Certified Nurse Midwife (CNM): A registered nurse who has completed a nurse-midwifery degree. They attend births primarily in hospital settings, although some do attend out-of-hospital births in Oregon.
Licensed Direct Entry Midwife (LDM): A midwife licensed to attend birth. Must pass a written exam and certify in neonatal and maternal resuscitation. No formal education is required.
Certified Professional Midwife (CPM): A midwife who has passed a written exam and skills assessment. May practice in Oregon with or without a license. No formal education required.
Direct Entry Midwife (DEM): Any midwife who is not a nurse. Can be licensed or unlicensed; may or may not have completed a formal midwifery program.
Lay midwife: A generic term used for a midwife who is neither certified nor licensed. May or may not have completed a formal midwifery program.
Abel Andrews was born in the middle of the night on April 5, 2010, at the now-defunct Motherwise Birthing Center in Bend. And for the first 35 minutes of his life, he took no breaths.
Still fuzzy from a prolonged and painful labor, deprived of sleep, her brain flooded with hormones, Kristine Andrews looked to her midwives to bring her son out of what had become a dire situation.
“I just remember looking at them and thinking, ‘Holy crap. They have no idea, just that look of somebody who just got a pop quiz and you’re trying to remember something you read three years ago,” she said. “That was the first time I felt really scared.”
Unable to revive Abel, the midwives called 911 but could not remember the address of their own birthing center, Andrews said. Andrews had to tell them.
As they waited for help, Andrews and her husband, Greg, called Abel’s name, told him they loved him and implored him to breathe.
A policeman was the first to respond and the look on his face helped Andrews snap out of her funk. “I could see what he was seeing — it was a mess.”
Andrews was half off the bed; her son lay motionless on a warming board. When the paramedics arrived, they tried to resuscitate Abel but didn’t have the proper equipment for a newborn.
“One of them finally said, ‘Let’s just get him to the hospital. Let’s just go,’” Andrews recalls. Within moments, the paramedics, the midwife, her husband and her newborn son were gone, leaving Andrews alone with the midwife assistant, wondering what had happened.
None of what she had read online about home births had prepared her for something like this.
“Nothing came up, nothing but beautiful, orgasmic birth stories,” she said.
It was only later that Andrews learned the tragic stories of dozens of babies who died or were profoundly disabled as a result of mishandled home births in Oregon. While the vast majority of home births result in a healthy baby and satisfied mother, for the small percentage of births that turn into crises, the decision to give birth out of the hospital turns out to be a tragic one.
Those cases have prompted public health officials in Oregon to gather the most comprehensive data on out-of-hospital births anywhere in the country. And with the number of home births growing both nationally and in Oregon, the state may soon become the fiercest battleground in the home birth debate.
Abel Andrews, 4, sits in his chair in his familys home in Redmond. Abel has a form of cerebral palsy, developed during complications at birth through a midwife.
Joe Kline / The Bulletin
In 1900, almost all births occurred outside of the hospital. But by 1940, the rate had dropped to 44 percent. Rates continued to drop through the rest of the century, reaching a low of 0.87 percent in 2004.
Then something changed. Concerns over the high rate of medical interventions in hospital births, particularly cesarean sections, proliferated over the Internet, and parents increasingly turned to home births instead. According to the National Center for Health Statistics, by 2012, the rate had inched up to 1.36 percent of births, and in many states, particularly in the West, rates were much higher.
Oregon now has the third-highest rate of out-of-hospital births, with 3.8 percent of births occurring at home or in birthing centers in 2012. Only Alaska (6 percent) and Montana (3.9 percent) have higher rates.
And now there is concern that the gains made in driving down maternal and infant mortality are being reversed for those women who choose to avoid the hospital.
For the first time, in 2012 Oregon collected data on infant birth and death certificates regarding the mother’s intended place of birth. (In the past, deaths that occurred after women or babies were transferred to a hospital when things went wrong in home births were counted among hospital deaths.) The data showed that out of 2,021 full-term, out-of-hospital births, eight children died during labor or within six days of birth, a mortality rate of 4 per 1,000 births. In hospitals, there were 84 deaths in nearly 40,000 births, a rate of 2 per 1,000 births.
At a minimum, out-of-hospital births were twice as risky as in hospital births.
But the Oregon data hid an important distinction. While the out-of-hospital rates excluded any deaths that happen before labor began — and thus unrelated to the place of birth — the hospital data included those deaths.
Using analyses of in-hospital births from Missouri and Scotland, which do break out prelabor births, public health officials have estimated that only four to eight of the 84 in-hospital deaths in Oregon are likely to have happened after the start of labor. Combined with the 26 deaths that occurred within six days of birth, the comparable in-hospital mortality rate would be 0.75 to 0.95 per 1,000 births.
“It’s not twice as high — it’s five to six times as high,” said Judith Rooks, a certified nurse midwife who analyzed the data for the state.
Consider that the anti-inflammatory Vioxx was pulled when data showed that 3.5 percent of people taking the drug incurred heart attacks or strokes, compared with 1.9 percent in those taking placebos, nearly a doubling of the risk.
If home birth were a drug, it would be taken off the market.
“These women are basically white, married women who aren’t smokers, who aren’t obese, who aren’t physically being beaten by their husbands — they’re low-risk women and they should have been the lowest risk women there are,” she said. “And yet they have these terrible outcomes.”
Oregon officials wanted to know why so many of these low-risk births ended up with babies dying, so they had an epidemiologist investigate every one of the out-of-hospital deaths. The analysis showed that in six of the eight deaths, the women had conditions or factors that would have categorized them as high-risk births. Four were more than two weeks past their due dates; two were carrying twins, including one who didn’t know because she declined an ultrasound in her prenatal care.
“And then there were people who said, ‘All of a sudden, there was no fetal heartbeat,’” Rooks said.
Dr. Amy Tuteur, a Boston obstetrician who blogs about the risks of home births, said that’s a common theme among the deaths that occur during out-of-hospital births.
“It’s always the same thing. An emergency happens from one moment to the next, and they’re far away from help,” she said. “People say, ‘Well, I was only 10 minutes away from the hospital.’ And I say, ‘Could you hold your breath for 10 minutes?’”
Moreover, she believes that many of the babies would not have died had the mothers given birth in the hospital, where mother and baby could be monitored for signs of trouble, with a team of physicians and nurses ready to step in if needed.
“If you read enough of these stories, everything was supposedly fine and the baby came out dead. That never happens in a hospital, ever,” Tuteur said. “It’s because they don’t know what they were doing. They didn’t realize the baby was suffocating in front of them.”
The beautiful birth
Abel was the Andrewses’ first child. She had been told she would have trouble conceiving — so when she became pregnant, she read everything she could on the Internet and in birth books about the birth process.
“They all seemed to be pointing toward this really beautiful birth experience,” she said. “I was fairly excited, and we really wanted to do the very best we could.”
Growing up in John Day, she had plenty of exposure to lay midwives, who would pull up in the car outside a mother’s home carrying a bag of herbs. So when she met Christyn King and Nicole Tucker, the licensed, certified professional midwives at Motherwise Birthing Center in Bend, they seemed much more professional.
“They were professional women. They were articulate. They had a building and an office,” she said. “I didn’t know the difference between a certified professional midwife and a lay midwife.”
Andrews said the midwives described it more as a difference in approach. Nurse midwives had opted to take a more medical approach, whereas they had learned natural birth techniques.
“They didn’t present their education as any less, just different,” she said.
Andrews also liked how free the midwives were with their time.
“The amount of attention they were willing to pay me really made me feel like they cared for me and were really so invested in me and my baby,” she said. “I felt like they were on this journey with me, that I was their friend, and that really played into my level of trust.”
Although she had previously worked in a gynecologist’s office and had started her prenatal care with a doctor, four months into her pregnancy she switched to the midwives.
Over the next few months, she set aside concerns about the way they were handling her care. At one appointment, they had her go to the bathroom and conduct a urine protein test by herself, Andrews said. When she had trouble matching up the results with the color on the color grid, they told her to just throw away the test strip. As she got closer to her due date, her blood pressure rose to 140/95, reaching the levels used by doctors to designate the condition known as preeclampsia. They recommended monitoring the blood pressure at home and eating cucumbers to bring it down.
When she asked if she should be concerned about her blood pressure and whether she should return to her doctor, the midwives discounted the worry, Andrews said.
“I don’t think they were concerned,” she said. “The general attitude was those levels come from a fear-mongering place. Looking back, all of their approaches were how to get around this, instead of what we do about it.”
Despite state guidelines that women with high blood pressure not attempt a home birth, Andrews’ blood pressure went unaddressed.
What’s a midwife?
In Oregon, there’s a continuum of birth attendants all sharing the name “midwife.” At one end are certified nurse midwives, who are registered nurses who complete a graduate degree in midwifery from an accredited program. Most CNMs practice in a hospital setting or in a practice with obstetricians. But many women prefer the nurse midwife to a doctor, because they spend more time with the woman and are more likely to support a natural delivery.
All other midwives are called “direct entry” midwives, meaning they enter midwifery directly, not via a nursing track. In Oregon, licensed direct entry midwives (LDMs) must pass a licensing test, attend classes about the drugs and devices they’re allowed to use and attend at least 50 births. LDMs, however, can have varying levels of education. Some have completed three- or four-year academic training programs, while others may have passed the exam only based on past experience and personal study.
Many but not all licensed midwives are also certified professional midwives, meaning they met the certification standards set forth by the Midwives Alliance of North America. CPMs can also have varied levels of formal or informal education.
At the other end of the spectrum are unlicensed midwives, sometimes called lay midwives, who are not vetted by the state in any way and may have any level of education or experience.
“This group of women who claim to be midwives are really lay people; they didn’t want to get a midwifery degree, so they made up their own credential so that they could make money from going to births,” Tuteur said. “And you have to admit from a public relations point of view, it was brilliant. Most people don’t know the difference.”
Proponents and critics of out-of-hospital births often use the term midwife generically, further clouding the picture for prospective parents.
“Home birth is an industry, and it’s an industry that uses a lot of deception in order to continue to make money,” Tuteur said. “And a lot of babies have died.”
Home birth proponents counter that it is the medical establishment that operates more like an industry. Physicians, paid by the procedure, have a financial incentive to do more inductions and more cesarean sections, and to move women through the delivery process quickly. As a result, about a third of women deliver by C-section in the United States, despite World Health Organization recommendations that C-sections should account for no more than 10 to 15 percent of total births. Similarly, induction rates continue to rise in the U.S., with an estimated 20 to 30 percent of women receiving the synthetic hormone pitocin to speed up contractions.
Anna Johnson after the home birth of her son, Colin, in 2012.
“The OB/GYN experience, it’s more of a specialty experience,” said Anna Johnson, a Bend nurse trained at Johns Hopkins University who has attended both hospital and home births. “It’s more a need when there’s a high-risk pregnancy. But in our country, it’s now become the norm. A lot of time you go in and you’re treated like you’re high risk even though you’re not.”
Johnson has had two children with midwives, one in the hospital and one at home. She is now expecting her third child, which will also be a home birth.
She says the labor process is much easier for a woman if she feels comfortable, and that labor can stall if she doesn’t.
“It is a safe option as long you have a trained professional,” she said. “And that’s where it gets sticky in some of these states. You have somebody calling themselves a midwife and they have no credentialing — they may not monitor the baby. That seems crazy.”
Fetal heartbeat monitoring is crucial to ensuring a safe birth, because it shows whether the baby is getting enough oxygen. With every contraction, the supply of oxygenated maternal blood to the baby is shut off for 30 to 45 seconds. Most of the time the placenta has enough oxygen to tide the baby over until the contraction ends. If the baby has no reserve, the heart rate will drop after the contraction, known as a late deceleration.
Hospitals generally use electronic fetal monitoring devices. But many midwives eschew the technology. Some feel it detracts from a natural experience; others maintain it results in more interventions than necessary. The alternative is to monitor heartbeats manually, with a specially designed stethoscope.
Rooks said that while the manual approach is perfectly acceptable, it must be done properly and consistently.
“I don’t believe the direct entry midwives have any idea how to do it,” she said. “They’re often not listening to the fetal heart enough.”
If late decelerations aren’t picked up, there is an increased risk the baby isn’t getting enough oxygen, which could result in death. If the baby’s heartbeat disappears altogether, physicians will perform an emergency C-section and attempt to resuscitate the baby. A 2005 study found that asphyxia deaths dropped 95 percent after the introduction of electronic fetal monitoring in hospitals in the 1970s. But at least two of eight deaths in 2012 occurred after the baby’s heartbeat was lost during labor. When that happens in a hospital setting, doctors can immediately extricate the baby via C-section or other types of assisted delivery and then seek to resuscitate the child. In a home setting, midwives can either transfer the mother to the hospital or continue with the natural delivery and then try to resuscitate the baby. Both options, however, may leave the baby without oxygen for too long. Experts say it’s difficult to project whether such babies could have been saved at the hospital.
“I think it’s hard to say ‘what if’ because you didn’t have the opportunity to intervene on that baby’s behalf,” said Mara Kerr, former director of the family birth center at St. Charles Bend and now a nursing professor at Central Oregon Community College. “We really can’t say we could have saved that baby here. Chances are we could have. But babies die in hospitals, too — just not at the rate they do at home.”
The 2012 Oregon data shows how much education and licensing affect outcomes. Certified nurse midwives had a mortality rate of 2 per 1,000 out-of-hospital births. Licensed direct entry midwives had a rate of 3.8 per 1,000, while unlicensed direct entry midwives had a rate of 10.2 per 1,000. Naturopathic doctors delivered 219 babies out-of-hospital in 2012, with one death.
With such small numbers of births, mortality rates should be viewed with caution as they can easily be skewed by one death. But the rates do provide at least a comparison between provider types, and analyses with larger numbers of births have shown similar results.
National statistics collected by the Midwives Alliance of North America show similar risks. The group has been collecting data from midwives since 2004 and recently published the data for the first five years of the registry. It’s unclear how reliable the data is, given that reporting is voluntary and heavily skewed toward licensed midwives. Nonetheless, that data showed a mortality rate of 1.71 per 1,000 out-of-hospital births, substantially higher than what occurs in hospitals. Like the Oregon data, the MANA registry showed that many of the women who lost their babies had conditions or factors that would be classified as high risk.
“If you included breech, twins, vaginal birth after cesarean, gestational diabetes and preeclampsia in the sample, the intrapartum mortality rate went up significantly,” said Melissa Cheyney, a certified professional midwife and professor of anthropology at Oregon State University in Corvallis. “Many people wondered why those women would be choosing home birth.”
Some women may be choosing home birth because they want to deliver vaginally and don’t believe the hospital will allow them that option, Cheyney said. Others simply might not know their risks.
“For a woman who is low risk, when the midwife is well-trained, the home birth is planned, you have access to medical backup when needed — home birth can be a viable option for women,” Cheyney said. “The problem is, I don’t think we have all of those parameters in place all across the United States.”
But Cheyney, who also serves as the chair of the licensing board for direct entry midwives in Oregon, doesn’t believe stricter rules on what types of patients midwives can serve and what conditions should trigger hospital transfers will help.
“Where we need to be focusing our efforts is on education, making sure that midwives are very well-trained around not just initial risk assessment when you’re asking whether this person is someone I should engage in a care relationship with, but ongoing risk assessment that leads you all the way through to the delivery of the baby,” she said. “Because people can become high risk at any moment.”
Andrews said that at 39 weeks, the midwives told her they would induce labor. Initially, they had told her they had a number of births planned for that month, although later they told her it was out of concern for her blood pressure.
They used a technique called membrane stripping, where the amniotic sac is gently separated from the wall of the uterus with a gloved finger, releasing hormones that can spur contractions. Studies are mixed about how effective it is at inducing labor.
Andrews’ first contraction came the next morning along with excruciating back pain. She called King, who expressed doubt that she was truly in labor, and told her to stay in touch. She suggested that Andrews take Tylenol PM, a pain relief/sleep aid combination. The next afternoon, as her contractions became more frequent, her husband drove her to the birthing center.
King examined Andrews and decided the back pain and contractions were likely a urinary tract infection. She sent the couple home, telling Andrews to take vitamin C for the infection, Andrews said.
“She made me feel like I was being a silly, first-time mom,” Andrews recalls. “I felt shamed that I wasn’t handling the pain very well.”
The pain continued to get worse and she hadn’t slept in days. That night, her husband intervened. Andrews was in the shower screaming in pain and not even realizing it. “We’ve got to go back,” he said.
Proponents of out-of-hospital births point to the studies of home births in Canada and Europe, where a much larger proportion of babies are delivered at home. Canada, for example, had unlicensed midwives into the 1990s but no longer does. The provincial health plans wanted to integrate them into the health care system through licensing and regulations. The midwives agreed to the licensing mandate as long as the education standards did not require a nursing degree.
In countries such as Denmark and the Netherlands, midwives practice under strict parameters, with specified lists of what constitutes high-risk deliveries that must be handled in a hospital, and what factors during labor necessitate an immediate transfer.
Studies show that high-risk pregnancies include twins or breech babies; advanced maternal age; or pregnancies carried into the 42nd week. First-time mothers have a higher risk of stalled labor and generally have higher rates of medical intervention. And women who have had previous delivery problems, including C-sections or infections, are at higher risk.
Add women who develop high blood pressure or diabetes during pregnancy and the number of low-risk women, those who could safely have a home birth, begins to dwindle.
Even low-risk pregnancies can become problematic once labor starts. Women who don’t deliver within 24 hours of their water breaking are at higher risk for infection, which can have serious consequences for mother and baby.
In a small percentage of cases, the baby’s shoulder can get stuck in the birth canal after the head is out, a condition known as shoulder dystocia. Experienced midwives can often free the baby, but in many cases, only a C-section will avert disaster. And about half of the cases of shoulder dystocia are unpredictable.
“I think what’s tricky is recognizing the high-risk factors that develop during labor and necessitate transport,” said Dr. Wendy Smith, an obstetrician at Legacy Emanuel Hospital in Portland. “And I think that’s where we’ve had some issues, that some of the risk factors were either not recognized or not determined to be high-risk factors.”
Smith collected data on planned out-of-hospital births that were transferred to Legacy in 2012, the same year that Oregon began collecting its data. The hospital recently implemented policy to help remove barriers to such transfers and now receives about 20 percent of all the home-birth transfers in the state.
Comparing those transferred cases with women choosing certified nurse midwife deliveries in their hospital, Smith found much worse outcomes. Three of the eight deaths in Oregon in 2012 were from home births transferred to Legacy.
Smith said the data should be used by both doctors and midwives to help women understand their individual risks when choosing in-hospital or at-home births.
“In order to make thoughtful choices, the women have to understand all the risks and benefits,” she said. “And the problem right now is so many out-of-hospital providers and in-hospital providers don’t know all the risks and benefits.”
Bad outcomes, Smith said, do prompt midwives to restrict such high-risk cases in the future.
“We had a second twin that died from an out-of-hospital birth, and that provider stopped doing multiple births,” Smith said.
A rough start
When Andrews arrived at the hospital, nobody could give her a straight answer about what had happened to Abel. Doctors were able to revive him when they pulled out the breathing tube the paramedics had put in, and her son was now in the neonatal intensive care unit.
“I think they were trying to be overly understanding of some religious beliefs or some anti-medicine beliefs we had because everyone just kind of tip-toed around us and said nothing,” Andrews said. “They wouldn’t address the issue, wouldn’t tell us what or why.”
At first doctors thought Abel might do OK. They did not opt for a head-cooling protocol often used to minimize brain damage in babies deprived of oxygen during the birth process. Over the next few days, it became clear Abel was worse off than they had initially expected. They started to talk about the possibility of developmental delays.
“You think, ‘Oh, it’ll be a little bit harder to get where he is supposed to be. You??re not thinking about disability,” Andrews said. “Our main goal was to get him out of the hospital.”
While Abel was recovering in the NICU, Andrews and her husband met with the midwives at the birthing center.
“They had some really bizarre theories about what had happened,” she said.
Had she had any milk with growth hormone in it? Had she taken any antacid?
“They thought something might be physiologically wrong with my body. They asked me if I had subconsciously not wanted my baby,” Andrews said. “So basically they had a lot of things that ultimately pointed back to me.”
Suddenly the women who prior to the birth had been her best friends, she said, had turned on her.
“What they sell you is the opposite of what they did,” Andrews said. “This caring, in-tune, womanly connection that I was supposed to be having was much worse than how I think a doctor, a male doctor, would have ‘clinically and coldly’ — their words, not mine — helped me through that.”
The Andrewses took Abel home after 10 days in the NICU. Now that they had him on their own turf, they could love him and care for him and help him catch up from his traumatic start in life.
“We thought that would be it,” Andrews said. “The nightmare is over.”
Trust our bodies
The resurgence of home birth might be part of a larger sociological trend. While in the past, home births might have been the only option for lower-income women who couldn’t afford a hospital birth, the current growth is occurring in a much different demographic. Studies show that women choosing out-of-hospital births are predominantly white, middle-to-higher-income, college-educated women. Many have become skeptical of modern medicine, science and technology, preferring to rely on their own intuition of what is best for their bodies and their babies. They seek more control over their birth process and worry that doctors will force them down roads they would prefer not to take.
“I believe that more things are likely to go wrong in the hospital setting, things that I’m not comfortable with,” Tara Clasen, a Bend woman who practices ayurvedic medicine (a form of alternative medicine native to India ), said a few weeks before her planned home birth in March. “And I also have complete trust in my body’s natural process.”
Tara Clasen holds her three-week-old baby, Maggie Laymon, in Maggies room in her home in Bend.
Joe Kline / The Bulletin
Clasen was concerned that a hospital birth could mean a C-section or being induced into labor, not being given enough time to deliver naturally. She didn’t want to be kept from eating or drinking during labor or from moving around freely.
She planned a home birth with a certified professional midwife instead, and had prepared for the birth process by choosing the food and drink she would prepare, even the music she would listen to at home during labor.
“(My midwife) is going to be encouraging me to use the natural instincts of my body,” she said. “She’s also a very calming presence, and she’s someone who I know will watch out for signs of trouble and will just be with me.”
She, too, worries about unqualified providers setting up shop as midwives. She’s seen similar attempts in her field of ayurvedic medicine, individuals who take a weekend workshop and start to see clients. But with a qualified midwife, she believes the risks are minimal.
“I feel like a lot of women experience very trouble-free home birth, and for those who get transferred to the hospital, at least those women know they gave their body time and they were able to labor very peacefully for a lot of hours,” she said. “I think a lot of people assume without knowing that it’s more dangerous, but truth be told, it’s not. What’s most important is that the woman feels completely comfortable and happy with her choices.”
When Clasen went into labor in March, her labor progressed very quickly and she was pushing hard before she was completely dilated. She and her midwife decided a transfer to the hospital was the safest option. Her daughter, Maggie, was born naturally just a few minutes after arriving at the hospital, delivered by a “very caring and nonjudgmental” doctor.
“I labored entirely at home, which was important to me. Even though I transferred, midwifery was still a part of my natural birth success. I had someone with me the whole time telling me my body was very intelligent and letting me make the decisions,” Clasen said. “I wanted to be in control, and using a midwife allowed me that.”
Tara Clausen holds her three-week-old baby, Maggie Laymon, as Maggie's hand rests on hers in Maggie's room in her home in Bend.
Joe Kline / The Bulletin
Many home birth advocates also believe the vast majority of medical birth interventions are unnecessary, and that healthy women with low-risk pregnancies face few risks delivering outside the hospital.
Theresa and Nick Reid, of Tumalo, went to Canada to have their first child delivered in a home birth. Originally from Colorado, she never thought about using a midwife before she became pregnant.
“It was my hippie husband who brought that up,” she said.
The Reids decided to give birth in Canada primarily so their daughter, Rogue, could have dual citizenship. They traveled to Sooke, British Columbia, about a month before the due date, and rented a house on a cliff, with 85 steps from the driveway to the front door.
Their nurse midwife was trained in Germany and fully integrated into the provincial health care system in Canada, working with local doctors and hospitals. The nearest hospital if something went wrong was in Victoria, 45 minutes away. Reid’s husband, a former emergency medical technician, confirmed that local EMTs had the specialized equipment needed to bring his wife down the stairs. But ultimately, the two felt confident the birth would go smoothly and their midwife could handle any emergency.
“I think that people think doctors are more qualified than midwives, and I don’t think they have confidence in what the human body can do,” she said. “I think that’s the biggest misconception, that it’s a medical procedure that needs intervention.”
That’s a common theme among home birth proponents, that women need to trust their bodies, to have confidence in themselves, and they can give birth on their own. Medical interventions such as C-sections, inductions and pain medications are often portrayed as weakness or failure, or giving in to the pressure of an aggressive, intrusive medical system.
“My sister wussed out. She did have drugs, which I think is unfortunate. If she had had more mental power, she could keep it together,” Reid said. “If you think you can do it, you can do it.”
Tiffany Seiders, an unlicensed midwife in Bend, went even further. She and her husband, Lonnie, delivered their fourth child in an unassisted home birth earlier this year. Seiders began learning midwifery and attending births at age 11 and has now attended more than 250 births. According to her website, she completed course work in midwifery through the Ancient Art Midwifery Institute home study course as well as through continuing education courses.
Her first child was born in a hospital 16 years ago, her middle two children with a midwife.
“The third one, I felt the midwife took away all of my control and took away all of the things I wanted to do,” she said. “It just left me feeling that it was an incomplete experience. Nobody knows my body the way I know my body.”
The Seiders monitored the baby’s heartbeat themselves and delivered the baby successfully after 12 hours of on-and-off laboring.
Seiders said she has chosen not be licensed so that she is not limited in the types of services she can provide to her clients.
“I’m offering something to women right now that licensed midwives can’t always offer,” she said. “I try to follow the same rules they do, but somebody will come to me and say, ‘I’ve had three C-sections; will you attend my birth?’ I have the ability to say, ‘Yes, I will,’ or, ‘No, I won’t.’”
The Seiders also maintain that licensing is a way for the state to exert control over midwives, and that current laws reflect the heavy lobbying by various interest groups on the Legislature.
“If you are licensed and break the rules, you’re subject to fines and a suspension of your licensure,” her husband, Lonnie, said. “Then you’ve got a black mark on your record for trying to do what’s right for the mother and something that you know you’re perfectly capable of doing.”
Seiders said some insurance companies will cover her services, but most of her clients pay out of pocket, about $3,500, including prenatal and postpartum care.
“Birth trauma doesn’t have to do with pain; birth trauma has to do with loss of control,” Seiders said. “You don’t have control over yourself in the hospital.”
Such statements rile medical providers like Tuteur, who believe that women are risking the safety of their babies for the sake of an idealized vision of some sort of transcendent birth experience.
“It’s the relatively well-off white women, the anti-vaccine crowd, the natural this and the natural that,” she said. “It’s a lifestyle choice, not a medical choice.”
Once home, Abel continued to struggle. He seemed to be in constant pain and screamed all day. It reminded Andrews of a coyote’s call or a wounded animal. He wouldn’t feed and Andrews had difficulty pumping enough milk for him. The midwives were supposed to provide weeks of postpartum support but were nowhere to be found.
“So I didn’t have a doctor following up with me, and I didn’t have midwives either,” she said.
At his one-year checkup, doctors finally helped Andrews understand what was going on.
Four-year-old Abel Andrews uses his gait trainer while sitting with parents, Kristine and Greg, in Centennial Park in Redmond. Abel has a form of cerebral palsy, developed during complications at birth through a midwife.
Joe Kline / The Bulletin
“‘This is cerebral palsy,’” she recalls him telling her. “‘I’m really sorry that no one has more directly explained to you what’s going on. He was born not breathing; he was deprived of oxygen, which caused brain damage, which equals cerebral palsy.’ He really laid it out for me.”
The lack of oxygen at birth damaged the motor control portion of his brain. He lacks the core strength to stand on his own. He uses his left arm to stabilize his trunk and has about 30 to 40 percent use of his right arm. He can walk with the help of a gait trainer, into which he must be strapped. He uses just a few words and sounds to communicate. An intuitive person can catch on fairly well, Andrews said, but some people don’t. Now 4 years old, he attends an early intervention school for children with developmental disabilities in Redmond.
“He has gone through some really hard times for him at school, and he has just gotten it in the last few months that he is different, and he is upset about it.”
Faced with a lifetime of added costs, Andrews contacted Motherwise about its liability coverage.
“We had tried to take the high road and not be bitter or angry,” she said. “So I was basically asking, ‘What do we do here?’”
It was then that Andrews found out for the first time the birthing center had no liability coverage. They had signed an arbitration agreement, which had been presented as a way to avoid “the ugliness of lawyers.”
“In my mind, it’s the same as a lawsuit, only faster,” Andrews said. “So I thought there were funds backing that arbitration up.”
She said that Tucker told her she should have known that home birth was risky and that she wouldn’t get a dime from the birthing center. The Motherwise midwives were later disciplined by the Oregon Board of Direct Entry Midwives for failing to disclose they carried no liability insurance. The center has since closed, defaulting on a loan from the Central Oregon Intergovernmental Council. Tucker is now working as a lactation consultant in Bend, while King is providing craniosacral therapy to mothers and infants in Vermont. Neither could be reached for comment.
The Andrewses, meanwhile, are facing thousands in extra costs to provide for Abel and are reduced to one income, as Andrews must take her son to school. herself. His gait trainer does not allow him to ride a bus
Kristine Andrews helps her son, Abel, remove his coat at the family's home in Redmond.
Joe Kline / The Bulletin
“We’re strapped for money; we’re strapped for time,” she said. “There’s just a lot of things that you don’t have to pay for with a regular kid.”
Their house has not been adapted for the gait trainer, nor can they afford a van that could better accommodate him.
“I wish that people could see that because I think they think of a lawsuit and they think of people being greedy or vengeful or wanting to get rich,” she said. “It’s not about that. It’s about providing for this person who has been injured.”
According to Ann Geisler, president of Southern Cross Insurance Solutions, licensed midwives in Oregon can purchase about $1 million per claim liability coverage for about $4,500 per year. Nationwide, she estimates that only 10 percent of midwives purchase coverage.
“They’re rarely sued because they’re serving low-risk moms and they have lower-volume practices,” she said.
Midwives also have a different relationship with women than physicians.
“The midwife empowers a mom to have the child. The midwife is not delivering that child; the mom is delivering the baby, and she knowingly recognizes the risk and the benefits of having a natural childbirth, and because of that you don’t see as many claims,” Geisler said. “The mom is like, ‘Oh right. I made this decision. I’m going to take responsibility for this decision.’ The buck has to stop somewhere.”
Geisler also advises midwives to take precautions to protect their assets. She advises midwives who aren’t going to purchase liability insurance to incorporate to protect their personal assets and to require binding arbitration.
“It basically allows grievances to be handled more efficiently, typically fairly,” she said. “I tell my clients it’s a great way to screen your clients, because if they don’t want to agree to binding arbitration, maybe they’re looking to you as a deep pocket.”
Arbitration, as the Andrewses found, tends to protect the midwife much more than the family. Physicians carry liability insurance not only to protect themselves financially but to protect their patients in case they make a mistake. Arbitration agreements offer no means of paying a family when a midwife is found negligent. The Andrewses opted not to pursue what they saw as a futile effort.
It’s unclear how many families are dealing with lifelong disabilities that could be attributed to a home birth. Oregon and other states have just started collecting data on deaths, but there is no good analysis of how many babies are injured during in-hospital or out-of-hospital births.
Researchers at Cornell University looked at the use of head cooling protocols in NICUs as a way to approximate brain damage. They found that babies delivered at home had 17 times the risk of requiring head cooling treatment than did babies delivered at the hospital, and home birth babies were nearly four times more likely to have seizures or neurological problems than hospital-delivered babies.
The Cornell group also looked at five-minute Apgar scores, a standardized way of judging the health of the baby after delivery. Certified nurse midwives in hospitals had half the rate of zero Apgar scores of obstetricians, likely reflecting their lower-risk patients. But midwives in freestanding birth centers had 3.5 times higher rates than physicians and midwives at home births had 10.5 times higher rates.
“Apgar scores of zero is associated either with a dead baby or, if the baby survives, more often than not, it is associated with brain damage,” said Dr. Amos Grunebaum, a Cornell obstetrician who conducted the research. “If a baby has an Apgar score of zero at home, there’s no team, there are no doctors, that are able to sufficiently resuscitate the baby.”
Grunebaum says he understands women’s concern about unnecessary interventions but says most obstetricians will accommodate requests for a fully natural birth if possible. Other than lighting candles in the delivery room, almost every reasonable request can be granted.
But if something goes wrong, the hospital has a team of physicians and nurses ready to take care of the baby.
“When a (pregnant) mother comes in with a live baby, it is highly unusual — it still happens, but it is highly unusual — for this baby to be born dead,” he said, “because we monitor it extremely well. At home, the monitoring available is less than optimal.”
It’s clear that doctors do err on the side of caution, perhaps out of liability concerns, perhaps because they’ve seen too many bad outcomes. So some women do get C-sections they don’t need; some women will be induced when they might have delivered just fine on their own. On the other hand, those medical procedures do save babies.
“It’s the interventions that save babies’ lives,” Grunebaum said. “If you reduce interventions to a point where it’s unavailable, you will have babies die.”
Midwives attending out-of-hospital births may err on the side of letting the birth progress naturally, and in the vast majority of cases, that occurs without a problem. But the consequences of avoiding needed medical intervention are much harsher.
Andrews, for one, finds it frustrating that women seem to worry more about the medical interventions than about the risks to their babies.
“I think that those women who get C-sections are very lucky. You’re lucky to live in a time where we have people who do this and you have a choice,” she said. “I think it’s very elitist and detached to not recognize that, and to appreciate that you lived and your child lived, instead of feeling like, ‘You ruined my beautiful day.’”
A baby’s death
After learning they had little recourse to hold their midwives accountable for Abel’s injuries, Andrews began reading much more about licensing and regulations in Oregon. Then in the summer of 2011, she read about Margarita Mareboina, a Eugene woman whose son, Shahzad , died at birth. Like Andrews, she had been under the care of physician when she first became pregnant. But she watched the movie, “Pregnant in America,” which promotes home birth over hospital birth.
“I just kind of got sucked into what they call ‘the woo,’” she said. “They glamorized home birth as being so special.”
She found an unlicensed midwife, Darby Partner, who had done apprenticeships in Mexico and India. The two hit it off at once. Mareboina loved the attention she was getting from the midwife, a big difference from the 15-minute appointments at the OB’s office.
She was more than a week past her due date when she felt her first contractions. It would be another eight days before she would deliver. After five days of on-and-off contractions, she was exhausted and told the midwife and her partner she need to go the hospital. They persuaded her to stick it out.
“They were telling me things like, ‘You’re doing so great. Look how far you’ve come. Everything is fine. You’re such a warrior,’” Mareboina said.
When her water finally broke on a Friday morning, it was stained with meconium, the baby’s first bowel movement. The presence of meconium is generally considered a reason to transfer the mother to the hospital, but the midwives downplayed any concern.
The midwives took away her phone and turned concerned friends away at the door, as Mareboina labored another two days. By Sunday morning, Mareboina was in extreme pain and in active labor. She begged the midwives to take her to the hospital, but again they talked her out of it.
By early afternoon, they told her she was ready to push and two hours later, Shahzad was born. The midwives had told Mareboina to catch the baby herself, and that they would stay quiet if everything was OK.
But Shahzad emerged limp and motionless. He wasn’t breathing. He was completely blue, covered in green meconium. The midwives started rubbing his back and said, “Just call his name. Usually they come back when you call their name.”
After six minutes they called 911 and tried to follow the operator’s instructions on how to perform CPR. When the ambulance arrived, they all piled in and took Shahzad to the hospital, but doctors were unable to save him.
“He had no chance at all,” Mareboina said.
In the hospital, the nurses cleaned up her son. He looked perfectly healthy. An autopsy report listed it as a stillbirth, indicating there was 1 milliliter of meconium in his stomach and that his lungs had never taken a breath.
“I thought I was doing the right thing. From all the research I did on them, I thought they knew what they were doing,” she said. “I’m not saying we shouldn’t allow home births. They just need to be safe for everybody, and all birth providers need to be held to that same standard of accountability, safety and transparency.”
Margarita Mareboina holds her son, Shahzad, who was stillborn in a home birth in Eugene in 2011.
Mareboina’s story revealed to Andrews that there were more families that experienced problems with a home birth. Soon she found more than a dozen families that had written about their experiences online. Eager to protect other families from similar fates, she filed a lawsuit against Motherwise, her midwives and the state of Oregon. The suit alleged the state’s regulations governing when midwives must transfer cases to the hospital were inappropriate and not evidence-based, nor did it have a mandatory disclosure form if a midwife didn’t have liability coverage. The state was eventually granted sovereign immunity and the suit went nowhere.
But the legal action and Mareboina’s story prompted state legislators to consider a mandatory licensing statute for midwives in Oregon in 2013. The bill was eventually watered down with exceptions to the point that the mandate became meaningless, said Sharron Fuchs, a legal assistant from Portland who has fought for strong oversight of midwives in Oregon. Those calling for greater regulation of out-of-hospital births say the bill just adds to the state’s history of inaction on the issue.
“Oregon has failed miserably in the regulation of this group, because they were mandated by law in 1993 to keep track of bad outcomes and they didn’t do it,” said Fuchs, who was injured in a home birth in the 1980s.
Midwife groups had sought licensure in the state as a way of securing payment through the Oregon Health Plan in the 1990s, she said.
“When these people went to the Legislature, they marketed themselves as low risk, low risk, low risk. But as soon as they got a license, low risk went out the window,” Fuchs said. “They started adding higher-risk care into their scope of practice, and the state of Oregon did nothing.”
Fuchs doesn’t want to ban home births and sympathizes with the notion that doctors may be overly eager to turn to medical interventions.
“On the other hand, there are probably hard-core women who are hell-bent on having an out-of-hospital birth, and anything short of that is a disaster or they feel they’ve failed,” Fuchs said. “And any sort of help is met with hostility.”
Home birth remains a highly divisive issue in Oregon, and particularly in Central Oregon, where there is great tension between obstetricians and midwives. That leaves midwives unable to consult with local doctors about a case and creates a barrier to transferring patients to the hospital when concerns arise. The midwives know they are likely to get an unwelcome reception at the hospital.
“There would be a much safer environment for women giving birth at home if there were a bridge from home to the hospital,” Kerr, the COCC nursing professor, said. “But nobody here has effectively built that bridge. When a midwife gets into trouble, they can’t just call up their consult and say this is what’s going on and have them meet them at the hospital.”
Tuteur is much more frank about the division between OBs and midwives.
“Most OBs look at these women as killers,” Tuteur said. “They can’t understand how anyone could be so cavalier about the life of somebody else’s child. It isn’t just a medical thing. It’s a really visceral reaction.”
Kerr said the antipathy keeps midwives from transferring patients earlier, and often patients arrive at the hospital too late.
“I know that women will continue to choose home births. They’re going to see themselves as not a good fit for a hospital birth, and they’re going to continue to choose it,” Kerr said. “So we need to figure out a way to make it safe, and maybe not even to make that safe, but to make that transition safe and give them the best outcome we can.”
Doctors at St. Charles Redmond are trying to move in that direction. Unlike in Bend, where all of the obstetricians delivering babies at the hospital are in private practice, the Redmond hospital employs its own obstetricians and the region’s only certified nurse midwife.
“We have a catchment from Prineville to Madras and we work with and know of lay midwives and licensed midwives who practice here,” said Dr. Barbara Newman, medical director at the St. Charles Redmond birthing center. “We’ve been reaching out to them to try to make a better relationship.” There are seven certified professional midwives with active licenses in Central Oregon, but it is unclear how many unlicensed midwives are attending births in the region.
At the same time, both the Redmond and Bend hospitals are trying to make in-hospital births a much more natural experience for women.
“We don’t monitor everybody; we don’t put IVs in everyone; we have people eat and drink,” she said. “The rooms are homey and warm, it’s not a sterile atmosphere and nobody is encouraging a cesarean section. It’s not your home, but it’s a good alternative.”
She does acknowledge that doctors may have been a little too aggressive in intervening in the past, particularly those trained on the East Coast.
“I think that is reversing. The pendulum is swinging backward,” she said. “The residents that are coming out are far less aggressive than I was.”
Time also tempers that aggressiveness, she said. More experienced doctors are more likely to be comfortable sitting and waiting.
“Everybody’s goal is the same, to help the baby and to help the mom,” Newman said. “It’s not the old model of doctor says and that’s what happens.” •
Editor’s note: This article has been corrected. The original version misidentified the location of Motherwise Birthing Center. High Desert Pulse regrets the error.