Sunday, March 2, 2008

Utah Midwifery--Why You Should Care

Utah has a long history of midwifery as a well-respected profession. In 19th century Utah, midwives not only delivered babies, but often cared for any health care concerns of the citizens, since physicians were scarce. Midwifery was a calling in the early LDS church, and leaders sent midwives "back east" for extensive training. Utah had the best midwives in the country because of that commitment.

When the Medical Practice Act was written and codified in Utah law, it was not intended to limit or even affect midwifery, because midwifery was clearly considered a separate profession. Over the years, the laws of the state began to change as there became a distinction between the "Certified Nurse Midwife," who had medical training and licensing, and the "Direct-Entry Midwife," or "Lay Midwife," whose training is done outside of the nursing field.

Here's a tidbit of which my blog friends are unaware: I personally have had midwives for three of my births, and home births for two of these. My first child was born in 1985 with a CNM at Orem Community Hospital, my third child was born in 1988 with a lay midwife at home in Provo, and my fifth child was born in 1991 with the same midwife at my home in Fayette, Missouri. This woman was a second-generation midwife and part of a group of trained and competent direct-entry midwives then active in the Utah Midwives Association.

Shortly thereafter, in 1993, a statute which once excluded midwifery from the practice of medicine was quietly removed. Many lay midwives were not even aware of the change until October of 2000 when Liz Camp, direct-entry midwife in St. George was charged with four felony counts of practicing medicine without a license. These charges centered on two basic offenses: 1) using Pitocin to stop a postpartum hemorrhage and 2) cutting an emergency episiotomy. She faced 20 years (5 year max penalty for each of 4 charges). She plea bargained down to 2 misdemeanor counts of practicing medicine without a license, and received 18 months probation and a $250 fine.

Because midwifery had now been found illegal in Utah, The Utah Midwives Association formed a Legislative Committee to address the issue. Along with other home birth supporters they created a bill that legally defined direct-entry (non-nurse) midwifery. This bill was furiously opposed by the Utah Medical Association and the Certified Nurse-Midwives, and it took several years and many concessions to enact. Finally, the Direct-Entry Midwife Act was passed on May 2, 2005. Under this bill, direct-entry midwives were allowed to practice, perform prenatal care and to legally administer some few life-saving medicines if they certified with the state to do so.

However, the opposition by the medical field to lay midwifery continues. Last year (2007), the UMA introduced a bill to amend the Direct-Entry Midwife Act. The bill did not pass, but was sent to an interim committee for further study. The interim committee did not choose to study it because the bill is unnecessary given the excellent outcomes for Licensed Direct-Entry Midwives (2006, 2007). These reports show that midwives practicing in Utah are very safe, and consistently produce better results than hospital providers. Now the UMA has brought forth its second legislative attempt to re-write the circumstances under which a direct-entry midwife (licensed or not) can practice.

This year’s version (SB 93) is sponsored by Sen. Margaret Dayton, a former labor and delivery nurse. She says that she and the Utah Medical Association want to stop midwives from attending "high-risk" pregnancies that could result in the harm or death of baby or mother. The bill includes a myriad of restrictions that would exclude a woman from the care of a direct-entry midwife. Some of the exclusions are valid and already addressed in rules approved by DOPL (HIV positive women, premature babies, etc.). Most of them, however, are not. In fact, over 90% of the women who currently choose the care of a direct-entry midwife would no longer be able to qualify as "normal." The bill goes beyond the definition of normal birth, and is clearly a restraint of trade.

In just one example, multiple gestations, line 226, are precluded. One midwife writes:

This one really steams me. When you look at home born twins vs. hospital born twins you find a very drastic difference in treatment and outcomes! Home born twins are commonly born at term–many even go a full 40 weeks or longer! Home born twins are generally larger–some are even 8 or 9 lbs. each! Home born twins are born vaginally. Hospital born twins are commonly born prematurely. Sometimes this happens spontaneously, other times mothers are induced or c-sectioned early, often without a clear medical indication. This results in premature babies that could have been born as healthy full-term infants. Hospital born twins are usually much smaller as well, and suffer the complications small and early babies are subject to. Given this information, I would not at all feel comfortable giving birth in a hospital with twins unless they came prematurely on their own.

Also affected in the exclusions are women who have had miscarriages, women who have had infections during pregnancy, women with diabetes, women over 35, and women who have had previous cesaerean births. Utah Midwives Association President Jules Johnston said Dayton has gone overboard. "If they sneeze, they're risked out." SB93 also removes one of the midwife positions on the state midwife board and adds three members who are either a licensed physician or certified nurse midwife. There is one member of the public on the board.

Elizabeth Smith, CPM, LDEM, is very concerned about how SB93 has been presented. She writes:
The Utah Medical Association has very sneakily and dishonestly proposed a bill to the Utah Senate, much like last year's bill, that will take away the rights of most mothers to birth at home. At the Senate committee, both sides were ordered to work out a compromise. The UMA met with midwife representatives and came up with compromises to everything except a few items. Yesterday, the UMedA sent their own bill, without the agreed compromises to the Senate floor saying that it was the "Compromise" bill. They totally lied and all but one Senator bought it and voted for it. Now the bill SB93 has gone to the house to be voted into law.

Women of Utah have become very heated on the issue. An anonymous commenter said:
"The bill Dayton is trying to amend took a very long time to come to. It was a miracle the groups involved could come to such compromises and articulate boundaries that all sides could agree to and support. This is becoming a war on an idea, a promotion of personal feelings rather than fostering freedom and providing appropriate healthcare. No one should be forced into care another feels comfortable with but they, themselves, are not. A family should be supported in birthing at home, in the hospital, or in a birthing center without fear of stigma. It's time for Mrs. Dayton to remove her hands from the wombs of all the women in Utah and allow them to birth the way their studies and conscience determine. Women have proven to do whatever it takes to acheive what they're looking for. Scaling down this already thin bill allowing for freedom of choice may well increase the likelihood of traumatic outcomes because women who abhor hospitals could move toward unassisted birth rather than submit themselves to the perceived emotional and physical raping of their rights that they may fear. It's time to leave well enough alone."

I believe that our LDS emphasis on the family requires us to care about this and similar issues. My research has convinced me that midwife assisted home birth is safer than hospital birth. In many countries, home birth is considered the first choice for healthy women. The countries with the lowest mortality and morbidity rates are those countries where midwifery is an integral part of maternity care and where homebirth is commonly practiced. The home birth debate has been carried out in many places. I am aware of many studies which indicate that home birth is safer than hospital birth and that fewer complications occur at home (see, for example, the Mehl study. Feel free to link to other studies in the comments to this post.) If this is indeed the case, shouldn't Utah women maintain the legal right to have access to this service? Our Utah lay midwives are well trained and knowledgeable. They attend and assist in many more births than CNM's when they are undertaking their training. I feel that legislation should support what they are doing and assist them to become even more qualified in their field of specialization. We should not set them back in their efforts. Because of the excellent outcomes obtained by Direct-Entry Midwives, this bill seeks to solve a problem that doesn't exist.

SB93 has now gone to the House and is now going through several substitutions. I will be watching this issue carefully to see how Utahns will respond.



m&m said...

This is something my sister is directly involved in. She recently said that they have gotten some compromise that wasn't in the original bill, which may be about all they can get at this point.

One of the things that has been frustrating about this bill and the others that UMA has tried to push through is the lack of statistical support for the kinds of restrictions they have outlined.

bigbrownhouse said...

Thanks for posting this! My three births were attended by midwives. The first two were homebirths with lay midwives (in Utah and Massachusetts)and the third was a natural hospital birth with CNM.

Ayla said...

This is exactly corrent. I love the post and I thought I would share a few sections of my Master's degree thesis which I did on Mormons and homebirth.

"The Word of Wisdom is very in tune with the practice of midwifery and directs herbs to be used in the healing of disease (Brady 88). The Word of Wisdom was given as a health code for all Mormons however Smith also directed midwives to use it in particular. He “set apart” Ann Carling, a midwife in Nauvoo, IL, and while laying his hands upon her head he told her that she would be successful in caring for the sick if she would use herbs exclusively in her work (Brady 88).Using the same method discussed for Ann Carling, Joseph also placed his hands on the heads of Patty Sessions and Vienna Jaques, anointing them and directing them not only as midwives for the women but community healers as well (Noall 16).

Patty Sessions and Vienna Jacques were women of priestly authority following their anointing. They used their skills both herbally and spiritually to assist in birth and to heal the Mormon pioneers who walked from the east to Utah, ending in the Salt Lake basin (Noall 18). So effective were their abilities to heal and so great was the confidence place in them by their fellow Mormons, that often when doctors attempted to assist in difficult situations Mormon men would slam the door in their face (Noall 18).

In the early days of Utah Mormon settlements, midwives were, as Margaret K. Brady puts it, the feminist alternative to regular medicine (Brady 87). Midwives were the voice of authority in Utah and held a mystical place for their patients (Noall 15). Intertwined with spirituality the midwives and other women blessed each other often. Eliza Snow, a woman whom we will remember had been given the priesthood and had revelations on Heavenly Mother, is known to have blessed midwife Patty Bartlett on the occasion of her birthday (Noall 33).

Mormon midwife healers lived in the land that their Book of Mormon described and they knew through their spiritual beliefs that the thistle and sage growing in the hills around them had once been used by the Nephites, one of the early American tribes according to The Book of Mormon (Noall 16). This speaks to the midwives deep connection with the land on which they lived and they knew through their faith that the earth would heal them."

CatherineWO said...

Thank you for this post. I don't live in Utah, but I have been following this in the online SL Trib. We have some similar issues going on in Montana. I had a midwife assisted hospital birth in 1982, and I had the beautiful experience of witnessing the homebirth of twin grandsons in Utah almost two years ago (just the day before my 1982-born daughter was married in SLC). The boys weighed almost eight pounds each (and their mother is barely five feet tall). The competance of the midwives involved (there were three) was beyond reproach. I have no question that those babies, and their mother, were safer and healthier with the home birth. I challenge anyone who questions homebirth to witness one.

I have just discovered in some research that my third-great grandmother, Diantha Morley Billings, was a midwife in early Utah. She was a well-respected and essential part of her community.

I truly see this as a women's rights issue, as well as a health issue. To me, it's a no-brainer. Why would we deny women the choice of providing the best care for themselves and their children?

I wish I had a Utah lesgislator to write to. I hope those of you who live there will speak up about this, no matter what your age or child-bearing status.

Bored in Vernal said...

Ayla, thank you so much for taking the time to add this information about the anointings/setting aparts!! Fantastic stuff.

FoxyJ said...

I have problems with my uterus and would have died without intervention and a cesearean. Especially with my second where I had a placental abruption and was bleeding to death. But, my mom had four home births (including me!) and I am a big advocate for home birth for most pregnancies. I wish people weren't so weirded out and scared by it. Especially obstetricians and other hospital personnel. Yes, if you have certain risk factors you probably shouldn't do it. But it is possible for a lot of people and I wish more people would realize that. I think it is also a healthy, positive thing for families. My mom's descriptions of births (I don't remember them very well) involve all the other kids being home and being able to greet their new sibling and their mother right away. Part of my second little one's birth that was so stressful was the fact that we couldn't find anyone to watch our daughter and I had to spend four days in the hospital basically alone.

AzĂșcar said...

Dayton was a labor and delivery nurse? Well, that explains a lot.

I had an OB at a regular hospital with my first. Never, never again.

I went to CNM with my second and I absolutely loved my experience. I felt cared for as an entire person, not as this thing that needed to be medically administered and controlled.

I'm a little too chicken to try an at-home birth at this point, but I love the idea and respect any woman's right to make that decision.

I mean, if you think about it, aren't these types of laws misogynistic? As if we poor women haven't a thought in our heads and couldn't possibly make an informed decision? Give me a break!

Thank for for a well-written article. I loved all the historical background.

woundedhart said...

I totally missed the boat. I didn't even know there was a difference between lay midwives and CNMs. I had all three of my kids with a CNM at a birthing center. I thought that was just the modern way of doing it. (I'll admit that I'm still pretty naive.)

Recently I've been questioning my own choices in childbirth. I feel like I was so ill informed. I wish I had known about the options. I actually wish men had never commandeered the birthing world, because, honestly, they broke the whole system with their ignorance and "modern" and "sanitary" ways of dealing with birth.

I feel cheated. Even with the CNM who delivered all three of my kids, I still had pitocin, epidurals, hemorrhaging, etc. I know it's useless, but I wonder if I'd experienced more birth in my life, like participating in family and friend's births, I might have known better what to expect, and I would have known to not let them do anything that wasn't really going to help. (I was labeled with "failure to progress," which led to the pitocin and all the rest. I recently read this article about it, and hadn't really considered before that the term was invented for convenience. Though I know my CNM wasn't in it for her own convenience, maybe she wouldn't have given the diagnosis without the idea having been planted in her head by the medical world.)

I love the image of the traveling midwife/priestess

Anonymous said...

THANK YOU for posting this. I am so tired of people thinking that I'm nuts for wanting to labor without drugs and to have a midwife by my side at all times. Thankfully I live in Los Angeles where there are some other "natural" women here who prefer to go to midwives over ob/gyn's. I have nothing against medical doctors, btw, but I do think that they are not forthright in telling a women about all of our options in giving birth. My first ob/gyn told me I wouldn't get a "medal" if I did it w/o drugs. I told him it was NOT about getting a medal! I want to do what is best for my baby. If it means that getting drugs and having a c-section is the best thing -- then by all means -- do it. But let's not use that as the FIRST option.

As you can tell I have strong feelings on this subject. If you're interested in reading more about women's rights in giving birth - I highly recommend the book "Pushed: The Painful Truth about Childbirth and Modern Care" by Jennifer Block.

Also, women should learn to trust their bodies to do the work of labor.

My first child I was literally FORCED into being induced and everything went wrong. It was not a beautiful time and it sent me into post partum depression.

My second child I birthed naturally (mainly at home) and it was the MOST AMAZING and WONDERFUL experience of my entire life! It was magical. It was humbling and spiritual. Natural birth does not mean screaming and wrenching in pain. If you do your homework and prepare -- it's amazing what you can do. And I'm a baby -- I do not like pain. I almost cry over papercuts, so no, I'm not different than most women. But childbirth is different.


Bored in Vernal said...

well, folks, I just found out Dayton's husband is an OB-GYN. Figures.

jenica said...

i just found you through anna's page. i had my first at home and my next three at the birth and family place in holladay. the other day a *friend* of mine commented on my birthing choices saying, "you just don't know how LUCKY you are!" i felt like replying that she just didn't know how ignorant SHE IS! get's my g's in a twist just thinking about it.

did they actually pass this bill?

callgirl said...

Dear BiV,

You say that your third child was born at home. According to her, she was "born dead", and it wasn't untill after a priestood blessing that she began breathing. The midwife was about to declare FB dead. You confronted your husband, reminding him that in the blessing he gave you before the birth that you were promised a positive outcome for you and the baby. He then took the baby in his arms and blessed her. She miraculously was revived. This is her version of the story. I laughed and said, "See (FB), your mom really does love you after all!"
Is any of this true? If so, did it give you any pause about having home births? Just curious.

(P.S. FB is an exceptionally wonderful person and I love her like my own daughter. I consider it a priviledge to rub shoulders with her.)

callgirl said...

Oops--I meant "privilege". Sorry. I hate misspelling things. Too bad I'm not an educated intellectual like the rest of you probably are! Sorry again.

Bored in Vernal said...

Callgirl, How awesome that you came to my blog! I looooove Daughter #3 and her birth was indeed miraculous. She was born completely blue with the cord wrapped around her neck. The midwives worked on rescuscitating her for about 10 minutes. They handed DH a bottle of consecrated oil and he blessed her for quite a while, calling her spirit to come to earth and to enter her body. They were indeed starting to comfort me by telling me "it was the Lord's will," when we claimed the blessings that had been promised and the stubborn little thing finally came to us. Everyone in the room felt her spirit come into the room. It was pretty amazing.

Some might find this story a testimonial against home birth, but I am confident that the midwives were prepared and skilled and able to do everything that could have been done in a hospital. In addition, if this was indeed a spiritual manifestation, perhaps the hospital environment would not have been conducive to bringing her spirit down. Who knows?

...and did she tell you she was my sweetest baby? She was cuddly and sweet and rarely cried.

Kathleen said...

K.Matheson Sutherland.
I don't know of any theodicy that works for me, and my x worked mightily hard to write a cogent paper and present it. We talked alot.

Have you read Pilgrim on Tinker's Creek?
Do you remeber the words to the hymn?

Ben & Windy Shaffer said...

I know I'm picking up an old thread, but I want to thank all of the contributors and let you know I appreciate the information. I have had a UT CNM birth in Feb 2005 (Medicaid wouldn't pay for a non-hospital birth) and my miscarriage and second live birth were handled with care and efficiency and kindness (and national health insurance $10 USD for the D&C and $300 USD for the hospital delivery) overseas in Taiwan by a "traditional" western medical doctor who was flexible enough to actually let me do the birthing, my husband cut the cord and break a hundred Chinese/Taiwanese (customs along the way). I really think knowing our own bodies and not being afraid of labor is what is best for each of us as women, I think we all need to find that rational space and know that each pregnancy, delivery, person is different and we need to TRUST our instincts, and respect others choices (like the epidural, episomoty, c-sections who WANT it that way!) I do hope that in UT especially that the local government did/will find the correct and honest balance rather than a twisted political agenda... I hope to move back someday and would love to have the option of a home birth with a mid-wife.