By John Murawski
The News & Observer (Raleigh, N.C.)
WWR Article Summary (tl;dr) As John Murawski reports, “an underground culture of home births, assisted by illegal midwives, thrives in North Carolina among women who seek an alternative to what they perceive as a sterile, mechanized and unhealthy childbirth industry controlled by doctors and hospitals.”
The News & Observer (Raleigh, N.C.)
Ashley Kopp-Houston was in her 81st hour of labor, too weak to walk on her own, when her midwife insisted it was time to go to the hospital.
Kopp-Houston was having her first baby and had wanted a natural home birth: without medications, without doctors, without electronic monitors. But three days into labor, the baby wasn’t making progress, and her midwife was increasingly concerned. She convinced Kopp-Houston to go to UNC Hospitals in Chapel Hill, and accompanied her undercover — as her doula — because she was practicing midwifery illegally in North Carolina.
The next day, Kopp-Houston, at age 38, gave birth to a healthy girl weighing 7 pounds, 14 ounces.
To this day, she won’t name her midwife, even though she says the woman has retired.
North Carolina is one of six states that forbids certified professional midwives from delivering babies, and providing prenatal exams and other maternal care, according to the North American Registry of Midwives.
The ban, in force since the state established regulations for midwifery in 1983, has been occasionally enforced by court orders against certified professional midwives who have been caught practicing without a license.
The state does allow nurse midwives, who practice under the auspices of a doctor, but because few nurse midwives perform home births, the market for certified professional midwives has not entirely disappeared.
“It just forces things further underground,” said Nancy Koerber, a certified professional midwife who now works in administration as executive director of WNC Birth Center in Asheville, in a phone interview. “It makes people more rebellious.”
Indeed, an underground culture of home births, assisted by illegal midwives, thrives in North Carolina among women who seek an alternative to what they perceive as a sterile, mechanized and unhealthy childbirth industry controlled by doctors and hospitals.
The number of home births in North Carolina has doubled over the past two decades, exceeding 600 every year since 2010, even as all births statewide have stayed relatively flat.
A practice that a century ago was associated with poverty is now sought out by women, often college educated and able to pay in cash. That last is an important point, since a typical certified professional midwife charges between $2,700 and $3,200, based on interviews, and her services are not covered by health insurance. Blood tests, urine tests or ultrasounds all cost extra.
The renewed popularity of midwives has led hospitals across the state to add nurse midwives to their staffs, as The News & Observer has previously reported. And now, the prospects for legalizing certified professional midwives in North Carolina appear brighter, as these midwives have agreed to expand their professional credentials.
‘I don’t want to be treated as a criminal’
“To be laying in my bed, in my home, holding my daughter, an hour after I birthed her, in my bathtub, in my home — I wouldn’t have traded it for anything,” Crissy Rollins, 40, a licensed massage and bodywork therapist who home-birthed in Garner in 2013, said in an interview last year.
“I helped pull her out and lift her up and immediately start nursing and holding her, and she was in my arms a full hour,” Rollins said.
The certified professional midwife who assisted Rollins was Jamie Perkins, who was forced out of business. Just months after delivering Rollins’ daughter, Perkins said she received a home visit from two N.C. Board of Nursing inspectors while providing pre-natal services to another client. Perkins was slapped with a cease-and-desist order and soon after signed a consent form, agreeing to stop practicing midwifery without a license, which is a misdemeanor under state law.
Perkins, who is also a trained emergency medical technician and teaches CPR classes, agreed to be named in this article because her disciplinary action is a matter of public record and she says she no longer practices midwifery.
“I don’t want to be treated as a criminal; I want to be integrated into the [health care] system,” said Perkins, at her home in Princeton, an hour east of Raleigh. “You can regulate me all you want, just let me work.
“It’s my calling and a lot of my identity, and I’ve not had that for so long.”
Certified professional midwives, who spoke with The News & Observer for this article said they have long stopped performing illegal home deliveries, but they said they know of plenty of others who deliver “under the radar.”
Obstacles to working legally
Currently, to become a certified professional midwife, a student must learn assigned study material, apprentice with an experienced midwife and pass a certification exam administered by the North American Registry of Midwives, or NARM.
A certified professional midwife typically studies at least three years and participates in at least 55 deliveries as an observer, assistant and primary caretaker before becoming certified, according to NARM. But they aren’t required to have nursing degrees or college diplomas.
That will change in 2020 under a deal struck between national organizations that represent obstetricians, gynecologists and midwives with nursing degrees. Certified professional midwives will have to graduate from one of the country’s 11 accredited midwifery schools, or complete 50 hours of additional training in emergency procedures and other skills, to hold themselves out as certified professional midwives.
The American College of Obstetricians and Gynecologists, or ACOG, estimates that as many as two-thirds of the nation’s 2,300 certified professional midwives lack the level of training that the 2020 standards require.
Charlotte obstetrician John Allbert, a past president of the N.C. OB-GYN Society, said the 2020 standards represent “a pretty extensive education” that could tip the scale in favor of letting certified professional midwife work legally in North Carolina.
“If they met the criteria, then we could discuss how we could integrate them into the system and maintain the safety of women and babies in North Carolina,” said Allbert, who also is active in ACOG.
Any effort would require the state legislature to act. Bills to legalize certified professional midwives are introduced in the North Carolina General Assembly year after year, but don’t get very far. Former state Sen. Thom Goolsby, whose wife had two home births, sponsored legislation, and after leaving the legislature in 2014, lobbied for N.C. Friends of Midwives in 2015 and 2016.
But state Rep. Donny Lambeth, a Republican from Winston-Salem, said he has spoken to obstetricians and gynecologists who are increasingly open to including midwives in the health care system. These doctors know there is a chronic shortage of doctors in the state’s rural counties, he said, and added that low Medicaid reimbursements are forcing doctors to look for ways to be more efficient.
Lambeth has four decades of experience in health care and was formerly CEO of Wake Forest Baptist Medical Center in Winston-Salem. The chairman of two health care committees in the state House of Representatives in the last legislative session, Lambeth said that properly trained midwives, combined with telemedicine, could provide much needed services in remote areas that lack access to prenatal health care and have high infant mortality rates.
Still, any legislation to legalize certified professional midwives in North Carolina would likely limit them to caring for women with low-risk pregnancies and would impose other stringent restrictions.
Even with that backing and those limitations, certified professional midwives still face obstacles to working legally. A major concern for doctors is that these midwives deliver in private homes, and home births — though legal — are viewed as unsafe by many medical professionals, because unanticipated complications outside a hospital can put a newborn at risk of death or brain damage.
ACOG’s official position, reiterated in a 2017 statement, is that the risk of a baby dying during or after childbirth is more than two times higher in a home birth than in a hospital.
Thus for some North Carolina doctors, endorsing certified professional midwives is tantamount to endorsing home births.
“That’s one of the concerns: If you legitimize it, home births would go up and more women may be lured into it,” Allbert said. “That is the past resistance: that we don’t want to validate poorly or inadequately trained individuals doing deliveries. We do not want to promote home births.”
Kellett Letson, the current president of the N.C. OB-GYN Society, remains unmoved by the arguments of certified professional midwives. He said that even with the stricter training requirements, they lack the medical expertise of midwives who hold nursing degrees.
“We have a model that works,” said Letson, an Asheville obstetrician. “I have seen many women shift from a low-risk to a high-risk pregnancy, and in those moments having the right kind of training and medical experience is very, very important. And it’s the level of care women in North Carolina deserve.”
Challenges of delivering at home
Home births, of course, were once all most women in rural North Carolina knew. In 1925, North Carolina led the nation with 6,500 midwives, who delivered one-third of the babies born in the state that year; of those births, 80 percent were African-American children, according to a 1992 article by East Carolina University anthropologist Holly Matthews.
Currently there are 42 certified professional midwives with North Carolina addresses on the rolls maintained by the North American Registry of Midwives. It’s not clear how many of them are illegally active in home births, because some of them could live in North Carolina and deliver babies in Virginia, Tennessee or South Carolina, said Ida Darragh, the organization’s executive director, in an email. According to the national registry, seven new midwife certifications have been issued in North Carolina in the past five years.
To find a midwife who will deliver a home birth, many pregnant women turn to the tightly-knit home birth community, where the midwives are known and protected.
For, Julie Feickert, a technology entrepreneur in robotics education in Raleigh with an MBA and a masters in science and business strategy, this statewide speakeasy network involved getting vetted by email before the midwife would agree to meet with her. And Feickert, who had previously home-birthed three kids in Oregon, had to agree she would never disclose the name of the midwife who illegally delivered her son at her Raleigh home in July 2017.
“I realized I would as safe or safer by giving birth at home,” Feickert said an interview. “I knew if my stress level was high, in an unfamiliar hospital environment, if I had to regularly advocate for myself and my baby, I wouldn’t be able to manage my pain.”
Ashley Kopp-Houston, who had used a midwife with her first pregnancy, also had trouble finding a midwife when she became pregnant with her second child.
Her original midwife had retired and because she refuses to take medication for a blood clotting disorder, Kopp-Houston had “risked out” of a home birth and could not find a certified professional midwife or a legal nurse midwife to deliver the baby anywhere — at home, in a birth center, or in a hospital.
Her delivery did, in fact, turn into a scene of “panic and chaos,” she said.
Last October, when she was 41 1/2 weeks pregnant, she went to UNC Hospitals, for a planned natural birth, without medication, and with the hope that her husband could “catch” the baby as the child emerged.
But the baby, weighing nearly 10 pounds, developed shoulder dystocia — a complication in which the infant becomes stuck in the birth canal — requiring emergency medical intervention. Kopp-Houston said the doctor on call was supportive and “wonderful.”
“He did what he had to do,” she said. “I’m completely fine with that.”
Which is safer: home or hospital?
In states where they’re legal, certified professional midwives can assist during home births and they can also work at freestanding natural birth centers. Certified professional midwives say that home births are a cheaper, simpler — and safer — option than hospitals, when all factors are taken into account, a view shared by Audrey Trepiccione, a Garner certified professional midwife who is under a 2012 cease-and-desist order.
“At home, let’s face it: The challenge is managing pain,” Trepiccione said. “If she can relax, it will be much quicker.”
Hospitals mean more intervention, more drugs, more surgery and more mistakes, Trepiccione said, echoing the belief of many certified professional midwives. Hospitals are a pathway to an unacceptably high c-section rate, said Trepiccione, who serves as vice-president of N.C. Friends of Midwives, the state advocacy group for the legalization of certified professional midwives .
Midwives frequently point to the damning statistic that in the United States, nearly 1 of 3 babies is delivered surgically, a rate deemed excessive by ACOG, the U.S. Department of Health and Human Services and the World Health Organization.
A common argument in favor of legalizing traditional midwives is that they would coordinate with doctors and hospitals if pregnancy complications arise, instead of delaying medical care for fear of getting caught.
Midwife acceptance by the health care system is seen as a proxy for newborn safety by midwife advocates. A February 2018 study in the online peer-reviewed journal PLOS One gave North Carolina the lowest score in the nation in this area, saying a low score reflects low integration of midwives and health care providers.
The question of home birth safety remains a matter of dispute, because safety is not easy to measure. Studies cited by certified professional midwives conclude that the rate of newborn deaths and complications is comparable between home births and hospital births.
But Barbara Levy, ACOG’s vice president of health policy, said the comparisons can be misleading. For example, if a home birth goes awry and the newborn is transferred to a hospital emergency room and dies there, it’s likely to be counted as a hospital death, not a home birth death. Additionally, newborn deaths at hospitals typically include high-risk pregnancies — women past term, obese women, women with previous c-sections, and women with diabetes and other complications — which are rejected as candidates for home births.
The New England Journal of Medicine ran a study in 2015 adjusting for some of those factors. That study found the death rate in an out-of-hospital birth compared to a hospital birth was 3.9 deaths per 1,000 versus 1.8 deaths per thousand, or more than twice as high. The study was based on 2012-2013 Oregon data using newly revised Oregon birth certificates that distinguished between planned hospital births and unplanned out-of-hospital births.
Raw data show that the newborn death rate is roughly twice as high in home births compared to hospital births in North Carolina. The state reported 11 fetal deaths during home deliveries in 2017, 12 in 2016 and 10 in 2015, which is more than 1.5 percent of all home births each year. In the same three years, the number of fetal deaths during delivery in hospitals was 792, 808 and 892, less than 1 percent of all hospital births, according to records at the N.C. Department of Health and Human Services.
Midwifery care can go terribly wrong, as evidenced by a 2012 murder charge against midwife Tina Louise Bailey in western North Carolina. Bailey assured the parents that the presence of meconium was nothing to fret about, just days before the baby was stillborn. Bailey pleaded to lesser charges in 2015 after spending 298 days behind bars, according to news coverage and information from the Buncombe County district attorney’s office.
However, Bailey was not a certified professional midwife as recognized by the national registry; she was a graduate of The Matrona, an unaccredited school in Asheville. If certified professional midwives were legalized, midwives like Bailey would remain illegal in North Carolina, unless they obtained additional credentials.
And with regulation, midwifery advocates say, a prospective mom would be able to check an online state registry for valid licenses and any disciplinary actions against certified professional midwives, just as they can currently check for certified nurse midwives.
“Here’s a group that wants to be regulated,” Koerber said.
