Midwives Give Birth to Lawsuits, Criminal Charges

Thousands of American women give birth at home each year aided by unlicensed midwives whose assistance violates state laws governing medical practice.

In the last decade, more than 300 midwives have been disciplined by state medical boards, sued or charged with committing crimes. Many have been forced to give up their practices.

About 50 have been sentenced to prison -- mostly women who charge small fees to assist at home births.

Most cases, court records show, begin when a baby born at home dies or is disabled after complications during delivery. Charges against the midwives range from practicing medicine without a license to child endangerment. Sometimes the parents are also charged.

Midwife advocates say the prosecutions are part of a systematic attack on home-birthing. Most of the medical establishment opposes the practice, and insurance companies often refuse to cover patients and professionals who participate in it.

The prosecutions are a witch-hunt prompted by a “struggle for control of maternity services, the key underlying issues being money, power, sex and choice,” said neonatologist Dr. Marsden Wagner, a midwifery advocate and neonatologist who worked for the World Health Organization for 14 years.

The American College of Obstetricians and Gynecologists disagrees, saying the issue is safety. Unpredictable hazards to both mother and child “require standards of safety which are provided in the hospital setting and cannot be matched in the home,” academy policy states.

Prosecutors who handle the cases say there is no attempt to force women to accept hospital care. They say they are merely enforcing the law.

“The state has an interest in making sure the mother and baby are safe,” said prosecutor Joan Risse of Sonoma County, Calif., who brought child endangerment charges against a midwife in a pending case involving a brain-damaged infant.

No organization keeps track of midwife prosecutions; the Associated Press compiled the numbers by examining court records, news reports and data from organizations representing midwives.

Controversy over the prosecutions raises anew fundamental questions that policy makers, medical professionals and families have debated for years:

Is giving birth a natural process or medical procedure? What rights do women have in choosing where they give birth and who assists them? And when does a woman’s choice become the government’s business?

Some midwifery advocates say the forces arrayed against home birth are succeeding only in driving the practice underground -- making it more dangerous than it needs to be.

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About 1% of the 4 million babies born each year in the United States are delivered at home, according to the National Center for Health Statistics. But that’s still 40,000 home births a year.

Women choose home birth for many reasons: They want to avoid anesthesia or Caesarean sections; they favor home birth for religious reasons, or they simply view birth as a natural process best done at home.

“When a baby is born, the universe is opening up to let a new soul into the world and everybody feels that new energy,” said Pamela Hunt, a Summertown, Tenn., midwife who had her six children at home. “That energy is allowed to flow easier at home.”

Bettina Zastrow of Nyack, N.Y., had her first baby, Karl, in 1999 in a hospital and her second son, Wilhelm, slightly more than a year ago in her bedroom.

“The big difference was that at home, it just seemed like a normal part of life instead of a medical crisis,” she said.

Nearly all home births are attended by midwives, who come in two varieties.

Certified nurse midwives have medical training; all states license them, although with varying requirements on insurance and obstetrician backups.

There are about 8,500 certified nurse midwives in the United States, mostly in hospitals and clinics, according to the American College of Nurse-Midwives in Washington, D.C.

So-called direct-entry or lay midwives learn through apprenticeships and non-medical training. Only 19 states issue licenses or permits for them; nine states and the District of Columbia forbid them to practice. In the other states, regulations are evolving or nonexistent. There may be as many as 2,000 direct-entry midwives, according to the Lilburn, Ga.-based Midwives Alliance of North America. The exact number is unknown because in many states, they are practicing illegally.

Certified nurse midwives attend only 3,000 of the country’s 40,000 annual home births, according to the National Center for Health Statistics. Nearly all the rest are attended by direct-entry midwives, many in violation of state requirements.

“Being a direct-entry midwife is actually a radical and political thing to do,” said Susan Moray, a midwife and spokeswoman for the Midwives Alliance.

The number of home births attended by certified nurse midwives is not only small but believed to be declining -- largely because of insurance.

Most states require that certified nurse midwives have obstetricians on call to back them up when complications arise. However, few obstetricians provide this service because doing so results in astronomical malpractice insurance premiums or cancellation of their policies, according to officials at the American College of Nurse Midwives.

Even when certified nurse midwives offer home births with doctors backing them, women’s own medical insurance usually won’t cover home births. Larry Akey, spokesman for the Washington, D.C.-based Health Insurance Assn. of America, said insurers believe that mothers and babies are safer in hospitals.

Furthermore, Akey said, lawmakers in many states have made it impossible for midwives not under a doctor’s supervision to bill for maternity services.

“That’s the real stickler even for insurers who would like to support this,” he said.

All of this, midwifery advocates say, leads many women who want to give birth at home to turn to unlicensed direct-entry midwives, making home births more risky.

Dr. Thomas Purdon, former president of the American College of Obstetricians and Gynecologists, said unlicensed midwives who assist with home births are “unethical, immoral and, in cases where babies die, deserve to be criminally prosecuted.”

The group considers home births so risky that it discourages them even with a certified midwife present.

What are the risks of home birth compared to hospital delivery?

More than 50 studies since the mid-1980s have looked at the question, and many concluded that home births involving a low-risk mother, good prenatal care, a trained delivery assistant and a nearby hospital are as safe as hospital births. Some studies, however, contradict this.

Dr. Michael Speer of Baylor College of Medicine, who chairs the American Academy of Pediatrics’ perinatal section, says he doesn’t have a problem with home births as long as proper procedures are followed, including having someone available to quickly resuscitate a baby. However, he says, midwives should be held as accountable as doctors and face legal consequences for mistakes in judgment.

Home-birth advocates offer an array of views. Some would like to see the practice unregulated. But Eric Dyson, American College of Nurse Midwives spokesman, says medical complications and occasional prosecutions could be largely avoided if all midwives were trained and certified.

Prosecutors say the last thing they want to do is get involved in the debate, but they must enforce laws.

Earlier this year in Mansfield, Mo., unlicensed, direct-entry midwife Victoria Kocher was charged with child endangerment after attending the birth of Ethan Criswell, who died a week after he was born at home seven weeks premature. The infant’s parents, William and Cheryl Criswell, were charged with involuntary manslaughter.

Authorities said Ethan, who weighed 3 pounds at birth, suffered from multiple birth defects, but no one took the child to see a doctor until the day he died.

Larry Tyrrell, prosecutor in the pending case, said he believes that the Criswells were criminally negligent and “failed to provide medical care, nourishment and liquid to sustain life.”

Kocher “created a substantial risk by not advising the parents to seek medical attention for the child,” court documents charge.

In San Luis Obispo, Abigail Odam, a direct-entry midwife, was charged in 1997 after a baby she delivered was not breathing at birth and was later diagnosed with cerebral palsy.

She was convicted of six felonies, including practicing medicine without a license and child endangerment, and spent two years in state prison. After her release, she vowed never go back to assisting childbirth.

“I wouldn’t practice midwifery again in California or the United States because we aren’t in a culture of accepting responsibility,” she said. “We’re in a culture where if something goes wrong, it’s someone’s fault.”

Midwife advocates argue that prosecutions are not just about promoting responsibility and safety. Many midwives who have been criminally charged are high-profile home-birth advocates who have trained other midwives, said Katherine Prown, an advocate for midwives facing legal challenges.

“Prosecutors and state medical boards are trying to send a message,” said Prown, a Wisconsin mother of three children, all born at home. “I think this comes down to an issue of authority. Who has the authority to define how birth is managed?”