Midwife crisis

Sara Batchelor gave birth to her daughter Lauren in a tub of water in a bedroom with her husband nearby. The room was quiet, no monitors were attached to her body and there were “no hot lights on my crotch or harsh needles,” she said. During the labor, she walked around, showered and labored privately with her husband nearby. She didn’t take an epidural, opting instead for a natural birth with the help of a midwife. After giving birth, she settled into bed and midwife Ruth Cummings handed her the baby to nurse.

“It was so unbelievably beautiful,” Batchelor said.

The birth of her first child, Kate, was not quite the same experience, and it’s a memory that almost makes her cry thinking about it seven years later. During that hospital birth, a mistake on the part of the medical staff resulted in Kate being transferred via ambulance to UC Davis Medical Center, where the baby was placed in intensive care. Batchelor was not allowed to nurse Kate or return home until 12 hours later.

“Everything was completely out of my control,” she said. So when the second pregnancy came around, she and her husband decided to have their child at the Birth Center in Fair Oaks, operated by Cummings, a certified-nurse midwife.

Since opening the center in 2000, Cummings has delivered about 180 babies. The center offers full-scope midwifery services, including preconception counseling, pre-natal care, attending birth, post-partum care, nursing information, contraceptive counseling and well-woman care. Cummings runs the center on a basic premise: The vast majority of births are normal and don’t belong in hospitals.

“This is how babies were meant to be born,” she said of the center’s homelike atmosphere.

Earlier this month, she became the only CNM offering full-scope midwifery in a free-standing center in the Sacramento area after Dr. Rita Biesen-Bradley closed the obstetrics portion of her private practice in Roseville, letting go of her CNM, Rita Shapiro.

“That I am the only certified-nurse midwife that is serving women in an area this size is mind-boggling,” Cummings said.

Despite public-health recommendations that midwives help reduce infant mortality and studies showing that planned home or birthing-center childbirths for low-risk women are just as safe as hospital births, midwives continue to face an uphill battle when it comes to carving out a niche in the modern U.S. health-care system. Less than 15 percent of all births are attended by midwives, and the overwhelming majority of these happen in the hospital setting, which some midwives argue does not reflect the “true midwifery model,” said Beth McManis, CNM with Sutter West Women’s Health in Davis and the Sacramento region representative of the California Nurse-Midwives Association.

Currently, about 877 CNMs in the state—certified by the California Board of Registered Nurses—practice in private hospitals, public-health departments, family-planning clinics, HMOs, universities and homebirths. There are fewer than 200 licensed midwives in the state, according to a database search of the Medical Board of California, which certifies this group. The majority of these midwives service homebirths.

Kaiser employs CNMs but they are not available around-the-clock at all locations, and the midwife a woman interacts with during her pregnancy may not be the same one who delivers her baby. The UC Davis Medical Center does not offer midwife services nor does Sutter Memorial. The Sutter Davis Hospital system employs four CNMs through Sutter West Women’s Health and four through Communicare, which delivers babies at the Sutter Birthing Center.

“Where I work, the doctors embrace the midwife model and support it. … Some other physicians have never been exposed to it or they see it as competition,” McManis said.

Only three licensed free-standing birth centers exist in Northern California, including the Birth Center in Fair Oaks, one in San Francisco and one in Santa Rosa, Cummings said. The Bay Area is receptive to midwifery, she said, but that’s not the case here.

“Sacramento is not a welcoming community to midwives and certainly not to the Birth Center,” Cummings said. The California Department of Health Services visited her site twice (and found no problems), and her license was reported once to the CBRN. The reports were filed anonymously, but she has her suspicions about the culprits—they take the form of two older, male physicians.

Cummings said the day childbirth was medicalized was the day that marked the downfall of the midwife.

She remembered as a young nurse standing in the back of an emergency room watching a doctor use forceps to deliver a baby even though the baby was not distressed and the procedure was unnecessary, but it’s how the doctor had been trained.

“[Birth] is part of life,” Cummings said. “It’s not a medical event.”

But some physicians seem to want to maintain that perception. In August, four physician organizations in Missouri filed a lawsuit against the state over a law that would have allowed certified-professional midwives to deliver babies without collaborating with a physician. The groups claimed that they were only concerned for the well-being of the pregnant woman and her baby, but midwives don’t buy this argument. Cummings has never lost a baby at the Birth Center. She does have an ongoing relationship with a doctor who acts as a medical consultant and oversees that medical protocols are followed. She refuses to accept high-risk pregnancies, and in the rare cases where she needs to transition care to a hospital emergency room, she does.

Midwifery will become more readily accessible for women when philosophies change and doctors don’t view it as encroaching on what they see as their territory, McManis said. And while the pendulum may eventually swing back, it likely won’t happen anytime soon.

“The [American Medical Association] is just so powerful,” McManis said.

Cummings will keep running the Birth Center as long as she can, continuing to give women control over their own bodies and pregnancies. During the pregnancy, women weigh themselves, check their urine, prepare their own DNA samples and discuss their options.

“We really view women as being more responsible for their own care,” Cummings said. “They get to participate more. They get to make more decisions.”

When a woman comes in, Cummings calls her by her name and understands her fears and concerns, because the woman is someone with whom Cummings has created a long-term relationship. For Cummings, midwifery empowers women and refutes the notion that pregnant women are ill and need to be hospitalized.

“People don’t remember babies used to be born at home and midwives were the ones attending them,” she said. “It doesn’t have to be a physician. It doesn’t have to be in the hospital.”