The Power of Midwifery
at Home and Around the World

By Cindy Hill

Vermont’s midwives celebrate the joys of helping women transition to the role of mother. “It’s a total honor to be part of this time in a family’s life,” says Marti Churchill, a certified nurse midwife at Fletcher Allen Health Care in Burlington. “It’s very, very special. It never loses its magic.”

This year is the 20^th anniversary of the International Day of the Midwife, celebrated around the world on May 5. But Vermont’s midwives are also girding themselves for the many continuing challenges of remaining a vital facet of safe birthing options for Vermont mothers—and for mothers in need around the globe.

Midwifery in Vt. Hospitals

The practice of midwifery within FAHC was established in 1968 by Claire Linthilac, who had served as a midwife in China. Five of Vermont’s 50 Certified Nurse Midwives, or CNMs—nurses with advanced training in midwifery—engage in a broad practice at FAHC.

<Well-woman OB/GYN, family planning and obstetrics, antepartum and birth. We do all of it,” Churchill says. A CNM is the first contact a pregnant woman has with the hospital. “If a woman comes to us they are guaranteed a midwife at their birth,” Churchill says. “They see a primary midwife for continuity of care, then later in pregnancy rotate through so they get to know all of us. We cover in 24-hour call shifts. The day after labor, we are always off, and a fresh midwife who has slept all night is there to attend to the moms.”

Unlike CNMs, nurses in maternity practice are assigned to shift work, and take direction from physicians who are OB/GYNs. “The nurses are wonderful and work side by side with us, but we function like a doctor for labor and delivery. We just can’t do surgery,” Churchill explains. “We sit and do labor support for patients, we honor the gentle normal process. We aren’t as tied to the clock as the doctors are. We don’t use medical intervention unless it’s needed or medically indicated. We tend to be non-interventionists at heart.”

No intervention is needed for the majority of women with normal pregnancies. “Birth is not an illness, and physicians are trained to tend to people with illness. Ninety percent of all women have normal, healthy pregnancies. We educate them to make good decisions on what’s right for her and her family. We don’t impose, telling her what to do. We help her discern what’s best for her,” Churchill says. “When a woman comes to a midwife practice she gets the best of both worlds; we have doctors we work with and can consult with every day, including the high-risk doctors.”

That balance was Claire Linthilac’s goal in establishing midwife services within the hospital, but those services are frequently under attack. In 2007, 24-hour midwifery care was scheduled for termination by Fletcher Allen, but public outcry—and the intercession of the nurses’ union—reversed the decision.

            “We continue to hope that midwifery will rise to the surface of the panoply of services offered at FAHC,” says Phil Linthilac, Claire’s son. Under the administration of Phil and Crea Linthilac, the Linthilac Foundation continues to keep a watchful eye on the provision of midwifery service at Fletcher Allen. It’s an eye which does not always approve of the trends in hospital care; they have, for instance, provided substantial ongoing financial support to the hospital’s breastfeeding education programs and facilities.

About this, Crea Lintalhac says, “The C-Section rate at FAHC is high; the lactation rate is dropping. This is the wrong direction. In my era it was women taking it back. Now it’s going in another direction. Phil’s mom, Claire, was trained to massage inverted nipples, to turn a baby, to massage woman’s tissues so no episiotomy was needed. We go backwards and lose skills because we do not emphasize the non-interventionist paths.” 

Costs and Benefits

Medical intervention in a hospital setting is driven by financial incentives, according to Cassandra Gekas, a health advocate at Vermont Public Interest Research Group. “Hospitals are insurance company-reimbursed, based on the number of services they provide. Complex services are reimbursed for more than non-complex services. It’s a fee-for-service system,” Gekas says. “That’s why our C-section rate is high. The rate in Vermont statewide is nearly 30 percent.”

Changing the financial incentives is the fundamental challenge of health care reform. “It’s fighting the health care lobby to utilize the providers in the right way,” Gekas says. “Having a specialist OB attending a low-risk birth is not the best use of resources.”

“There’s no experience more intense than the birthing process,” Crea Linthilac adds. “The midwives are there and never leave your side. The OBs are in and out of the room. They aren’t holding you, cradling you. Midwifery should be the gatekeeper.”

Women should have options that include hospital services, she says, but ensuring availability of other options takes constant vigilance. “I’m thrilled that we have this university and Level 1 trauma center if we need it, but I want to see a landscape where women have the option of nurse midwives and licensed midwives in home birth. Doulas, lay midwives, apprentices, support for breastfeeding. How are we supporting the best practices for the best health?  We need to put the birthing process back in the hands of women.”

Midwifery at Home

In addition to Vermont’s CNMs, 59 non-nurse midwives—Licensed Midwives or LMs—are licensed by the state to attend home births. LMs must pass the substantial requirements of the Midwives Alliance of North America and become a Certified Professional Midwife before Vermont licensure.

LM CPMs share the concerns of their licensed CNM counterparts about medical intervention in childbirth. “I do have a real concern about the state of childbirth in the U.S. and in Vermont,” says LM Carol Gibson Warnock of Bristol. “The insurance companies seem to run a lot of what happens. We have to revamp health care for pregnant women. Fifteen-minute doctor visits for pregnant women with very little hands-on, lots of tests ordered—this is often driven by fear, both fear on the doctors’ part and fear on the parents’ part. These doctors are good people who spent all this time and money training to do what they do. Many of them are my friends and they are good quality human beings. Then the insurance companies and this fear drive what they do.”

Warnock feels strongly that home births are not only a safe choice, but “for most women the safest choice because it has the least intervention and there is a strong emphasis on education and prenatal care. It’s more about prevention.”

The joys of home-birth midwifery in Vermont today are the same as those that drew Warnock into the profession 37 years ago. “The very best part is the families I meet and get to be friends with. Everyone I work with, I really like,” Warnock says. That refers to a lot of people, since she has assisted in over 1,400 births. “I like getting to be part of the community, and feeling like I’m contributing good to my community in my life.”

That positive contribution includes facilitating bonds between the adults who will be raising the soon-to-be-born child. “We really get to know the women and talk to them, with a lot of emphasis on love, respect and trust. I like the parents, or the mom and her friends, to do a lot at the birth themselves,” Warnock says. “I keep a careful eye out, of course, but I try to help them work together, because parenting comes right after the birth and they will need to work together on that for a long time.” 

About three percent of Vermont’s planned home births are transferred to hospitals, when the midwife and mother determine that more extensive medical care is required. “I just made a decision in my own practice to transfer a woman’s care to a hospital at 42 weeks. And everything she was prepared for about the birth vanished when we walked through those doors,” says Katherine Bramhall, an LM in Barre. “As soon as we walked into the hospital, she was looked at as a number. Women don’t have to lose their personage.”

But depending on the receiving hospital, not all transferred cases cause tension between midwives and mainstream doctors. “When I visit hospitals after birth in that three percent of cases that transfer to a hospital, it used to be a struggle,” Warnock admits. “But now, if I go in with a good attitude and no chip on the shoulder, then the medical providers are very positive. We all need to work together cooperatively because the goal of all of is the best outcome.”

Established Resistance

That desired cooperation is sadly lacking at the Statehouse in Montpelier, as home-birth midwives square off against the state and a contingent of the medical community over health insurance coverage of midwife services. Last year, the state passed S.15, with a clearly stated intent that health insurance companies in Vermont should cover homebirths. The fighting was fierce—many homebirth midwives like Warnock “took a year off of midwifery practice and basically lived at the Statehouse”—but was ultimately successful.

Or so midwifery advocates assumed. “Blue Cross Blue Shield was not complying with the law,” says Gekas of VPIRG. Insurance companies were restricting patient coverage to contracted network providers. To join these networks, providers needed to meet qualifications, including medical malpractice liability insurance, which licensed midwives—or nurse midwives working outside the hospital—cannot afford.

“It would take more than what an average midwife makes in a year to pay for medical malpractice insurance. So it is very not-do-able,” Gekas says. By contrast, under Medicaid rules—for the 60 percent of the 120 annual home births in Vermont covered by Medicaid—practitioners merely have to disclose their lack of medical malpractice insurance. Gekas explains, “So if someone wants to sue a midwife who does not have insurance, they can still sue. They just may not get a lot of money.”   

Despite the fact that homebirths save health care systems money—a study by the Washington State Medicaid Department determined that their state’s homebirth rate of around 2 percent saved the state $3.2 million a year—opponents of the bill in this year’s legislature to re-direct insurance companies to cover home births are taking the position that insurance need only cover hospital births.

“There is fierce lobbying among physicians to keep their corner of the market,” Gekas says. “The Vermont Medical Society is viscerally opposed to this bill. I heard they are bringing in pediatricians to testify about the bill.”

Warnock maintains cautious optimism about the outcome. “I started being a midwife [when I was] 23 years old and at the time I felt like I had to struggle through my relationships with other health care providers,” she says. “But over the years I developed an appreciation of other perspectives. I have acquired more grace in accepting other points of view. It appears like a big number of people are fighting you, but usually it’s just a few who are stuck in the old viewpoints. Vermont is such a small state and we can talk to each other.” 

Around the World

While women in Vermont fight to maintain access to midwife-supported birth as an alternative to intervention-laden hospital births, third-world women are fighting for midwives as an alternative to having no care at all. Some Vermont midwives, like LM Katherine Bramhall, fight both battles at once. Bramhall is president of the Vermont-based nonprofit Bumi Sehat Foundation International. She attends the births of Vermont babies and then flies to post-earthquake Haiti or post-tsunami Indonesia for several months each year to supervise midwifery student programs at Bumi Sehat’s midwife schools and birthing centers.

he contrast between the birthing process in the U.S. and in developing nations is stark. The American medical system misses the transcendence of childbirth for women. “Worldwide, 75 percent of babies are born at home,” Bramhall says. “In the U.S., it’s only 1-plus percent of babies born at home with skilled professionals attending. So what is lost in this culture is the memory of the transformation of the birth process.”

The challenges of childbirth in developing nations also include support of women’s spiritual and emotional well-being. But essential matters of bodily life-and-death must take precedent. “Lack of access to anti-hemorrhaging drugs. Lack of clean water. Lack of sterilization capability.” Bramhall ticks off the list of daily hurdles. “The biggest problem in Haiti is lack of access to any care. The Minister of Health said to me, 'Throw a dart at the map anywhere in Haiti, and you have people 3 ½ hours from any medical care.' Only 25 percent of the people in the entire country have any care at all.”

And if a woman in labor experiences difficulty in post-earthquake Haiti?  “She dies,” Bramhall says bluntly. “Even if we don’t concern ourselves with that, a woman dying in labor, the living children without their mother are left with a rotten life. The father has to go to work, and either leaves them to raise themselves or be taken care of by people who may mistreat them or exploit them.”

The midwife who founded Bumi Sehat brought positive ripples back to Vermont by winning an important acknowledgment of midwifery’s power to change the lives of women and families in far-flung regions of the globe. “In 2011, being a homebirth midwife in Vermont was brutal,” Bramhall recounts. “We had so many people coming at us in regards to S.15, and it became very difficult. With every success you meet with resistance, and it’s hard to keep your balance. The bill passed, but we were exhausted. But by Dec. 12, 2011, CNN changed that whole thing. A homebirth midwife was named CNN’s Hero of the Year.” Bumi Sehat’s midwife creator, Robin Lim, won the coveted prize and $300,000 for the foundation’s work.

The Needs of the Community

Health care reform provides a good opportunity for Vermonters to consider the paradigm of birthing services. As Gekas says, “We have to work through the historical hostilities between the different provider groups and talk about what makes a quality birthing experience. We need to match the services to the actual needs of Vermonters. We can’t keep going to the statehouse and fighting with each other every year.”

Meanwhile, for pregnant Vermont women, Bramhall has advice. “The most important thing to consider when deciding when to have a baby and where to have a baby is this: will the decision leave you with a sense of peace?”

When the mother is well cared for, when the child is born into a loving environment, Bramhall says, “that starts a vibration that continues throughout that child’s life. In times of stress they can always return emotionally to that sense of peace and true caring. A midwife’s job is to meet the needs of her community, specific to her community. Homebirth midwifery is not for everyone—but neither is hospital birth. We have significant numbers of well-trained, brilliant women to offer options of birthing to families in Vermont.”

Writer Cindy Hill of Middlebury is a Vermont Woman contributing editor.