Carla Viles of Labor of Love Midwifery Services talks with patient Elaena Shepard about her choice for a homebirth.
The birth of Elaena Shepard’s first son happened so quickly that she barely made it to the futon, where her husband caught their son. Odin was born three years ago in the Shepards’ old home before their midwife even arrived.
Now seven months pregnant with her second child, Shepard has yet to experience the smell of latex-gloves and sterilizing cleaners indicative of a hospital. She doesn’t plan to give birth there either.
Shepard helps make up the 1 percent of women in the United States who have chosen to give birth in their own home with a midwife.
“I felt like if I went to a doctor, I would be someone who had an appointment that day—a piece of paper,” Shepard says, preferring instead a natural and personalized birthing experience.
Midwife Carla Viles has been providing homebirths for the past twenty years. She assisted Shepard with her first pregnancy and is guiding her through her second. The two women share a close bond and chat freely with one another during appointments.
But unlike an obstetrician at the hospital, Viles has never been to medical school and doesn’t carry a license to practice. Viles learned her trade through field experience and by completing apprenticeships with other midwives. Some medical professionals argue this training isn’t sufficient for midwives to handle complications during birth.
The conflict between doctors and midwives concerning the safest way to give birth has been going on for years, and the issue recently faced legislative action. Homebirth midwives are illegal in ten states and eighteen states require midwives to practice under a government-regulated license.
The question of whether or not a compromise exists still lingers in Oregon—one of only two states that still allows voluntary licensure for midwives.
Only seventy-seven licensed midwives practice in the state of Oregon, and they are required to follow regulations set by the Oregon Health and Licensing Agency (OHLA). A license guarantees that a midwife has accomplished a certain level of training and permits her to carry medications. It also allows the OHLA to investigate a midwife’s records if a patient or doctor files a malpractice complaint.
Viles uses a stethoscope to listen to the heartbeat of Shepard’s baby during a prenatal exam.
Midwives who choose to practice without a license are not allowed to carry medications and are not held accountable by the government. This is the issue that Margarita Sheikh of Eugene, Oregon, now faces after losing her son during her homebirth in July. When Sheikh hired an unlicensed midwife to help her deliver her first baby, she never imagined her midwife wouldn’t know how to perform CPR on her son when he was born without a heartbeat. “I didn’t know my midwife was lying to me,” Sheikh says.
Sheikh says the midwife made false claims about her experience and training, but she can’t receive any aid from the government because the midwife is unlicensed.
This tragedy put midwives in the media spotlight, placing the push for mandatory licensing—once again—at the forefront of the homebirth debate in Oregon.
Melissa Cheyney, a licensed midwife and chair of the Oregon Board of Direct Entry Midwifery, argues that mandatory licensure is not a matter of making the practice safer but a matter of holding midwives accountable and making sure every midwife has a minimal entry level of training.
“The real danger in our state now is that you could have somebody who knows absolutely nothing, but calls herself a midwife,” Cheyney says.
Oregon Representative Mitch Greenlick has been pushing for mandatory licensure for several legislative sessions after he realized there were midwives practicing without the credential. “That to me is completely crazy,” Greenlick says. “Midwifery is a real health profession. Why is it not licensed?”
But Cheyney is wary about establishing a law so soon without data proving licensed midwives produce better birth outcomes than those without a license. Though a project to obtain this data is under way, it will take at least three years to compile the information and determine the results.
Greenlick isn’t waiting for this information. He plans to once again present a bill in 2013 that would mandate licensure and allow the OHLA to set regulations. The regulations would establish specific training requirements and possibly restrict certain home birthing situations including twin births, breeches, or VBACs, which occur when a woman attempts a vaginal birth after previously having a cesarean section.
Oregon license holders currently receive entry-level training in those procedures and only face minor limitations assisting high-risk births. But midwives who oppose licensure and government involvement in the practice fear that restrictions will only tighten.
According to Viles, if Greenlick’s law passes, the number of hospital transfers could increase. “It could prevent women from getting the experience they really want,” Viles says.
Many women who are uncomfortable with having cesarean sections in hospitals often look to homebirth as a natural alternative. Viles fears the government might prohibit certain options, infringing on a women’s right to choose her own birthing method.
“It’s an issue of women’s reproductive rights, not midwifery rights,” Viles says. “My main concern is that birthing women will lose their rights.”
Colleen Forbes has held a license for all ten years that she has served as a midwife. She says a lot of energy is spent preserving the rights of a small number of women instead of thinking about the 99 percent of women who choose to give birth in hospitals.
Sarah Macrorie, a licensed midwife, discusses the necessities her patient, Bree Staffelbach, will need to prepare for the birth of her baby.
“Shouldn’t we be promoting the safety and credentialing of midwifery so that more of the mainstream population sees it as a viable alternative over medicalized hospital birth?” Forbes asks.
She believes more women than the 1 percent currently choosing homebirth fit into the low-risk category, and therefore more women should be choosing to give birth at home with a midwife. “I don’t think [mandatory licensing] is going to make a damn bit of difference in terms of safety,” Forbes says. She thinks mandatory licensing should be viewed in terms of setting training standards and increasing accountability for all midwives so women, such as Sheikh, are more protected.
Forbes says midwifery should be held to the same standards as other health practices.
“The government has a responsibility to oversee the practice of midwifery, just like they oversee the practice of medicine or getting a tattoo or getting your hair done,” Forbes says.
Sheikh agrees that the government needs to take action. “If the state is not going to protect you from untrained practitioners, how can you protect yourself?”
The death of Sheikh’s son could be the last push legislators need to finalize a new law. But barriers still prevent some midwives from obtaining a license, like the hefty licensing fee that recently increased from $630 per year to $1,800 per year.
“It’s a really significant problem,” Forbes says. “At $1,800 it’s really cost prohibitive for some midwives.”
Forbes is able to charge $3,300 per birth and performs about thirty births per year. Lane County has one of the highest planned homebirth rates in the state, with thirty-eight this year according to the Midwives Alliance of North America.
Cheyney is concerned for many midwives, including those with fewer client bases such as student midwives who are just starting out, midwives who work in rural towns, and midwives who work with under-served populations. If those midwives can’t afford a license under a new law, they would be forced to give up their practice.
“Would that mean that those communities then have no one to serve them? That seems like a problem,” Cheyney says. “I have always been a fan of bringing the cost down and giving an incentive to midwives to license.”
Greenlick is also aware of the issue and says he hopes to reduce the cost of a license and possibly wave the fee for the first year if his bill passes.
Obtaining a license gives midwives the ability to legally carry medications such as anesthetics and antihemorrhagics, a drug that controls bleeding. Cheyney says she is more comfortable attending a birth with those medications.
Among framed art pieces and sculptures, the workspace of Macrorie’s workspace reveals subtle hints of a doctor’s office. Macrorie works with Modern Midwifery Care.
While many unlicensed midwives choose to use herbal remedies in place of medicine, Viles says medication makes the birthing process much safer.
However, Cheyney argues that the intent of voluntary law is to protect those midwives who want to practice traditional midwifery for cultural or philosophical reasons. “I have less sympathy for a midwife who wants to practice like a licensed midwife but doesn’t want to pay to get the license,” Cheyney says.
Cheyney wants to maintain protection for traditional midwives regardless of licensing laws. She suggests allowing midwives to apply for exemption from mandatory licensure to preserve those traditions. “I think it’s a travesty around the world that Western-style obstetrics have come in and annihilated long traditions of traditional midwives,” Cheyney says.
Tradition holds a different meaning for Eugene midwife Amanda Moore, who says the license training requirements disregard the traditional learning aspects of midwifery.
“Midwifery is something that is passed down. You gain experience by seeing things happen over and over again,” Moore says. “It is not textbook. It is not something you learn at school; it’s [a] midwife teaching a midwife.”
The majority of midwives who choose to serve the mainstream population may be forced to adapt to modern changes in their practice. “Midwifery has always changed and morphed and evolved to fit the community and the culture that it’s working in,” Cheyney says.
Midwife Macrorie examines her patient at a prenatal session.
Despite the high costs of acquiring a license, midwives covet the long-term economic and security benefits that come with credentials, such as the ability to serve women who rely on the Oregon Health Plan. “It opens the door to more women who would never be able to pay out of pocket,” Forbes says.
Even midwives who don’t agree with licensing are making the shift to secure their business. Moore just received her license in August, after practicing the trade for five years. “I could serve more people,” Moore says.
And an increasing number of mainstream women are choosing to eschew hospital sheets and epidurals for the comfort of birthing in their own home. Many mainstream women feel more confident hiring a midwife that carries state-recognized credentials and can access medical care if it becomes necessary. “It’s not just radical women choosing to have radical births anymore,” Moore says.
When the time comes, Shepard plans to have her baby on a couch in her Oakridge, Oregon, home. She wants her husband to be there for support and hopes her three-year-old son will get to be a part of the process. There are only two months left until the baby comes, but Shepard feels confident and ready with Viles by her side.
At a prenatal appointment on a Tuesday afternoon Shepard lies down atop a pink duvet cover in a small bedroom in Viles’s home. The two women sit quietly as Viles runs a handheld Doppler over Shepard’s bulging tummy. A rhythmic pulse fills the room. Both women smile as they listen to the strong heartbeat. “It sounds like a girl,” Viles says.
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