All Commentary
Monday, June 1, 1992

The Home-Birth Controversy

Hannah Lapp is a dairy farmer and writer in Cassadaga, New York.

Modern America has much to say about rights and opportunities for women, even down to the right to terminate a pregnancy. However, when it comes to nurturing and bringing their offspring safely to birth, American women often find their options severely restricted.

More than a dozen states have enacted laws to prohibit unlicensed midwifery, while others prosecute midwives for practicing medicine without a license. Some midwives have responded by ignoring the laws; some have gone underground; others have been arrested or imprisoned. But most have ceased to practice their profession and thus have failed to pass their skills on to new generations. As a result, most of our expectant mothers are denied a feasible alternative to a high-tech hospital delivery dominated by a hurried and often distant male physician, and overshadowed by a one-in-four chance of undergoing a Caesarean section—much higher than the rate for midwife-attended births.

Throughout history, midwifery has been an integral part of health care. Marsden Wagner, M.D., European director of the World Health Organization (WHO), reports:

“Even today the midwife attends two-thirds of all births in the world. She is the basic care-giver for maternity care services in every single European country. And in the European countries with the lowest infant mortality rates (all lower than the United States which ranks an embarrassing 21st in infant mortality), the midwife is the senior person attending at 75 percent of all births, whether the birth occurs in a hospital, a clinic, or the home. It is, therefore, an incredible enigma that women within the United States and Canada can be denied the services of a midwife when the rest of the world considers midwifery to be an essential and basic service.”

Wagner further notes that “there has never been a single scientifically valid study which shows that the hospital is safer than the home for low-risk women.”

After studying the health implications of various approaches to childbirth, WHO issued a “Report on Appropriate Technology for Birth,” which calls for a greater emphasis on emotional and social factors rather than on advanced technology, and which rejects a number of common obstetrical practices, including the routine use of electronic fetal monitors or drugs during labor, the imposed flat-on-the-back position for delivery, and unnecessary separation of the newborn from the mother. For a birth to proceed successfully, the organization emphasizes, the woman must be comfortable and in control of her situation.

The issue, however, goes beyond the pros or cons for one method of delivery versus another. Indeed, we shouldn’t summarily dismiss the technical advances in modern obstetrics. The real issue is freedom of choice in what many mothers and their families view as a profoundly personal experience: bringing a new life into the family circle.

Despite nationwide complaints on the availability and quality of obstetrical care, and the corresponding demand for birthing alternatives, there is strong political opposition to midwifery in the United States. The family choosing home birth risks being scrutinized by social welfare and medical agencies, and may even face child-neglect charges. The attending midwife may be prosecuted, particularly if something goes wrong during the birth. Even licensed nurse-midwives and physicians who assist a patient seeking home birth are in danger of being ostracized by the medical community—or worse.


The Home-Birth Movement

The home-birth movement is made up of people from all walks of life, including medical professionals. It includes parents who quietly and privately choose a home birth, as well as men and women turned into “childbirth activists” when their convictions clashed with a powerful social-welfare/medical monopoly.

J. L. English, a biologist from California, became involved in the childbirth controversy when, after she had labored for 24 hours while awaiting her first child, her hospital’s doctors insisted she have a Caesarean section. When her objections were disregarded and nurses began restraining her, she fled to a hospital bathroom where she easily and successfully gave birth on the floor while her friends and relatives fended off the staff.

Drusilla Gonzalez, from upstate New York, is a homemaker who decided on a home birth for her fourth child because “that’s the way Mom had hers,” and because it was always a hassle to get to the hospital on time. After a frustrating search, she found a nurse-midwife to help with her delivery. Like many women who have experienced home birth, she felt she “just had to let everybody know how wonderful it is.” Her midwife moved out of the area at about the time Mrs. Gonzalez’s sister decided she wanted a home birth too, so Gonzalez started studying midwifery material and going on calls with an older midwife, to learn enough to help her sister.

Soon other mothers she met in childbirth meetings started asking her to help in their births, since no one in the area would risk serving them. Gonzalez says that was when she bad to reassess her principles. “My primary aim in life,” she says, “is to serve God and my fellowman. How could I turn them down just because I feared what someone else might say or do?”

Although Gonzalez does not solicit clients because she prefers to stay at home with her family, she hesitates to turn down anyone who asks for her services. As a result, she finds herself swamped with requests. She makes no secret of her work. “if your cause isn’t good enough to defend publicly, it’s not worth it,” she says. “The law has no right to interfere with friends and neighbors helping each other in their own homes.” Even if they’d want to interfere, she points out, there is nothing they can do. “Nature will bring forth the baby, no matter what a doctor or legislator has to say about it.”

Since most regulations regarding midwifery are difficult to enforce, the legal threat usually takes the form of intimidation from medical and welfare agencies, backed up by a few arrests and raids. In California, there have been several murder charges filed against midwives after infants died in delivery, even though the parents and midwives did what they felt was their best. One of these midwives, 62-year-old Rosalie Tarpening, was convicted of second-degree murder and jailed. Now free on an appellant bond, she is appealing her case and is determined to clear her name.

In a 1989 Pennsylvania case, parents of a baby delivered by midwife Lucille Sykes were charged with child abuse by Mercer County Children and Youth Services. Agency director Eugene Morttone explained that the charges were necessary to expose Mrs. Sykes’ practice. The child-abuse petition, he said, would force the family to provide information on Sykes, or face a juvenile court hearing by which he could obtain the evidence. The charges against the couple would be dropped as soon as they “were honest and said what happened.”

The parents were frightened and outraged over being confronted by Montone and two police officers, simply because they decided to have their daughter delivered by Mrs. Sykes. Their baby was perfectly healthy, and both parents attested to the midwife’s competent and caring handling of the birth. Lucille Sykes had successfully delivered over 600 babies during the previous 13 years. Montone, however, contended he could not allow Mrs. Sykes to practice because she wasn’t licensed, and “because we are going to do everything under the sun to protect children.”

In Missouri, state and county investigators raided a birth clinic headed by a registered nurse who thought she was operating legally. The 2:15 A.M. raid interrupted a mother nursing her hours-old infant, her sleeping husband, and their 2-year-old son. It ended with the seizure of a variety of items, ranging from sheets upon which the mother had lain to essential equipment and records pertaining to the clinic’s 38 pregnant clients.

Even physicians are not exempt from intimidation. In California, Dr. Patte Coombes was forced out of practice when the executive committee at Sonora Community Hospital declared her incompetent and revoked her hospital privileges. The committee was unable to find a single patient who would testify against her, and no wonder: Dr. Coombes’ record reflects two decades of exceptionally humane and responsible medical and birth services. Among 3,000 deliveries, there were no infant or maternal deaths, no malpractice suits, and less than one-tenth the national rate of Caesarean deliveries.

The committee dismissed Dr. Coombes’ infant-survival record as mere “luck” and got down to the real issue: their philosophical differences with the doctor. Coombes rarely performed episiotomies (vaginal incisions for delivery), questioned what she felt were unnecessary surgeries, and delivered babies wherever parents wished. On top of everything, she refused to perform abortions, although she contends she made referrals to doctors who did when her patients wished. In an interview with J. L. English, published in Midwifery Today, Dr. Coombes declared: “I respect each patient’s right to non-aggressive medical intervention; I refuse to control my patients; I serve all patients regardless of financial status. For this, I have been accused and judged incompetent.”

Although official measures against midwives are meant to discourage home births, they don’t always work that way. In the case of midwife Lucille Sykes, the litigation against her backfired on those who initiated it. Eugene Montone had her arrested on criminal charges in April 1989; by May the charges were dismissed after a brief trial attended by hundreds of Sykes’ supporters. An injunction sought against her by the State Board of Medicine was similarly dismissed by a Common Pleas judge on the grounds that the state’s midwifery regulations did not clearly apply to lay midwives. The ruling essentially gives the Pennsylvania home-birth movement a green light, and its repercussions are being felt nationwide. In the meantime, Montone came under severe public fire and was temporarily removed from his office as the county Director of Children and Youth Services.

In Arkansas, a midwife threatened with a physician conspiracy to deny her hospital backup sued in federal court and swiftly won an out-of-court settlement. The Arkansas State Department of Health, fearful of finding itself a defendant in the suit, scrambled to change the wording in its regulations that had required midwives to have physician backup for their work. Thus, an attempt to force a midwife out of business ended up offering greater liberties to midwives statewide.

In Iowa, two midwives charged with practicing without licenses are carrying the constitutional-rights issues surrounding midwifery to federal court. If the case continues to the Supreme Court, it will have tremendous impact on childbirth options nationwide.


Unclear Laws

The dilemma of unclear laws regarding midwifery can be seen both as an advantage and a disadvantage. Some midwives are weary of the legal uncertainties and are calling for state licensure for midwifery on feasible terms. (Most states that license midwives have educational and legal requirements that make licensure inaccessible to the average midwife.) Thus, some in the childbirth controversy say that the requirements should be changed. Others feel that legislation isn’t needed, that every woman has the inherent right to choose the birth attendant she wants. After all, fathers can and do deliver their own babies successfully. If this is legal, why ask the government whether friends and neighbors can help?

There are midwives who will have nothing to do with government regulation. The only kind of certification they might find acceptable would come from private childbirth organizations and would not be based on the midwife’s formal qualifications, but on how competent she proves herself. And the tradition of apprenticeship training and peer review for midwives, they contend, must not be lost to academic studies.

No one is denying that physicians and hospitals are sometimes needed in complicated pregnancies or deliveries. Obviously, the medical and hospital setting offers services the midwife cannot provide: fetal monitors, drugs, I.V.’s, and surgical procedures. These services, however, differ from those needed for normal deliveries, and may become detrimental when applied to every situation.

Marsden Wagner observes that the physician’s role is different from that of the midwife. “Physicians,” he notes, “are trained in pathology rather than normality. They are committed to a ‘do something’ approach with routine intervention . . . .” Midwifery, on the other hand, should encompass “continuity of care; good nutrition; a normal, natural (non-medicalized) birth without intervention unless absolutely necessary; birth within the home; . . . and a moral respect for every woman’s need and right to be in control and retain the central role in all aspects of the birth process.”

It’s not only impossible for most male physicians to take the place of midwives, but attempting to do so would be unethical if the midwife’s total range of duties is considered. Midwives often attest to a one-to-one “sister” relationship with their clients, beginning with prenatal consultations and continuing through the baby’s first weeks or even years. Many mothers prefer to have these consultations supplemented by physician checkups or tests to prevent complications.

At the delivery, the midwife offers her client every possible psychological and physical comfort—anything from confiding about motherhood to massaging the laboring woman’s feet, to helping with household chores. Family members, particularly the birthing woman’s husband, are encouraged to remain involved and pick up skills themselves. In her home surroundings, the laboring woman can take advantage of the law of gravity to encourage progress, sometimes remaining active and on her feet until minutes before her little one’s arrival. The midwife stays at her beck and call, distracts her from the pain, and helps support her in kneeling, prostrate, or squatting positions—anything the mother prefers.

The midwife’s most important task is promoting her client’s happiness and comfort. According to data from a number of states, these services result in an astonishing record of maternal and infant well-being. As a reward, midwives enjoy almost zero risk of malpractice suits.

Safe childbirth in America, as well as personal liberty for women and families, can be attained only when midwifery and medicine recognize each other as two legitimate professions whose boundaries are established by free consumer choice.

  • Hannah Lapp is a dairy farmer and writer in Cassadaga, New York.