midwife. She would like to see lay midwives become licensed in Illinois.
House and Senate bills introduced last year that would have set up educational and clinical requirements for the licensing of midwives in Illinois never made it out of their respective committees. But supporters are undaunted. "State after state keeps bringing back midwifery," says Cryns. "I'm hopeful something will happen here before long."
In 15 states lay midwives are licensed, and in six they can practice because courts have determined so, says Debbie Pulley, a lay midwife who chairs the legislative committee for the Midwives Alliance of North America.
24/February 1994/Illinois Issues
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In 11 others, lay midwifery is legal by omission, in that no laws specifically prohibit its practice. A national exam administered by the North American Registry of Midwives has been implemented as a licensing exam by several states. Supporters offer other states' statutes on lay midwife licen-sure — such as those in Florida, Washington or, most recently, California — as models for Illinois to follow. For example, Washington state law allows its secretary of health to grant a lay midwifery license to applicants who have passed a state exam and completed an accredited state midwifery program or a program of equal requirements at a foreign midwifery institution. At least two years midwifery training is required depending on whether an applicant has nursing experience, as are classes in nutrition, behavioral sciences and other health-related subjects. The law requires licensed midwives to consult with physicians whenever there are significant deviations from normal health in a mother or fetus. The reasons people have for preferring a midwife's care vary widely. "I think mature adults should have choices, in that anyone should be allowed to be assisted in birth by anyone they |
Some women, says Pulley, simply dislike the artificial technology presented in the hospital. "Midwives tend to not use technology," she says. "And it's a more natural treatment all around." For instance, the pain of labor may be more intense in the hospital because expectant mothers generally aren't allowed to move around, she says. "They want something for pain, and if a pain-reliever is given, it usually decreases contractions. Then the mother is given something for speeding up contractions. A midwife's epidural may be a shower or a bath." Fraedrich says the intensive prenatal care that midwives tend to provide is valuable to many women. "Midwives tend to spend 45 minutes to an hour during each prenatal visit, whereas with a doctor it's more rushed, about 15 minutes," she says. "I also found midwives seem to pay a lot closer attention to nutrition and spend a great deal of time discussing its effects on a pregnancy.
Midwives stay with birthing mothers throughout the entire labor and delivery process, which is not sped up no matter how long it takes, Fraedrich says. In hospitals, extended labor may be sped up, and physicians generally are not there for the entire process.
Costs also are a factor. In its most recent survey, the Health Insurance Association of America found average delivery costs in the Midwest in 1989 were $4,149 for physician fees and hospital charges, and $875 for midwives. "It would be folly to eliminate the option of low-cost home deliveries in favor of high-cost, high-tech hospital births," says Minkus.
But there perhaps is an overriding positive outcome to be gained from licensing lay midwives, say Pulley and Cryns: a willingness of midwives to come up from "underground" and increased cooperation between them and medical doctors.
"Now there's a lot of hostility on the part of doctors who don't want to serve as backups to lay midwives when patients move from a normal pregnancy to a high-risk one," says Pulley. "When physicians refuse this care, it makes it less safe. In order to protect the expectant mothers, midwives must feel free to bring them to doctors in emergency situations."
Bogard agrees. "Secrecy is required on midwives' parts, given the legal limbo they're in now, which makes the situation more dangerous for women," she says. "Safety is dependent on the experience of the practitioner and the availability of physician backup. Those are gone when midwives move underground. Technically, no midwife should work without a backup. That's what is safest for women — a collaborative arrangement."
In rural areas, which often lack doctors and hospitals offering obstetric care, midwives could perform an especially valuable service, they say. "Some women way down here at the
February 1994/Illinois Issues/25
southern end of the state have to travel literally hours," says Fraedrich. "It would be much better for them to have a closer option, and it would probably mean they'd follow through with prenatal care more consistently if they didn't have to travel as far."
They all stress that not every pregnant woman would want to be under a midwife's care. "Midwives are not trying to undermine obstetricians' jobs," says Fraedrich. "They'd primarily be in rural areas; they're not going to make the big bucks. Actually it would free doctors to do more medical procedures. I'm not saying there isn't a place for doctors and hospitals. We need and respect them. We just want women to have another choice if they're having a healthy pregnancy." "Mid-wives are not for everyone," says Pulley. "But it is a wonderful option."
Some pretty powerful groups don't see it as quite such a "wonderful" option. "When a pregnant woman sees a physician, she's buying an insurance policy," says Dr. Arthur Traugott, president of the Illinois State Medical Society. "She doesn't want anything to go wrong. Physicians, because of their extensive training, are taught to treat medical emergencies. Midwives may not be able to recognize an emergency."
Traugott says there's not always much warning of pregnancies' taking a turn toward the dangerous. "A seemingly normal pregnancy can go sour in a matter of minutes," he says. "You need to be able to deal with that in a matter of minutes. A physician needs to be prepared to do a cesarean section within 30 minutes. Our concern is if an emergency comes up without a medical doctor immediately available, it could have disastrous consequences for mother and child. Of deliveries that start out normally, one in five pregnancies turns out to be problematic in delivery. The problem that arises is that a mother may not be aware of odds she's up against when making such a choice."
Dr. Minkus takes issue with Traugott's insurance policy metaphor. "Last time I checked, I got to choose to decide what insurance I want and if I want any at all," he says. "It's a little inaccurate to imply doctors and birth technology — internal fetal monitors, heart monitors — are there just if they're needed. A lot of people get it and don't need it."
The American College of Obstetricians and Gynecologists is strongly opposed to lay midwives practicing independently of doctors, says spokeswoman Alice Kirkman. The group endorses a hospital setting as the safest atmosphere for mother, fetus and infant during labor and delivery, and so cannot support home births, she says.
Traugott sees a trade-off between safety and the possible benefits of birthing at home. "There's a trade-off between quality of care and convenience, but the chance of a problem arising makes the inconvenience and cost of a highly trained individual worth it," he says. "Most families going through a pregnancy don't want to talk about birth defects, but then when something goes wrong they expect immediate attention to it."
And he says licensing of lay midwives would lead to increased prices for their services. "If you give credibility through accreditation, the costs of malpractice insurance are going to rise. When you get into licensing you're holding people to a standard. I don't think they've gazed down the road to know what it's like."
Minkus isn't optimistic about improved cooperation any time soon between obstetricians and hospitals and lay midwives — or anyone doing home births. "Even home deliveries that are attended by nurse-midwives or M.D.s are viewed by hospital-based obstetricians less than kindly," he says. "There's hostility. But the important thing should be the interest in patients. It's important for them to know backup is available.
"Medical doctors that attend home births are vilified by organized medicine just as much as lay midwives, so I have to question whether it's the degree of training they're concerned about. There's something threatening to hospitals about home births. I wouldn't want to speculate on what it is," he says with a laugh. Pulley doesn't mind speculating, though: "If you add it all up — all the money people pay to have their babies in hospitals — it's quite a tremendous financial loss," she said. "Hospitals have got a lot of money to fight and they've got a lot of clout. They're not going to take it lying down."
Representatives on both sides of the issue point to studies by prestigious organizations published in high-profile journals to support their views. One side may cite a study by the National Academy of Sciences only to have the other side counter it with evidence from the World Health Organization. It's hard to know whose side science backs up.
Some feel the money that doctors' and hospitals' associations have available for campaign contributions helps lawmakers see the birth process from this "medical" perspective.
A different money trend might end up working to mid-wives' advantage, though. High malpractice insurance costs and lucrative alternatives to obstetrics may continue to turn obstetricians' eyes away from birthing. "Obstetricians have been leaving small towns and even [metropolitan areas] and turning to other fields like gynecological surgery and infertility treatment," said Bogard. "There's a void being created that midwives may have to fill."
Whether they get the chance to fill it will depend upon a lot more than expectant mothers' desires — such as lobbying efforts and money. This isn't the most comforting way of deciding how babies come into this world. But in Illinois, it's simply realistic.
26/February 1994/Illinois Issues
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