By Cassidy Swanson
The advent of birth in hospitals quickly led to the politicization of childbirth. When physicians began attending births in the late 18th century, they began crusades against midwives, admonishing them as ignorant, dangerous, relics of the old country. Hospital births became increasingly medical in nature, with heavy usage of instruments, surgery and drugs.
But factions of the natural birth movement aren’t without an agenda and controversy. Fervent advocates of natural childbirth and parenting can be quick to judge the use of medicine in birth. Direct entry midwives (also known as DEMs or “lay midwives,” though this term is often considered pejorative) have an “a-legal” status in Massachusetts, with no official training or standards. Some (but certainly not all) midwives demonize ob-gyns and their methods of assisting women in labor and delivery. The same is true of many doctors toward midwifery.
Legislation would protect CPMs
Audra Karp is a certified professional midwife, or CPM, based out of Roslindale who attends home births. She also spends time at the State House, advocating for CPMs. She is the chair of the legislative committee for House Bill 3971, which would require all out-of-hospital midwives in the Commonwealth to be registered CPMs, making direct entry midwifery illegal.
“Around half of the country is regulating…out-of-hospital midwives, CPMs,” Karp said. “The politics have shifted nationally.”
House Bill 3971 would set up a committee under the state Board of Registration in Medicine to regulate CPMs. Not all DEMs are thrilled about this prospect.
“With regulation comes regulation,” Karp said of the bill. “People want to practice the way they want to practice. They don’t want anyone telling them what to do. There’s a lot of fear around it.”
But Karp believes these regulations are inevitable and ultimately positive.
“It’s a nationwide trend,” she said. “Massachusetts is not an island, and eventually, there will be legislation. It might be another 10 years, which will break my heart, but it’ll happen.”
Karp added that in states where midwifery is regulated, out-of-hospital birth rates increase. She also said the state legislation would provide “consumer protection” for patients.
“[DEMs] are deciding when they call themselves midwives,” she said. “You could call yourself a midwife in Massachusetts and start attending births.”
Water birth controversial, but proponents see many benefits
Another politically charged issue is water birth. The American College of Obstetricians and Gynecologists recently issued a committee opinion denouncing water birth, stating, “the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent.” ACOG’s opinion has been met with opposition from water birth proponents.
Joyce Kimball is a CPM, birth doula, childbirth educator, and sole proprietor of Birth Services, based out of Worcester. Water birth is one of the methods she uses in her practice, allowing women to labor and deliver in water.
“I do not believe that water birth is unsafe,” said Kimball, who has attended approximately 100 water births, all of which she says were successful. “I’ve never seen a baby swallow water or be harmed by being born in water.”
One of the most common concerns about water birth is that the baby will breathe in water and drown. Not only has Kimball never witnessed this, she says the chances of it happening are slim to none because of how infants breathe in the first moments of life.
“The theory is that the baby doesn’t breathe instantaneously until it hits cold air,” she said. “We keep the tub temp 98.6 [degrees Fahrenheit]-ish…and they don’t [breathe] until they hit this cold air and we lift them up and out of the water.”
“There are babies that are born on land that swallow their own amniotic fluid, or swallow mom’s blood, or do meconium aspiration,” Kimball added. “I see more respiratory issues with land babies that I do with water birth babies.”
Divya Kumar, of Jamaica Plain, works at the Southern Jamaica Plain Health Center as a post-partum doula and lactation counselor, and also teaches prenatal and postpartum classes at Mama & Me in JP. She also disagrees with the idea that water birth is never a viable option.
“How can you say that water birth is unconditionally unsafe?” Kumar said. “That doesn’t make any sense. How can that be true all the time?”
Toni Golen, M.D., is an ob-gyn at Beth Israel Deaconess Medical Center in Boston said that while babies can be and are delivered safely in water, the science needed for the medical community to officially endorse water birth in the second stage of labor just isn’t there.
“The reason is because it’s very difficult to do a high-quality scientific study to study the safety of such a thing,” she said. “If you have a very healthy baby who is doing fine, placenta’s working fine, there’s no other complications of labor, and the baby’s born under water, and someone quickly attends to that baby, and within seconds brings the baby out from underneath the water and into the air — it’s likely the baby’s going to be fine. However, if you’ve got a baby who’s slightly compromised — a baby who doesn’t necessarily have the energy to hold its breath for those first handful of seconds…then you put that baby at risk for aspiration.”
Criticizing the hospital care model
Just as doctors question the home birth methods used by CPMs, such as water birth, home birth advocates sometimes disagree with the care models used by ob-gyns in hospitals. Sarah McRell is a birth doula — a non-medical person who attends births, to both assure the mother’s wishes are respected by hospital staff, and to offer physical and emotional support to the mother and her partner — a labor and deliver nurse at UMass Memorial Medical Center in Worcester, and an aspiring midwife. In working with doctors as a doula, she has witnessed events that have led her to believe that midwives provide a more peaceful, positive birth experience.
“Midwives are more holistic, so they’re looking at the woman’s emotional health and supporting them in that sense, and supporting their partners,” she said. “It’s not [in an OB’s] nature to want to hang out in someone’s room and really be there to support them.”
Hospitals also have residents attend births, and McRell says their inexperience can make for a less-than-ideal birth experience.
“Some of them are better than others, but they’re kind of taught the same thing [as more experienced doctors] — they’re given a full load of patients, and so they’re in and out, ‘Can I check your cervix?'” she said. “It’s sad to me, because sometimes they don’t even ask permission. They just come in and get their tests done and leave. And I’m like, ‘It is a person, not just a cervix.'”
Like home birth, hospital birth is not without politics. Gene Declercq, Ph.D., is a professor of community health sciences and maternal health at the Boston University School of Public Health. Declercq, of North Andover, is a political scientist as well as a licensed childbirth educator. He was a technical advisor to the documentary The Business of Being Born, produced by Ricki Lake, and was also a producer and presenter of “Birth by the Numbers,” a 20-minute video that examines outcomes associated with current U.S. birth practices. Declercq also coauthored “Listening to Mothers,” a national study of women’s childbearing experiences.
“Some of it is sort of ‘big P’ politics, but a lot of it is ‘small P’ politics, the sort of internal hospital fights,” Declercq said of the findings of his research. “One of the things that they’ve pushed in a lot of states is for certified nurse midwives – who are generally more acceptable, because they’re nurses – in the medical community, to have more independence in practice, like a lot of nurse practitioners do.”
Declercq said that while these types of laws are usually passed, hospital bureaucracies can stop them from taking effect.
“As with so many other political things, they can find a hundred reasons to make it difficult, to find other explanations why they’re not doing it right away,” he said. “Those are political battles, and part of why midwives were driven out of the United States a hundred years ago was because they were so lousy at politics. They got beaten politically. They’re way more savvy now, but it’s an uphill battle.”
Striving toward a “middle ground” in birth politics
Kumar said that much of the birth politics we see today are a product of the “litigious culture” of the United States, particularly in obstetrics. She also believes the medical community and natural birth advocates need to learn to compromise.
“I think that we are still figuring out, in this country, how to find a middle ground,” Kumar said. “You have these OBs who are like, ‘No, you can never birth in the water, no, you can never do this, no, the baby’s going to die if you look at the wall too long,’ and they’re just completely freaked out. And then you have these natural people who are like, ‘Birth is always normal, natural, healthy and safe.’ The extremes are sort of screaming at each other, and the middle is getting lost.”