Having It Your Way?
The other labor movement
When Heather Ragsdale and her husband Eric got the unexpected news last spring that their first child was on the way, the decision to have their baby at home was obvious. "We were married in our house and we conceived in our house, so it seemed only natural to have our baby in the house," says Ragsdale. "We weren't sick and we weren't wealthy, so we didn't want to go to the hospital." The Starksboro couple's decision was helped along by their insurance situation -- they had none, despite working five jobs between the two of them.
The delivery was more intense than Ragsdale expected. She came down with the flu the day before her water broke, and was exhausted even before her 14 hours of labor began. If something had gone seriously wrong during the delivery, the nearest hospital was a half-hour away. But Ragsdale still felt safer at home, surrounded by her large family and with her husband by her side. And when their daughter, Eleanor, was born at 2:26 a.m. on January 23, she was delivered without the need for an epidural, forceps, fetal monitors, ultrasound or any other drugs or medical intervention.
Thirty years after Roe v. Wade established a woman's right to reproductive self-determination, most discussions about "choice" still focus on access to safe and legal abortions and what rights, if any, should be ascribed to a fetus. But what about the choices women have once they decide to have their babies? Where can they deliver? Who can supervise those births? What doors close when others are opened? Some argue that as the line blurs between a natural home birth and a hospital delivery, women now have more choices than ever. Others say our culture's increasing focus on what goes wrong during childbirth -- rather than what goes right -- is robbing women of the fundamental meaning of choice: an understanding of their own power.
At one end of the birthing spectrum are Vermont's 18 licensed home birth midwives. Ragsdale's birth was attended by two from Bristol, Melissa Deas and her partner Susan Kass. Deas, a "granny midwife," has been attending home births in Vermont for nearly 27 years. She can only guess how many babies she's delivered -- "enough to fill up a school or two," she surmises. Deas was among the last of the independent midwives to reluctantly comply with a state law passed two years ago that licensed and regulated their ancient profession. It was a difficult decision, but unavoidable if she wanted to continue practicing legally in Vermont.
Clearly, a license to deliver has its privileges. Many of Deas' clients can now get reimbursed for their midwifery costs by Dr. Dynasaur and Medicaid, the state and federal health programs that support low-income families. Deas is also allowed to administer oxygen, erythromycin for the babies' eyes, and pitocin, a drug used to stop severe hemorrhaging, though she rarely uses it. She can also hang out a shingle that reads "certified professional midwife."
But the letters "CPM" after her name came at a price -- fewer women who can avail themselves of her services. Deas can no longer attend many types of deliveries, such as breeches and multiple births like twins or triplets. Also off-limits are certain VBACs (vaginal birth after Cesarean section), as well as the pregnancies of women with diabetes, high blood pressure and AIDS, to name a few. "I became a midwife in order to allow women the broadest range of birth choices," says Judy Luce, a certified professional midwife in Barre. "But my ability to serve women in those situations has really been narrowed with licensing."
Currently, fewer than 3 percent of Vermont women choose home births, a number that's remained fairly constant over the last decade but is still higher than the national average. The rest opt for the security and peace of mind they see in a hospital setting -- even if their ultimate goal is a childbirth without drugs, incisions or other interventions.
One such mother is Maryanne Mac-Kenzie of Hinesburg, who delivered her second child two weeks ago at Fletcher Allen Health Care. "I think the idea of a home birth is a really beautiful concept and I admire couples who do that successfully," she says. "But if something really went wrong with my baby, I could not forgive myself if I didn't have access to immediate care."
For MacKenzie, insurance wasn't the deciding factor; complications were. When her daughter was born two years ago, it was not an easy birth. The delivery had progressed slowly, and ultimately the doctor had to break her water. She was given an epidural, a shot of Nubain (another painkiller) and an IV for fluids. "Once you get an IV, it's a domino effect" she says.
MacKenzie, who works at Fletcher Allen, can understand why some women might feel intimidated in a hospital environment. "But I feel strong about my ability to advocate for myself. I knew my husband and my doula were helping me make decisions," she says.
Doulas, a relatively new addition to the birthing scene, are labor-support professionals trained in the art of childbirth. Unlike midwives, they don't actually deliver babies, but provide physical and emotional support to both partners during and after a birth. Among their other benefits, doulas have been shown to ease breastfeeding and reduce delivery complications, postpartum depression and interventions such as epidurals and C-sections. "Our doula helped me know why people would suggest what they're suggesting, and helped me with the decision," says MacKenzie. "We do have choices, but sometimes you feel like you don't, if you don't have the right support and advocacy."
In one respect, Vermont's pregnant women have more choices to make. Thirty years ago, for example, Fletcher Allen was the only hospital in the state where a woman could even get an epidural. Today, the spinal anesthetic is available at hospitals around the state. At Fletcher Allen, where a third of all Vermont babies are born, epidural rates have doubled in the last decade, from about 30 to 60 percent, according to Dr. Eleanor Capeless, director of obstetrics. That trend, she says, is driven largely by the women themselves, who are asking for less painful childbirths.
The availability -- and frequency -- of C-sections has also grown. Today, they're performed in 12 of the state's 14 hospitals. Although Vermont's Caesarian rate is well below the national average, the procedure is far more common today than it was 30 years ago.
Needless to say, many of Vermont's home-birth midwives find such trends disturbing. They fear that women are surrendering more control over their own bodies than they might imagine. Barre midwife Judy Luce recalls an article she saw in Cosmopolitan a few years ago that showed a photo of a woman's naked back and a hand holding a long needle to her spine. The title read, "The second most joyful part of childbirth: getting your epidural."
"The article didn't talk about the increased risk of C-sections as a result of epidurals, or the need for forceps, or the inability of women to push their babies out," says Luce. "It's all part of the marketing of fear. I think that kind of cultural environment restricts the choices women have."
Of course, home birth midwives have seen the impact they've had on the medical profession reflected in the philosophies hospitals have adopted toward childbirth. In fact, Deas credits many of those changes to one family doctor from central Vermont who wasn't afraid to challenge the status quo.
"Women didn't have many choices when I started in 1973," recalls Dr. Thurmond Knight, who practiced family medicine for many years at Gifford Medical Center in Randolph. "I was discouraged by the hospital practices that we were required to participate in."
Knight entered the profession at a time when pregnant women routinely had their bellies shaved and were given enemas and episiotomies prior to delivery. When women at Gifford were ready to give birth, they were moved from the comfortable bed of the labor room to the cold, impersonal environment of the delivery room -- lying flat on their backs with their legs up in stirrups. After the babies were born, the mothers weren't allowed to breastfeed or even keep them in their rooms at night. Instead, all newborns were bottle-fed through the night by nurses.
One day, Knight and his wife were invited to attend a home birth, an experience unlike any he had witnessed in the sterile confines of a delivery room. Soon, Knight was making house calls with local midwives on complicated deliveries, a practice that raised eyebrows not only in his small town but among his colleagues. "One member of my medical board called me an embarrassment to our profession," he recalls. Knight was strongly urged to cease the practice immediately before he "gave the profession a black eye."
Then in 1975, Knight read an article about a small rural hospital about 20 miles outside Atlanta that had found a unique solution to the large number of childbirth complications they were experiencing. The hospital had set up a birthing room on its premises with a nurse-midwife on staff. For $100, expectant mothers -- mostly poor black women with little or no access to prenatal care -- could come in with their family members, give birth with the help of a midwife, and then go home the next day.
Knight showed the article to the hospital pediatrician, Lou Dinicola, who liked the idea so much he convinced the hospital's administrator to try it. Soon Gifford Medical Center had opened the first birthing room in New England: a homey environment with a rocking chair and birthing stool, a comfortable labor bed, a private bathroom and a shower.
Shortly thereafter, Knight and Dinicola were invited to give presentations at the hospital in Burlington, then Dartmouth-Hitchcock Medical Center. Within months both hospitals had opened their own birthing rooms. When Knight finally retired in April 1988, Gifford had five birthing rooms; the old delivery room hadn't been used in years. Gifford's new birthing unit is now nationally recognized for its unique approach to childbirth, boasting the state's highest rate of breastfeeding and the nation's lowest rate of circumcision. At least 60 percent are delivered by midwives.
Today, at least three other hospitals in Vermont have ongoing nurse-midwife programs. The oldest, at Fletcher Allen, handles about 15 percent of the hospital's births. "We consider ourselves experts in the normal," says Amy Levi Rousseau, a certified nurse-midwife at Fletcher Allen. "It's not pregnancy as an illness or pregnancy as a medical event. It's pregnancy as a developmental occurrence in somebody's life."
Despite the incorporation of some midwifery practices into the medical environment, midwives can still get the cold shoulder at hospitals. So do some parents-to-be when they tell a family physician or obstetrician that they're using a midwife.
Shelley Gustafson and Bill Schoonover of New Haven, who expect their first child in a few weeks, explored several options before choosing Deas as their home birth midwife. Their decision was not well received by one doctor they saw.
"Within the first five minutes she said, 'Oh, you're using a midwife? Then I won't work with you,'" Schoonover recalls. "We felt it limited our choices. We want the best of both worlds, feeling that everyone's safe but also doing it the way we want to do it."
Gustafson and Schoonover's insurance won't pay for their midwife, even though a hospital birth costs on average several thousand dollars more than a home birth. But despite the out-of-pocket expense, both were impressed with the amount of time Deas was willing to spend with them during prenatal visits. One midwife who attended a recent national midwifery conference reported that nurse-midwives there were complaining insurance companies would only pay for a seven-minute prenatal exam. In contrast, Schoonover and Gustafson say they routinely spend at least an hour or two with Deas every week.
One suggestion for improving Vermont's birthing choices would be a freestanding birthing center. Often owned by midwives but also staffed with medical professionals, birthing centers combine the comfort and family-centered approach of a home birth with the technological support of a hospital. Birthing centers are not illegal in Vermont, but overcoming the bureaucratic hurdle of getting a Certificate of Need could be a formidable challenge. Moreover, there's a built-in economic disincentive, since many doctors who work with midwives have seen their malpractice premiums skyrocket or, in some cases, canceled altogether. And with fewer babies born every year in Vermont since 1989, the competition for deliveries has grown fiercer, especially at teaching hospitals, where medical students need the experience for their OB/GYN rotation.
If there's universal agreement among birthing professionals, it's that there's no one right way to have a baby. When Heather Ragsdale is asked if she'd go the home birth route again, she doesn't hesitate. "It was the right choice for us. But I probably swayed my sister the other way," she adds jokingly. "She'll probably sign up at the door for an epidural and C-section."