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Free the Midwives

I am typing this with my one-and-a-half-week-old daughter sleeping on my chest. This morning she went to her first ever political action—a rally to support the Midwifery Modernization Act, which would remove the bizarre requirement that fully licensed midwives in New York state need a “written practice agreement” with an OB in order to practice.

Though Molly obviously had no idea of what was going on, the issue was directly relevant to her. She was born more than two weeks after her official due date. When she came out, however, all the physical signs said she was no post-due baby. She was on the small end of average, covered in vernix (a waxy moisturizing substance on babies’ skin that disappears if they’re overdue), and the placenta was totally healthy. In fact, a nurse at our pediatrician’s office said her skin actually reminds her of babies who are early. So much for official due dates. They are arbitrary—calculated based on first day of last period—and for someone like my wife, with long, irregular cycles, not very accurate.

And yet, in most obstetrical practices, and even many midwife practices that have to answer to an OB who controls their ability to practice through the WPA, we would have faced heavy pressure to induce labor earlier, effectively forcing our baby to be slightly premature. I know people whose doctors start talking about inductions before due dates are even reached. I have friends who actually lied about dates with their third kid in order to get a later official due date and not face those pressures any more.

See, induced labor, especially when the baby or mom really isn’t ready, carries increased risks of interventions and complications, especially a higher rate of c-sections and their accompanying risk of infection, injury, and breastfeeding issues. In fact, Amnesty International just released a report tying the United States’ abnormally high rate of c-section to our too-high and rising rate of maternal mortality. We’re talking safety here, folks, not just feel-good birth experiences.

C-sections are important for emergencies, but according to the World Health Organization, in a functioning maternal health care system, they should be about 10 percent of births, not our national rate of 32 percent, New York state’s rate of 34 percent, and certainly not Albany Medical Center’s astronomical 43 percent.

My first daughter attended the rally with us as well, wearing a sign that said “My midwives knew what they were doing.” In her case too, this was more than mere rhetoric. After months of being in a perfect head-down position, she took it in her head to flip breech the night before I went into labor. Had I been in an OB’s care, this would have been a recipe for an instant c-section, since somewhere along the line, medical schools stopped teaching doctors how to deliver breech babies. Instant, and totally unnecessary, since our midwives did know what to do. It was an uncomplicated, picture perfect vaginal delivery.

I know one person who refused a c-section that was being pushed on her because her baby was breech. Despite the stress of the situation, she delivered a perfectly healthy baby, quickly and easily. And the hospital, widely known as the most friendly of the region’s hospitals to the evidence-based midwifery model of care, refused to accept her as a patient for her third child. And people wonder why women turn to home birth. In cases like this, they are driven there. As more and more hospitals refuse to allow women to try for a vaginal birth after a c-section (something that is successful for 60–80 percent of women who are allowed to try it, and associated with better birth outcomes), that’s only going to get more true.

The Midwifery Modernization Act would help. Midwives are already independently licensed professionals in the state of New York. But parents don’t have sufficient access to them, because too few doctors have been willing or able (due to their own malpractice insurance) to sign these practice agreements. And why should they have that sort of control anyway? OBs are not the experts in normal birth. Midwives are. OBs are surgeons, trained to address complications and deal with high-risk pregnancies and births. They are two separate specialties, and they should be working collaboratively, not in a hierarchy. Midwives already collaborate with and make referrals to OBs when it is indicated, just like family physicians refer patients to specialists without the need for a contract with each specialist.

The midwife model of care has been shown time and again to result in better outcomes and fewer interventions for less cost for low-risk pregnancies. Given this, the practice agreement requirement has damaging consequences for maternal health care across the state. Women in rural areas far from hospitals don’t have access to care. Medicaid can’t save money by encouraging low-risk women to be seen by midwives. Parents’ abilities everywhere to make choices about their care based on research about outcomes is restricted. It’s high time to free the midwives.

—Miriam Axel-Lute

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