Chapter 6

Mainstreaming Midwifery

Geradine Simkins, DEM, CNM

About twenty-five years ago, when I was a young self-taught lay midwife, I experienced my first life-threatening hemorrhage. All of the tricks in our midwifery bag did not work to stop the woman's bleeding, and I found myself transporting the woman while doing bi-manual compression, one hand in her uterus and one hand externally squeezing. Every two minutes or so her powerful uterus would forcefully expel my hand from her body, and with it, a sea of blood into my lap. I was scared, for up until this moment I had operated on the assumption that, "Women are strong, birth is safe, midwives are good, and all ends well." This was in the days when I did not carry Pitocin because it was illegal for midwives to have it. I subscribed to the midwife code of protecting the "safety of mother and safety of baby" and thought that my skills and herbs would truly be all I needed. After this birth I realized that I needed more. The mother survived and thrived after transfusions and two days in the hospital, my back-up doctor told me I saved her life, and the experience strengthened my conviction that "Women are strong, birth is safe, midwives are good," but I altered the last part of my mantra to "all ends pretty well." It was my first serious brush with the unexpected situation.

A few years later I attended a birth of a first-time mother pregnant with twins, with the first baby presenting breech. It was a long labor, the first baby was born fine, but the second baby turned transverse and would not move into a longitudinal lie. We tried some tricks and waited for a while, but finally, we transported her to the hospital and the physician on-call screamed at me, "You are going to kill someone someday," screamed at the mother and father for being irresponsible, and did nothing to try and turn the baby or facilitate a vaginal birth. He ordered an immediate C-section, swore at everybody in sight, and offered the woman no choices. As it turned out the baby was fine, and the mother was fine, but he kept the baby in the hospital for ten days, along with a forced admittance of the other baby to the NICU. It was an attempt to buy time to find something wrong with the twins, which he never did. In those intervening ten days he assembled a "prosecution team" with a plan to press charges against me and he attempted to turn the family against me too. It was only by the protection of my angels that one of the people on the prosecution team was a pediatrician who, unbeknownst to the obstetrician, was a homebirth client of mine. He talked the OB out of pressing charges because there was no harm done. The OB, who was a known alcoholic, misogynist and the least favorite doctor of the nursing staff, ranted that, "Of course there was harm done. This is a case of maternal trauma and child abuse!" Luckily for me, my pediatrician friend prevailed, and the case was dropped before it got going. But after that experience those words, "You're going to kill someone someday," haunted me for a long time, and I feared that if anyone ever died in my care, I'd go to jail. Birth didn't scare me but the doctors did. Actually, the power of their system is what scared me.

After that, I changed my "rule of thumb" in risk screening when determining the safety of a situation to include: "safety of mother, safety of baby, and safety of midwife." Those who were considered the "senior midwives" in Michigan at that time, that is, those like myself who began practicing in the mid-to-late 1970's, had numerous discussions and workshops on "The Safety Factors" when screening clients. Many argued that because my client had begged me to do her birth, knowing that her only other choice was a C-section, I had an ethical obligation (as I felt I did) to take her. There were others who felt that I had an ethical obligation to protect myself (as I came to believe) and that I should have screened her out. This was a hot debate and the first time that we in Michigan grappled with risk screening for "the safety of the midwife." We are an independent strong-willed group, we midwives, and we sometimes hold differing, valid, strong opinions. Would I do that kind of birth today? Probably not: it's too risky.

So now, fast-forward the time clock to the first (current era) midwife trial in the mid-1980s in Michigan. A midwife and her nurse assistant were charged with involuntary manslaughter and practicing medicine without a license following the death of a home born infant. The midwife was acquitted and the nurse lost her license to practice nursing. This incident marked the first time that contemporary direct-entry midwives were threatened in Michigan since the 1939 trial that acquitted another midwife. The 1939 case ruled that midwifery was not the practice of medicine, and thus defined Michigan, by judicial interpretation, as an "alegal" state in which to practice midwifery—not regulated, but not illegal. It was this court case that spawned another debate among Michigan midwives and added another criterion to our list of risk screening: "safety of mother, safety of baby, safety of midwife, and safety of the profession of midwifery." And again, we had numerous debates about whether we as midwives had a responsibility to one another to protect the safety of our profession, not only the safety of moms, babies, and ourselves. And if so, what are the things that we do to protect each midwife's right to practice our time-honored calling as well as ensure that consumers can choose midwifery and out-of-hospital birth as maternity care options?

You see, Michigan has the distinction of being one of those visionary states, as far as promoting and protecting direct-entry midwifery (DEM) is concerned, in the modern era. Way back in the late 1970's, when a bunch of young, smart, unruly, energetic lay midwives put together our first DEM trade organization—the Michigan Midwives Association (MMA)—we had a vision. Not only did we envision, research, and develop a statewide professional midwife association, but we created one of the first formal apprenticeship training programs leading to a direct-entry midwife credentialing process by creating the "Certified Midwife" credential. This not only preceded the North American Registry of Midwives (NARM), the Certified Professional Midwife (CPM) credential, and the American College of Nurse-Midwives (ACNM) Certified Midwife (CM) credential, but was one of the models upon which the CPM was constructed. (There are a handful of other states that simultaneously were doing the same thing.) So way back, we felt the need to unite ourselves under one banner; educate ourselves and those to follow; deal with the issue of accountability; set standards; establish a peer review system; and provide a certification and re-certification process. What we created was a way for independent practitioners to meet standards through multiple routes of entry, to verify skills and knowledge through a written and oral examination, and to be credentialed as meeting the basic requirements to practice out-of-hospital midwifery. Our process is over 20 years old, the development of which began nearly 25 years ago. We in Michigan have good reason to be proud of ourselves! The senior midwives conceived and birthed the MMA Certified Midwife and those that followed have continued to nurture and care for it for over two decades.

Nonetheless, I regularly pose the question to my colleagues: "So You Think We Are Safe in Michigan?" We, in Michigan, are like an island surrounded by a sea of states in which it is illegal to practice direct-entry midwifery. We have not only been lucky here; we have actively dedicated ourselves to shaping and maintaining our profession as we envision it. Many of our midwife sisters look to Michigan and say, "You have it good," but we also know that we have worked very hard to make it good, overcoming differences in opinions and working together to create a consensus regarding what will work for most of us. But it's not all bread and roses either. I now hold opinions that differ from many of my sisters in Michigan for a couple of reasons: First, I feel that it is time for us to set aside our Michigan "Certified Midwife" credential and embrace the national effort behind the "Certified Professional Midwife" (CPM) credentialing process. This is hard for me to say because I am one of the mothers who birthed our "CM" credential. In fact, there is no longer any other midwife practicing today who was on that original task force to create the MMA CM credential. So in a real sense, she is my baby. I was the first midwife in Michigan to receive our CM credential, and thus, one of the first credentialed direct-entry midwives in this country. Nonetheless, I feel it is time for us to join forces with the agenda to nationalize the CPM credential and make it the gold standard.

Secondly, I feel that it is time for us to initiate legislation that will regulate direct-entry midwifery in Michigan. This is also hard for me to say because I feel so ambivalently about this. Being an independent person by nature I agree with many of the very valid arguments put forth by my sisters here in Michigan who value independent practice. I also realize that when I earned my nurse-midwifery degree in the late 1990s it wasn't the magic bullet that made everything great. In fact it made some things worse as I continued to be an out-of-hospital midwife. Sometimes I feel it's like dancing with the devil to even consider legislation and regulation. Nonetheless, I feel that it is time for us to have a DEM law here. I do not feel that it is a matter of us being able to stay safe in our little island here in the Midwest forever; it is a matter of "how long will we be safe?" I also feel that legislation will fulfill one of the midwifery-screening criteria that we have come to embrace over the years, that is, "safety of the midwifery profession." And if we are active in designing legislation where midwives are regulated under a midwifery board—not a medical or nursing board, I feel we will have the greatest potential for control. Are there pros and cons to regulation? Certainly. Can we remain independent practitioners in Michigan indefinitely? It does not appear to be the prevailing trend in this country. But I see regulation as offering this potentially protective value: if charges are brought against a midwife it would be handled in an administrative manner—managed by a midwifery board of our peers—and not through the criminal law system. Competent midwives will not be punished unnecessarily and incompetent midwives will have a chance to be mentored by peers on the midwifery board and they would not be criminalized and unduly punished by a system that does not understand the midwifery model of care. This could save untold amounts of time, money, energy and trauma.

In the mid-1990's, a well-known midwife was involved with a couple of baby deaths in out-of-hospital settings in Michigan. During one of the investigations the story became a media circus—as many of the midwife and homebirth stories do. The American public loves drama, and live-versions of drama are relished even more than fiction. This story hit national news, including the scene where the investigator came to her door, caught her totally off-guard (and as one of my midwife friends said with concern "without her lipstick"), and the videotape was rolling of the investigator asking tough questions and the midwife bumbling through them, then finally resorting to "no comment," and closing her door. This particular film clip was not only played on all of the state news channels, but also on national news stations. What a horror. This is the kind of situation that should not be made into a mini-drama. You know, babies die; it's part of life. And only those entrenched in the bio-technical model think that that it doesn't, or shouldn't happen. I have traveled extensively in other countries, mostly developing nations, and people understand this reality elsewhere. I once arrived at the house of a midwife in another country the morning a baby had died in a homebirth. I found that the family had embraced the midwife and was so grateful to her—because the mother did not die. They were understandably sad about the baby, but families expect that a baby might die. A mother dying is considered beyond tragic. It's a matter of perspective.

As the Midwest Rep on the MANA (Midwives Alliance of North America) Board of Directors for the past five years, I have had the opportunity to view the midwifery movement from a bird's eye view. This positioning has given me a deeper insight into the struggles of our profession and especially into the struggles in our Midwest region. In every state, including my own, midwives are in trouble. Some midwives are in bigger trouble, some are in lesser trouble. On the MANA Board the Midwest is known as the "hot spot" of the country, a dubious distinction at best.

CNMs are recognized in every state but DEMs are not. Of the 12 states in the MANA Midwest Region, in only ONE state is direct-entry midwifery legal, and that is in Minnesota. And the CPM credential is accepted for licensure in Minnesota. Here is an analysis of the other 11 Midwestern States: 1) States where DEM is legal by virtue of a judicial interpretation or statutory inference—Kansas, Michigan and North Dakota; 2) States where DEM is not legally defined but not prohibited—Ohio and Wisconsin; 3) States where DEM is prohibited—Indiana, Iowa, Missouri, Illinois, Nebraska and South Dakota. Three States have recently been moved to the "prohibited" category from the category "not legally defined" by virtue of recent cease and desist orders and/or judiciary interpretations in those states. In other words, all of the states listed in the categories called "judicial interpretation" (#1 above) or "not legally defined" (#2 above) are in danger of shifting into the "prohibited category" if a midwife is arrested or charged with cease and desist orders in any of those states. In summary, only one Midwestern State is clearly legal; six are clearly illegal; and five are in a gray area that could change quickly to illegal with the current climate of midwifery persecution and prosecution.

However, having just provided legal status categories for the Midwest, let me say this: because of recent events involving prosecution of midwives and midwifery practice and the legal and regulatory consequences that follow, many of our legal advisors are now encouraging us to think only in terms of "regulated" and "non-regulated' states, as opposed to defining categories of DEM legality that include "a-legal," "not legally defined but not prohibited," and "gray areas." This requires a shift in our previous thinking. But the fact is that a state can very quickly move from a "legal" state in a flash via cease and desist orders or judiciary interpretation. We have seen this very thing happen in the past two years in Illinois, Nebraska and South Dakota. What this new perspective means for our 12-state Midwest Region is that we have one regulated state (Minnesota) and 11 unregulated states. Several states are in the process of creating midwifery legislation, but until legislation is passed DEM's safety is tenuous at best, and the freedom to choose out-of-hospital birth and midwifery care is limited.

For the past several years, my suggestion to my Michigan colleagues has been that we begin to do the research and develop a model piece of legislation—one that we can live with—so that when the time comes (not "if") we will be ready and will not be scrambling under duress. It would be a good exercise and would allow us to have all of the conversations, which will include a diversity of opinions, before the fact of having to do this enormous task. But the midwives in my state, though a few agree with my proposal, by and large want to maintain the status quo. However, last year a baby died after a transfer to the hospital from an intended homebirth scenario and the physician in charge at the hospital said something like, "I am going to get that midwife and I intend to get rid of all of those dangerous homebirth midwives." To our knowledge no definitive action has been taken, but it was a wake-up call. Babies die; it is part of life, but when the primary model of maternity care, the biotechnical model, promises a perfect baby but only if born in a hospital, anything short of that is unsatisfactory. Never mind that the Midwives Model of Care does a better job of keeping babies alive at birth than the U.S bio-medical model does, as do 26 other industrialized counties in the world. Never mind that maternal mortality has been increasing steadily in the U.S. since 1982 under the dominant medical system. Nonetheless, it is the "standard model" to which midwives will be compared when we stand before a judge and jury.

Make no mistake: there has been a systematic effort to eliminate midwives and a concurrent takeover by organized medicine. While some attempts initiated by midwives and midwife-supporters have succeeded at changing this direction, others have failed through the courts, and the court system frequently criminalizes competent midwives. In addition, the courts are often unwilling to entertain arguments that we bring to them about constitutional issues surrounding the practice of midwifery and parents' right to choose care providers, pregnancy and childbirth practices, and place of birth.

Let's be perfectly clear here: while midwifery is a fabulous profession, it is also an oppressed profession, whether you feel it in small ways; or because you can't get fee-for-services paid by insurance carriers; or because you have been told to "cease and desist" practicing midwifery; or because you have spent six months in jail; or because you have spent your life's savings on court cases; or because you have been prosecuted as a criminal when a baby dies in your hands. In the past two years all of the above has happened to Midwestern midwives. Therefore I ask you, what makes us think that we are so safe in Michigan? What makes us so sure that we won't run into the same problems that our sisters in Illinois, Indiana, Ohio, South Dakota, Nebraska, and other states have? I use Michigan as a metaphor here: Lest you misunderstand me, I intend to imply that we are all connected, and what happens to one of us will, and does at some very real level, affect all of us. I often think of the refrain of an African freedom song that goes: "None of us is free until all of us are free."

So what is the next step in our evolution? Taking the next step is about mainstreaming midwifery. What needs to happen now, I believe, is major reform. I believe that legislatures, laws, and other policy-making arenas are the appropriate forums for reform of this magnitude. At this point, with the "witch-hunt" intensifying, we need laws and policies to protect midwives and consumers. Powerful physician groups have successfully lobbied state legislatures for laws that would require women to submit to their exclusive control during pregnancy and childbirth. The majority of women in the U.S. have suffered unnecessarily medicalized births; infants have been subjected to unnecessary routines and separation from their mothers; families have been excluded from participating fully in this seminal life event. It is hard to imagine how physicians have successfully lured women from the loving hands of midwives into a system that has never been proven safe or beneficial. It is time to create a maternity care system with the midwifery model of care at its center.

This is my key message: policy-making arenas are the venues in which sweeping change is made. But this takes action! We need national and state maternal and child healthcare policies that support our right to choose, as parents, and our right to practice, as midwives. We need policies that install midwifery as a central pillar in the healthcare system in order to ensure access to services and achieve superior outcomes. We midwives, as change agents, and those who support and choose midwifery care, must show legislators the evidence that the midwifery model of care is not only safe, high quality and satisfying care but it also can save lives and money. But this takes political action! We must take action in the Midwest and all over the country to raise public awareness and create a system of regulation that ensures competence, involves consumers, and allows for the independent practice of midwifery. Proponents of the bio-medical model, with their political and economic resources, are fighting hard to maintain their turf even in the face of academic research and extensive evidence that standard childbearing policies and programs are failing to meet the needs of women, infants and families in fundamental ways. We must all become politically active if we wish to see manifested the changes that we dream. It's a big challenge. But given the growing trend in this country to limit choices in childbirth and oppress midwives, what is the alternative? The American College of Nurse-Midwives has been extremely successful in their marketing campaign and political action platform to get CNMs into the mainstream healthcare system. It is up to us to keep working to ensure that direct-entry midwifery has a place in the mainstream healthcare system, or I am afraid we will go by the wayside as the traditional and granny midwives have.

A young, smart midwife recently asked me, "Why do you support regulation in Michigan? This will eliminate the possibility for me to practice as an independent midwife in the way that you got to enjoy for years." I was stunned by her question as I contemplated my answer. I wondered, "How can I explain the past three decades and my involvement with midwifery activism to her in a short answer?" I thought: for one thing, it assumes that things have always been the way they are now and that they will remain the same, when we know that change is the energy of life. Secondly, she says, "I just want to catch babies," but that's what we all want to do. At this moment in time being a midwife is neither easy nor stress-free—and we can't just catch babies—because a turf war is waging on the other side of the door. Even in Michigan, CNMs are hiring lobbyists; DEMs are hiring attorneys; and women are being court-ordered to have cesarean births again their wills. It has come to this: in the United States the midwifery model is struggling in order not to be eliminated in favor of a system where healthcare priorities are determined by power and profit. Thirdly, how can I tell her that when I started this work almost 30 years ago, that I expected that the seeds of change that we planted and the fertile gardens that we tended with care would have harvested midwifery in the mainstream by now, and that we are far from that? We in Michigan are fortunate but are neither protected nor immune from the troubles suffered by our sisters in our contiguous Midwestern states just because we want to practice independent midwifery. It's not that simple.

In response to her, all that I could manage to say was, "We each have different visions, different dreams. I am a self-taught midwife who has worked for nearly three decades on the local, state and national levels, and each step of the way my peers and I kept envisioning how to organize ourselves, how to educate ourselves, how to create standards, how to credential ourselves, how to promote the midwifery model of care, how to ensure that midwifery care is a choice for consumers, and how to maintain safety for moms, babies, midwives, and our profession. I have put my life energy to both actualizing this dream and to removing any obstacles that might stand in the way of my vision. I want midwifery to be a choice for all moms and babies. My vision includes the sustainability of our profession. Your dream is to maintain the status quo of what you have inherited from my generation of midwives, and from the next generation of midwives who refined and expanded upon what we had begun. In your dream, you believe that ‘just catching babies' is a perpetual option." And I thought, "Who could blame her?"

There are no right and wrong answers here. I see excellent opinions being espoused in every quarter. My strong opinions are forged from my own experience and perception of reality. Midwives are the most brilliant, brave, and bold people I know. For the challenges that lie ahead we need one another. It is time for us to take the next step of mainstreaming midwifery. We need to muster all the strength and solidarity we can to mark our course and take action to protect direct-entry midwifery and the choice of out-of-hospital birth. We need the wisdom, experience and endurance of the older midwives; we need the spark, enthusiasm and resiliency of the younger midwives. We need to remember not only on whose shoulders we stand, but also who we are lifting to touch the stars. My heartfelt gratitude extends to all.

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