By Allegra Huston
Issue 136 - May/June 2006
In January 2002, as I sat in a New York City taxi on my way into Manhattan from JFK airport, I was suddenly hit with waves of nausea. I clenched my stomach, determined to hold on until I reached my friend’s apartment. She was four months pregnant. By the time I’d pressed her doorbell, I was sure that I was pregnant too.
In my old life, before I moved to New Mexico, I’d have gone to the doctor’s office and sat with sick people, waiting for a cursory examination and a snatched 15 minutes of office time. Now, having lived in Taos for four years, I knew better. I was not sick, so I didn’t need a doctor. What I needed was an expert on pregnancy—in other words, a midwife.
There are two kinds of midwives in the US, the majority of them certified nurse-midwives (CNMs). Trained as nurses, CNMs operate within the medical model and under physician oversight. Direct-entry midwives, on the other hand, are independent practitioners who are not subject to the directives of a physician. Their model of care is based on the conviction that pregnancy and birth are normal life events that do not require medical intervention except in unusual circumstances. Taos, New Mexico, is the epicenter of nonmedical midwifery in the US; in 2003, nearly a quarter of all births in Taos County were attended by direct-entry midwives.1
“The midwife’s goal is to empower women and their families by reminding them that they already have everything they need to master the challenges of pregnancy and birth,” says Julie Schochet—my Taos midwife and now a dear friend. In almost all industrialized nations, with the exception of Canada and the US, a pregnant woman’s primary caregiver is a midwife.2 In the Netherlands, 70 percent of women choose midwives for their care, and 30 percent of births take place at home; many Dutch women never see a doctor during their pregnancies.3 In Scandinavia, after an initial visit with a family doctor, 75 percent of women are attended throughout pregnancy and birth by midwives alone.4 These countries have cesarean-section rates as much as two-thirds lower than that of the US, and their perinatal and maternal mortality rates are among the lowest in the world.5
Studies undertaken in California, Scotland, Canada, and for the US government all concur that midwife care is equal or superior to physician care for low-risk women.6 The World Health Organization (WHO) recommends that midwives should be the principal providers of care for pregnant women, followed by family doctors, with obstetricians involved only in cases of clinical necessity. (Significantly, the International Confederation of Midwives’ [ICM] International Definition of a Midwife, which WHO endorses, does not require that a midwife have nursing training or operate under the supervision of a doctor.7) Marsden Wagner, MD, a former WHO Regional Officer for Women’s and Children’s Health and now an author on the subject of midwifery, compares using an obstetrician for routine prenatal care and uncomplicated births to using a pediatric surgeon to babysit a healthy two-year-old. “Such a babysitter will come with a very high fee,” he writes, “and the costs will be even higher when the healthy baby gets tired and fussy and the surgeon turns to medication to calm things down.”8
Yet in the US, obstetricians have a virtual monopoly on childbirth, attending more than 90 percent of births.9 We pride ourselves on having the highest standard of medicine in the world, yet in the early years of the 21st century, these highly trained practi-tioners achieved a ranking of only 15th in the world for maternal mortality (a figure that has not improved for 20 years)—and, shockingly, 27th for infant mortality.10 In fact, a study for the US Centers for Disease Control showed that midwife-attended births had an infant mortality rate 19 percent lower than physician-attended births.11 Clearly, specialized medical training and technology are not the decisive factors in successful childbirth. The midwifery model of care, which emphasizes individual counseling, hands-on assistance during labor and delivery, minimal technological intervention, and extensive prenatal and postpartum care, has proven again and again to result in healthier outcomes for both mother and baby.
For New Mexico, being the poorest state in the union has, in this respect, proved a blessing. As Roberta Moore, Maternal Health Program Manager for the New Mexico Department of Health, points out, “Because almost every county [in New Mexico] is federally designated as medically underserved, there is less competition than there is in many other states. Many areas cannot support enough obstetric providers, so midwives are welcome.” Yet midwives are not just a rural phenomenon. In the state’s largest city, Albuquerque, more than a third of births are attended by midwives; in Las Cruces (pop. 76,000), the figure is over half. Statewide, in 2003, midwives attended 30.5 percent of all births—by far the highest rate in the nation.12 The cesarean rate was 20.3 percent,13 significantly lower than the national figure of 27.6 percent14—which, in 2003, rose for the seventh straight year.
“Midwives are a safe and cost-effective resource, and they provide options that are not otherwise available,” says Moore.
How has New Mexico found itself in the vanguard of modern midwifery care? Moore points to the fact that New Mexico has two of the best midwifery schools in the country: the National College of Midwifery, in Taos, and the nurse-midwifery program at the University of New Mexico. These schools are, however, as much effects as causes. More pertinent, she explains, is the fact that “midwifery has never been illegal in this state. The lineage of midwives is unbroken.”
In that lies the crux of the matter, for in 1978, midwifery came close to being outlawed in New Mexico. Only a chance combination of circumstances, and the determined efforts of two midwives in particular, prevented it.
In New Mexico, with its deep Hispanic heritage, there had long been provision for licensing the traditional midwives known as parteras. The Territorial Practices Act of 1912, the year New Mexico became a state, specifically exempted midwives from prosecution under the Practice of Medicine Act, as they were not considered medical practitioners. A basic minimum of training had been provided sporadically by the state, covering topics such as hand-washing and the sterile cutting of the umbilical cord. Still, few parteras saw any need for a piece of government paper, and, in any case, their numbers were declining. By 1978, no licenses had been granted for approximately 15 years.
That year, as a result of the break-up of the Department of Health, Environment, and Social Services into its constituent parts, lawyers combed through old regulations and saw an opportunity to outlaw what most considered a primitive, outdated, and dangerous practice. Only by chance did Tish Demmin, a Taos midwife who had learned her craft on a Colorado commune, come to hear about the plan to discontinue licensing. “It was a can of worms that they didn’t want to open,” she recalls. “It only got opened because of the separation of those agencies. The last midwife that was licensed finally would have died, and that would have been the end of it. No one would ever have known.”
A few weeks earlier, Demmin had attended a midwifery conference at which Dorothea Lang, who headed the Bronx Midwifery Project, urged midwives everywhere to demand some kind—any kind—of legal recognition, and quoted the ICM, WHO-endorsed definition of a midwife as an independent, nonmedical practitioner. Alert to the implications of the removal of licensing, Demmin immediately began to organize resistance. One of the first people she contacted was Elizabeth Gilmore, who had moved to Taos only a few months before.
Gilmore, who had been raised in Mexico, was used to seeing birth and death not as the exclusive province of doctors but as part of the fabric of everyday life. When, at the age of 22 and living on the little island of Chappaquiddick, Massachusetts, she asked a doctor to come to her home and deliver her baby, she found herself on one side of a cultural abyss. “We had a conversation, and the upshot of it was, either you’re suicidal or you hate your baby,” she recalls. So she contacted her brother-in-law, who had just graduated from medical school, and asked for his obstetrics textbook. Soon, she had formed a group of women who wanted to give birth naturally.
Standard obstetrical practice in 1971, when Gilmore had her first child, was to give laboring women a hallucinogenic drug, scopolamine, to make them forget the pain, in combination with the tranquilizer meperidine (aka Demerol). “You’d see women with leather straps on their wrists and ankles holding them to the bed,” she remembers. “It made a generation of doctors think all pregnant women who went into labor were insane, because all they saw were writhing, screaming women talking about toasters and tuna fish and cans.” Her own doctor had never before seen a scopolamine-free birth and was so surprised when Gilmore demanded to be given her baby that he confessed he hadn’t known newborns could nurse.
Gilmore’s group of self-educated women—who, almost by default, became midwives—was typical of many scattered pockets of resistance. Ina May Gaskin and her colleagues at The Farm, in Tennessee, and Raven Lang and her colleagues in Santa Cruz, California, among others, worked out of a conviction that childbirth had been hijacked by the (male) medical establishment, sold out to the pseudo-heroic interventions of invasive and possibly dangerous technology, and stripped of its inherent spiritual joy. Sometimes barely tolerated, sometimes actively persecuted, these midwives operated in a semi-underground fashion. Their training was largely by practice, and reputation was their only guarantee of competence.
At the time, there was no model in the US for a modern midwifery practice independent of medical training and physician oversight. Midwifery was legal in some states and illegal in others, but in most, the practice was shrouded in uncertainty. (It remains effectively illegal in 14 states and the District of Columbia.15) The medicalization of childbirth in the 20th century, accelerated by advances in anesthesia and the powerful lobbying of doctors’ organizations, created a cultural demonization of midwives as uneducated, unhygienic, and, at best, irresponsible. With fewer midwives practicing, and those few operating among the lower echelons of society rather than among those who influence popular opinion, the juggernaut of medicalization might have seemed unstoppable. Fortunately, Demmin and Gilmore lived in a rare community where out-of-hospital birth was still common, both among the traditional Hispanic population and among the counterculture communes that had been established in the Taos area. Demmin, whose own practice was entirely in homebirths, also worked as a nurse’s aide at the local hospital and was respected there for her midwifery skills. Supported by the local doctors, she began a pilot project in which midwives and doctors worked together. Though never replicated elsewhere, this project bought time for the “lay midwives,” as they were then known, to defend the continued existence of their profession.
The midwives and the state agreed that if licensing were to continue, there would need to be a new code of practice that reflected current medical standards. At once, battle lines were drawn over procedures that doctors assumed belonged exclusively to the medical establishment. Demmin recalls Susan Nalder, then manager of the state’s Maternal Services Program, banging a table and declaring, “There will be no Pitocin!” Demmin was equally determined that she would carry Pitocin, illegally if it came to it, in order to treat postpartum hemorrhaging; she also insisted that she would continue to cut and suture emergency episiotomies. Still, she recognized that the continuation of licensing was the goal, and she held her fire. When the licensing issue was decided in a public hearing—with the president of the Medical Society of New Mexico, Dr. Ashley Pond III, refusing to argue his society’s position and instead supporting the midwives—the fight over the new regulations began.
Demmin was invited to sit on the first advisory board. At every meeting, as she tells it, she would begin by saying, “I am in violation of the following sections,” and then list them. “The attorney for the state would cringe,” she recalls, chuckling. “They didn’t want to hear it. And I just kept doing it, because what I said is, ‘Why would you put any conscientious practitioner in such a position? You’re setting us up to violate [the law].’ ” Her strategy succeeded. Incrementally, midwives gained a scope of practice that allowed the health of mothers and babies to take precedence over professional turf wars.
The midwifery examination that was developed by direct-entry midwives was grueling and exhaustive. Importantly, it was open to be taken by anyone whose midwifery skills had been observed by a qualified practitioner at a certain number of births. A formal degree, in nursing or anything else, was not required. Nurse-midwives who became licensed midwives could then work outside physician control, and midwives from other states would gain credibility. As Demmin explains, “If they were busted in somewhere like Rhode Island for practicing midwifery, they could at least say, ‘I have a license from the state of New Mexico.’ "
“A lot of the people we tested had come from elsewhere for their training,” says Linda Lonsdale, herself a nurse-midwife who, as head of New Mexico’s Maternal Health section from 1980 to 1984, developed the examination and the licensing process. “They used our process when they got back to get more stability and recognition in their own states . . . either to get licensure or at least to regulate themselves and set their own standards.”
Lonsdale, now a deputy district attorney in Santa Fe, has a lawyer’s reticence about claiming credit for New Mexico’s, and her own, influence in making midwifery acceptable in the US. (She herself traveled to Alaska and Oklahoma, to advise those states’ health departments on midwifery.) She does, however, point to the requirement, instituted during her tenure, that midwives keep statistics. “People have a lot of misconceptions about midwives,” she explains: “that they don’t transfer people in trouble, or they don’t recognize people in trouble, or they think everything is going to be resolved magically or spiritually. But not everyone who starts with a midwife ends up with her. If there are problems, midwives do get consultation or transfer people out; they don’t just keep the woman home until she and the baby die.” Those statistics, which now date back more than 25 years in New Mexico, have, she believes, played an important part in dispelling myths and demonstrating the safety of midwifery care.
In 1983, Demmin and Gilmore opened a birth center in Taos to give parents who didn’t want a homebirth a choice other than the hospital. Soon, Demmin heard that a group of nurse-midwives were proposing a national standard for birth centers, and she urged Gilmore to participate. “Tish really had the ability to see how what we did today would affect things way down the line,” says Gilmore. “I was allowed to help develop the rules, the standards, in such a way that we [direct-entry midwives] didn’t get cut out.” There was no legal requirement for the Taos birth center to be accredited by this organization, but Demmin and Gilmore saw an advantage. “One of the things that [direct-entry] midwives really struggle with is that we’re always being told there’s no oversight,” explains Gilmore. “There are all these accusations that we are somehow doing things that shouldn’t be done. Having this outside accreditation was one attempt to show that we work very hard to try to be responsible to another authority.”
Interestingly, for a time the Northern New Mexico Women’s Health and Birth Center did have four obstetricians on staff to handle higher-risk pregnancies and deliveries. In a reversal of the hierarchy that exists elsewhere, the doctors were employed by the midwives and subject to their philosophy and standards of practice. “Our policy and procedure manual was that we had control,” says Demmin. “I wasn’t going to let a physician do a forceps delivery and mess somebody up at our birth center. I thought that was very important—I thought it would be a recipe for disaster for it to be any other way.”
In 1985, Gilmore founded the New Mexico College of Midwifery (now the National College of Midwifery), another move in her quest to make midwifery more widely respected. She describes it as “a college without walls,” a way of formalizing the apprenticeship system through which aspiring midwives learn their craft. She finds it frustrating, however, that, because of the divide between nurse- and non-nurse-midwives, she cannot teach the full scope of skills that the WHO considers basic to midwifery practice, including the treatment of eclampsia and techniques for dealing with obstructed labor. “These are things you would have to learn in the hospital, so you’d have to have a different paradigm of how you train midwives, which is what I’d like to see,” she says. “Turn all midwives into one midwife. Train them all from home to birth center to hospital, [and] let their training make it possible to provide care in any setting.
“I just want to see the reduction of maternal and infant risk,” she continues. “Right now, our healthcare system is oriented toward money; it’s not oriented toward health. That’s something I’d like to see change in my lifetime: to have a healthcare system instead of a money-care system.”
Though the intellectual and political battle for midwifery care has been won in New Mexico, at least, its continued availability to all American women remains mired in financial and legal trench warfare. New Mexico is one of only ten states that provide midwifery care under Medicaid; elsewhere, it is an option only for those who can afford it. Despite its proven superiority to traditional medical care for low-risk mothers, managed-care organizations remain unwilling to pay for midwifery care, and insurance companies typically either refuse to provide malpractice coverage to midwives or charge exorbitant premiums, which most independent midwives cannot hope to pay. “At one point Elizabeth and I joked that if we really wanted to affect midwifery care on the largest scale, we should open an insurance company,” says Demmin.
“There were times when we could get [malpractice insurance] and times when we couldn’t,” recalls Gilmore of the early days of the birth center. “We just practiced bare and nobody cared.” But in 2005, a crisis was reached. The managed-care organizations who since 1995 have administered New Mexico’s Medicaid program began to refuse to pay out to providers without malpractice insurance, even as that coverage became impossible to obtain. The Taos birth center was threatened with closure; independent midwives like Julie Schochet faced the necessity of moving out of state if they wanted to continue in practice. Two bills designed to solve the problem were introduced in the New Mexico State Senate in early 2005; neither succeeded, and the report of the working party set up to review the problem of malpractice insurance across all providers, submitted in November 2005, was inconclusive.16 Only the personal intervention of Governor Bill Richardson broke through the impasse, and, at least for now, the HMOs will be required to pay for midwifery care, including homebirth, under Medicaid, regardless of whether malpractice insurance is in place. Susan Jenkins, the lawyer shepherding Richardson’s diktat through the contractual process, while delighted at this success, points out that it solves the problem in only one jurisdiction out of 51; federal legislation is, she believes, the quickest and most effective way forward.17 As yet, direct-entry midwives do not have a lobbying presence in Washington.
Meanwhile, New Mexico midwives are celebrating. “We midwives are never going to stop,” says Gilmore. “There’s no getting rid of us!”
1. New Mexico Department of Health, Bureau of Vital Records and Health Statistics, “New Mexico Selected Health Statistics Annual Report for 2003” (2005).
2. Ministry of Health, The Hague, The Netherlands, cited in Marsden Wagner, “Midwifery in the Industrialized World,” Journal of the Society of Obstetricians and Gynaecologists of Canada 20, no. 13 (November 1998): 1225–1234, note 28; www.asac.ab.ca/BI_fall99/midwifery.html.
3. Raymond DeVries, “Midwifery in the Nether-lands: Vestige or Vanguard?” in “Daughters of Time: The Shifting Identities of Contemporary Midwives,” a special triple issue of Medical Anthropology 20, nos. 2–3 and 4 (2001).
4. Statistical Unit, World Health Organization Regional Office for Europe, Copenhagen, 1998; cited in Note 2 (note 26).
6. Ibid., notes 6–12.
7. International Confederation of Midwives, Revised, “International Definition of Midwife,” www.internationalmidwives.org/modules.php?op=modload&name=News&file=article&sid=106 (19 July 2005).
8. See Note 2.
9. Sally C. Curtin, MA, and Melissa M. Park, BS, “Trends in the Attendant, Place and Timing of Births, and in the Use of Obstetric Interventions, United States, 1989–97,” National Vital Statistics Reports 47, no. 27, www.cdc.gov/nchs/pressroom/99facts/attendant.htm (2 December 1999).
10. Maternal statistics: State of the World’s Mothers 2002, Save the Children, www.savethechildren.org/publications/index.asp. Baby statistics: “Child Health USA 2001,” Maternal Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services: 22. Both cited in Carolyn Keefe, MLS, “Overview of Maternity Care in the US,” Citizens for Midwifery factsheet, www.cfmidwifery.org/pdf/OverviewofMatCareApr2003.pdf, notes 5 and 3 (April 2003).
11. M. MacDorman and G. Singh, “Mid-wifery Care, Social and Medical Risk Factors, and Birth Outcomes in the USA,” Journal of Epidemial Community Health 52 (1998): 310–317; cited in Note 2 (note 12).
12. See Note 1.
13. “Birth: Final Data for 2003,” Table 41, National Health Statistics 54, no. 2 (8 September 2005).
14. Fay Menacker, “Trends in Cesarean Rates for First Births and Repeat Cesarean Rates for Low-Risk Women: United States, 1990–2003,” National
Vital Statistics Reports 54, no. 4 (22 September 2005).
15. Independent midwifery is “prohibited by statute, judicial interpretation or stricture or practice” in Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, South Dakota, Wyoming, and the District of Columbia. It is “legal by statute but licensure [is] unavailable” in Alabama, Georgia, Hawaii, New York, and Rhode Island. Midwifery Association of North America, www.mana.org/statechart.html.
16. New Mexico Health Policy Commission and New Mexico Public Regulation Commission, Insurance Division, “Report of the Senate Memorial 7 Task Force on Health Care Practi-tioner Liability Insurance” (1 November 2005): www.hpc.state.nm.us.
17. Susan Jenkins, phone interview, February 2006.
Allegra Huston is a screenwriter, journalist, and editor based in Taos, New Mexico. For many years she was editorial director of the London publishing house Weidenfeld & Nicolson. She has written for publications including The Times (London), French Vogue, and the Santa Fean. She is the mother of a three-year-old son.