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Born free: midwives and the struggle for reproductive choice.

For three decades, American women have fought for reproductive freedom. That struggle culminated in the 1973 Roe vs. Wade decision, and continues to rage as pro-choice activists resist the encroachments of the newly conservative Supreme Court. For most women, the struggle for reproductive freedom has meant the hard-fought battle to win the right to choose not to reproduce. Yet there is another aspect of reproductive choice that is rarely mentioned--the right to give birth at home with a midwife. While the right to abort is constitutionally protected in America today, women who choose to carry their pregnancy to term are unable to choose where and with whom they wish to give birth.

Everyone knows that Abraham Lincoln was born in a log cabin, but few realize that home birth was considered the norm well into this century. In the mid-1930s Georgia had nearly four thousand practicing midwives. In 1945, Arkansas had 1403 midwives who attended at least 20% of births in the state. As late as the 1950s, the majority of babies born in New Mexico were born at home. Yet more recently, state after state has used restrictive laws or prohibitive licensing procedures to prevent direct-entry midwives from serving mothers. State legislatures and medical boards, in conjunction with the medical establishment, have consistently moved to foreclose the option of home-birthing with traditional midwives, despite the fact that midwifery has continued to demonstrate that it is safer and cheaper than conventional hospital birthing.

Midwifery is safe, effective, and cheap. So how do we get it? Midwifery itself is a movement in the process of definition, or redefinition. Midwives in many states are ambivalent about changes in their legal status. They fear that efforts to achieve recognition or licensure, rather than ambiguity, might ultimately lead to recognition on terms which are unacceptable, or licensure on terms which are unattainable. The Midwives Alliance of North America (MANA) is attempting to formulate a philosophy to guide its ongoing negotiations with the American College of Nurse Midwives about core competencies and training for midwifery as a profession. There is apprehension that to attain professional status by sacrificing the tradition of apprentice training for direct-entry midwives would be a Pyrrhic victory. It is clear that regulation and licensing, if it is to exist, must come from the profession itself, not be imposed from outside. That licensing must reaffirm, not displace, traditional apprenticeship. Our society is obsessed with formal training as the criterion for expertise. One merely has to look at Harvard to realize that it is not the only or even the best solution.

Midwifery has met a great deal of opposition from state legislatures and the medical establishment. Increasingly, the medical establishment has asserted its primacy over pregnancy and parturition, co-opting the role of the community-based "granny" midwife. This assertion was one of both legitimacy and legality: Obstetricians convinced both the consumers and the legislatures that a hospital setting was necessary to reduce infant mortality and ensure adequate standards of practice. Many states literally allowed midwifery to die off, simply by refusing to license any new midwives.

Despite these pressures, women, both poor and affluent, traditional and avant-garde, proletarian and yuppie, still desire to have their babies in their own homes, and midwives still deliver babies in homes across America. In some states they can do so only covertly. State regulatory efforts present a national patchwork of recognition and prohibition, encouragement and inconvenience. As of 1990, there were 9 states in which direct-entry midwifery was clearly legal. In six others, it is legal by statutory inference or judicial interpretation. Thirteen states have neither legally defined nor legally prohibited midwifery, and in most of those states direct-entry midwifery is openly practiced. Of the 23 remaining states (and the District of Columbia), 9 clearly prohibit midwifery, and an additional five have functionally prohibited its practice. Nine states hang in the balance: in most of these, midwifery is legal by statute, but licensure is unavailable, unattainable, or overly restrictive. In some, licensure requires graduation from accredited training programs, none of which are provided. These nine states are clearly ripe for change, but the political climate varies: some are on the verge of new and improved legislation, others at risk of total prohibition.

Proponents of home-birth and direct-entry midwives are not lobbying merely for toleration: their long-range goal is to win the recognition that pregnancy and birth are normal conditions, not pathologies, that intervention by institutional medicine should be the exception not the norm. Obviously, that goal must be a distant one: currently only about 1 to 2% of all births nationally occur in the home by plan.

In the short-run, midwives and their supporters have been striving to build a cohesive professional organization, raise consumer consciousness, create political coalitions, and foster rapport with members of the medical profession. MANA celebrated its 10th anniversary in 1992. There are also organizations in virtually every state which have been working hard to preserve midwifery where recognized and pass legislation leading to recognition where it is not. The biggest obstacle remains the medical profession itself. The official position of the American College of Obstetricians and Gynecologists (ACOG) advocates the suppression of and active opposition to direct-entry midwifery. The head of AGOC once declared, "Home birth is child abuse." The aura of authority and legitimacy possessed by physicians provides them a respected voice, though many physicians and obstetricians are ignorant of the actual practices, capabilities, and effectiveness of midwives. State Boards of Examination are generally dominated by physicians. Hostility toward midwives has a powerful chilling effect, for midwives and their clients need and want physician back-up in case a crisis develops.

It is little wonder that conventional medical professionals react so viscerally to the challenge posed by direct-entry midwives, for that challenge is nothing less than an effort to redefine the scope of "medicine" itself. In every state it is at least a misdemeanor, usually a felony, to practice medicine without a license. Generally, statutes emphasize disease or trauma in the definition of "medicine," a categorization that clearly excludes pregnancy from its expanse; in Maine, for example, the state attorney general has opined just that. In the ongoing Illinois court proceedings involving midwife Betty Peckmann, the judge stated that "Consumers do not have a right to choose their health care provider," but advised that the state amend its definition of medicine to include "conditions" as well as ailments, which they eventually did.

Midwives are persecuted and prosecuted around the nation no place more than in California. The Medical Board of California has rigorously investigated and prosecuted direct-entry midwives, despite failure to turn up evidence that they have been responsible for any maternal or infant fatalities. Instruction in lay midwifery is itself prosecutable as aiding and abetting a felony. This is the same Medical Board, incidentally, which allowed Dr. Milos Kivana to continue to practice for eight years after his first involvement in infant death. He was convicted in 1989 of nine counts of second-degree murder.

Americans have been brought to believe that aseptic, drugged-out, high-tech, hospital birth is the norm; in all probability most of us will continue to believe it. But there is an alternative, an alternative that supports the idea that birth is essentially a human event, not a medical event. The debate over programs like WIC and pre-schooling indicates a growing consensus from government, educators, and business that long-term success is dependent on getting the right start. But life does not begin at age four, it begins at birth. The choices that parents make in the months before and after birth are pivotal ones in the life of the child and the cohesion of the family. That this choice should be dictated to us by the state rather than our conscience is an unfortunate but unnecessary reality. We live in a nation conceived in liberty: it is a pity that we are not all born that way.

Yellow Light Breen, the author and his five siblings were all born at home. His mother, Jill, has been a midwife for fifteen years, and served as the New England Regional Rep. on the MANA Executive Board from 1988-1991.
COPYRIGHT 1993 Association of Labor Assistants & Childbirth Educators
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Breen, Yellow Light
Publication:Special Delivery
Date:Mar 22, 1993
Previous Article:Should you have a midwife deliver your baby?
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