Midwives to Leave Home : Denied Malpractice Insurance, Women Who Assist Home Births Face Two Choices: Go Establishment, or Go Underground

You can still have rocking chairs and back rubs and even bubbling warm baths. But if you are planning to give birth in the comfort of your own home, don’t get comfortable just yet.

The modern midwifery movement, founded to liberate laboring women from hospitals, has gone Establishment. With malpractice premiums soaring and coverage for home births impossible to buy, most nurse-midwives won’t be making house calls any more.

Some voices of organized medicine say that’s good for babies.

“Home birth is child abuse in its earliest form,” says Dr. Keith Russell, former president of the American College of Obstetricians and Gynecologists.

But some mothers and midwives see the loss of access to malpractice insurance as yet another attack on the reproductive rights of women.

“Once again, we’ve been co-opted by the medical model of pregnancy as an illness, and birth as a medical-surgical event to cure it,” fumes Kitty Ernst, a pioneer in the modern nurse-midwife movement.

She and others blame a nervous, male-dominated insurance industry for the latest defeat: the refusal of insurance companies to sell malpractice coverage to doctors or nurses who attend planned home births.

Most home births are attended by either lay midwives or certified nurse-midwives. The latter are backed up by on-call physicians, who may have other insurance options that midwives do not.

Insurance companies, in turn, blame the courts and a growing number of multimillion-dollar obstetrical malpractice awards. In most states, families can sue for birth-related damages any time during the first 21 years of the child’s life. And those payouts can run into the tens of millions of dollars, says Julie Rochman, director of the Alliance of American Insurers.

“Whether or not the doctor or midwife was at fault, the insurance company is probably going to have to pay because it’s the insurance company who has the pdeepest pockets,” she says.

When her insurance expires in September, Deborah Frank, director of the Home Birth Service of Los Angeles, will close her practice. She could go to work at one of 140 free-standing birthing centers left in the United States or she could work in one of a growing number of hospitals that are opening their doors to “homeless” nurse-midwives.

But her partner, Leslie Stewart, doesn’t want to leave home. She says she may continue to assist home births with a physician back-up, but without insurance.

Financially, the risk is not small. In California, she can be sued for her personal worth. But, Stewart says, “politically, I want to continue. Insurance companies should not be able to influence where women give birth. . . . “

CNA, the last insurance company in country to provide home birth coverage, will stop insuring midwives when current policies expire, according to the American College of Nurse-Midwives. That means, with the exception of a few special self-insured groups in several Eastern states, midwives throughout the nation will be without home birth coverage by the end of 1992. (Even those who do not participate in home births now face annual premiums of $7,000 to $13,000 per year from a new American College of Nurse-Midwives group insurer.)

“CNA’s largest payout in history was for an obstetrician doing a home birth,” says Karen Fennell, the senior policy analyst for the college of nurse-midwives. “And while we had only two home birth (settlements), that, combined with the emotion and controversy concerning the safety of home births, was enough to frighten them right out of the business.”

(A CNA spokesman said no one was available for comment.)

Only about 5% of babies born in California are intentionally delivered at home. And there is no question that, insurance crisis or not, there will always be women who want to give birth at home.

Tonya Brooks understands these women well, having delivered five of her own seven children at home. She is convinced there are enough women like her that the number of home births will not change, only the number of the lay midwives assisting them.

As founder of the Los Angeles-based Assn. for Childbirth at Home International, Brooks believes the future of home birthing is in the hands of lay midwives--women not certified by the American College of Nurse-Midwives.

Health experts say there are an estimated 250 lay midwives in California, compared to about 800 certified midwives. Because most of them are not registered nurses, they do not carry malpractice insurance.

But they handle most home births in California, according to the State Medical Board, which says lay midwives risk practicing medicine without a license. “The (legal) confusion is there,” concedes Brooks. “What is clear to us is that it is not illegal.”

“A lot of us are going to continue to use the lay midwife underground,” says Krista Tiberio of San Clemente, who used lay midwives for both her home births. “Obstetricians want to keep women afraid of birth and now it sounds like the insurance industry wants to make midwives afraid too.”

Brooks says hospitals and doctors are already wary of home births. Last month she received 122 complaints by California lay midwives about denial of prenatal care to women who were planning to deliver at home and emergency treatment for those who experienced complications during home deliveries.

Such complaints do not surprise Dr. Russell of California Medical Center. “Doctors and hospitals are reluctant, and rightly so, to say they will back up a delivery where there may be no resuscitation equipment, where the whole process could pose great danger to the baby.

“I know some people will always want home deliveries. They want their other children running around, the grandmothers there, the rocking chair . . . Well, that’s fine. But now you can find that at a birthing center or a hospital. You don’t have to risk your baby’s life so the mother can have nice atmosphere.”

The word midwife means “with woman.” And women have been helping other women have babies for as long as they’ve been having them.

But as medicine grew more high-tech--and, critics say, invasive--women moved into hospitals to have their babies. And there, they found doctors, not midwives, were in charge. And, more often than not, a busy doctor can’t always be “with woman.” If anyone is at her side during labor, it most likely will be a nurse.

In the past, midwives have not been particularly welcomed by hospitals, or more correctly, say some observers, by doctors.

“In the past, some doctors were very concerned about sharing their patients with midwives,” says Glendale obstetrician, Dr. Chand Aryasingha. “Because I trained in England, I was very comfortable with midwives and quite surprised there weren’t any in hospitals here.”

When actress Cybill Shepherd was pregnant with twins, she went from hospital to hospital, doctor to doctor, looking for a safe way to deliver “naturally.”

“At last, I found a place (with) plenty of experience, great outcomes, and wonderful midwives. It was County Women’s Hospital,” she recalls, “but I couldn’t go there because I could afford to pay!’ ‘

After much negotiation and a precedent-setting waiver of the rules, Shepherd delivered a healthy 8-pound, 11-ounce girl and a 7-pound, 2-ounce boy in a suite at California Medical Center in downtown Los Angeles. Two midwives were at her side.

The October, 1987, births were the first with midwives in that hospital. But they were not the last.

Faced with a growing pregnant population, the hospital began planning what many consider the most ambitious nurse-midwife program of any private hospital in the city. Later this spring, California Medical Center will open a new $3.4-million wing of labor and delivery suites for nurse-midwives. The wing will be open to private as well as MediCal patients.

For more than a decade, County-USC Women’s Hospital has had a similar nurse-midwife service for the county’s poor. Because the greatest number of patients have had little or no prenatal care, they are considered high-risk and may labor three to a room on the busy fifth floor.

But three floors above, where nurse-midwives trained to handle uneventful births preside, every laboring woman has her own room--and her own midwife, says administrator Consuelo Diaz.

The hospital, which delivered about 3,000 of its 16,000 babies last year with midwives, says the program is good for both patients and taxpayers. While county nurse-midwives are paid about $55,000 a year, the cost is a fraction of what many obstetricians command.