Midwife Crisis : Bill Certifying Non-Nurses to Deliver Babies Could Be a Step Toward Ending the Turf War With the Medical Establishment

Midwife Lorri Walker suspected there was something terribly wrong about the pregnant patient and her mother who walked into her Buena Park office that day.

They were not the jubilant expectant mother and grandmother whom Walker was accustomed to seeing. These women were nervous, demanding and hostile. Unknown to Walker, one was carrying a gun.

Suddenly, as Walker prepared to examine the patient, the women identified themselves as undercover investigators for the state Department of Consumer Affairs, flashed their badges, handcuffed Walker and told her she was under arrest for practicing midwifery without a license.

“I thought it was all a bad dream,” Walker says.

Thus Walker, 33, became a celebrity in the war between midwives and the established medical community in California.

For many unlicensed California lay midwives, Walker’s arrest last May at the office she uses in her home when not working at the South Coast Midwifery clinic in Huntington Beach was more than just an embarrassing and frightening experience. It was seen as yet another example of the kind of harassment they contend some midwives have suffered during their struggle to be recognized as legitimate care-givers by the medical community.

But their struggle may be coming to an end. A new midwifery bill recently passed by the California Legislature will be a big step toward resolving the midwifery war by allowing the certification of non-nurse midwives if they meet tough training requirements and aresupervised by physicians.

Until now, only registered nurses with accredited midwifery training were certified in California to deliver babies. They may be employed by a doctor, hospital or birthing center, or work independently, but they must be supervised by doctors. Lay midwives, most of whom have little or no formal training, are not allowed to deliver babies, unassisted, in the state. Midwives such as Walker, who is a graduate nurse midwife awaiting certification, are qualified to assist a certified nurse midwife in a delivery.

Criminal charges were never filed against Walker in connection with her May 1 arrest. After reviewing the evidence, the Orange County district attorney’s office decided not to prosecute. Walker has since filed a claim for damages against the California Department of Consumer Affairs, alleging false arrest and false imprisonment.

The bill, which Gov. Wilson has not publicly opposed, would make California the 15th state to allow lay midwives to legally deliver babies.

For years, midwives have lobbied state lawmakers unsuccessfully to ease the licensing restrictions to allow the certification of non-nurse midwives. The California Medical Assn. and other interest groups opposed the previous legislation, contending the education and monitoring requirements for the midwives were too lax.

Currently, there are between 700 and 800 certified nurse midwives practicing in California, Chavez says. The bill’s passage could enable about 200 lay midwives to be licensed in the state, said Nancy Chavez, who works in the office of state Sen. Lucy Killea (I-San Diego), who introduced the bill.

Supporters of the proposed measure say it will offer more women--especially low-income women--safe, low-cost, low-tech births as an alternative to having their babies in hospitals. Even women who do opt for hospital deliveries would have the opportunity to rely more on midwives for prenatal care, an important aspect in healthier births.

Chavez noted that while a hospital fee for delivery of a baby could run about $5,000, a midwife’s fee for an out-of-hospital birth could range from $900 to $1,800.

“The issue is money, not safe medicine,” says Sherry Johnson of the California Assn. of Midwives. Doctors see midwives as a threat to their business, she contends.

On one side, there is a segment of midwives who view arrests such as Walker’s as part of a witch hunt waged by the medical community and state regulators. Their intent is to harass midwives who practice legally or illegally outside the realm of physician-oriented medical practices, Johnson contends.

Strict licensing requirements, opposition by the medical community and arrests by state regulators have forced some midwives to go underground and practice secretly, according to Johnson.

On the other side, there are state medical regulators who deny capriciously targeting midwives, and physicians who insist their concern isn’t money--it’s adequate health care for women and infants.

“Harassment is too strong a word,” said Anthony Argil of the California Medical Board. “We are trying to enforce the law . . . put there to protect the public. Whether it was ill-ordered depends on who you talk to.”

If midwives are properly trained and supervised by physicians, the medical community welcomes the service they can provide, says Dr. Charles W. Plows, past president of the California Medical Assn., which dropped its opposition to the bill after those requirements were added.

Under the bill, non-nurse midwives will be required to complete a three-year post-secondary educational program to be licensed in the state. The training must be accredited by the California Medical Board.

Physicians contend strict enforcement by state regulators is necessary because untrained midwives can pose serious medical risks.

Though some midwives believe home births can be just as safe and be more satisfying than a hospital delivery, physicians such as Dr. Terence O’Heany of Fountain Valley raise concerns over incidents in which babies died or suffered complications during such births.

“Lay midwifery and home births might be adequate for deep Brazil. But not for a country like ours. We’re not a developing nation lacking in medical technology,” O’Heany said.

Advocates of home births “say they don’t want to give birth in a hospital because it’s so cold and technical,” O’Heany noted. “Well, that intravenous line in your arm in the hospital could save your life.”

“Sure, there are midwives out there who make me quake in my boots,” says Glendale midwife Tonya Brooks. “But there are also well-trained doctors who are horrendous practitioners who are armed with drugs. They make me lose sleep at night.”

Brooks, director of the Gentle Birth Center, faces criminal charges along with four other women in connection with the death of one infant at the center and another baby that suffered severe brain damage after birth. Brooks said her arrest earlier this year was an example of midwives being persecuted while bad birth outcomes involving doctors are ignored.

Those on both sides of the issue believe that the bill may ease much of the animosity that has developed between midwives and physicians.

“I think it would be a step in the right direction,” Plows said.

“Whether we like it or not, they (midwives) have done some service,” especially for people who may have not sought medical assistance during their pregnancies and births because they could not afford to or choose to stay away from hospitals, Plows said.

He acknowledges that in the past, “some physicians saw this as a turf battle” with midwives. To some doctors, the notion of “untrained people doing obstetrics goes against the belief that maternity cases deserve the best possible care.”

But now, many doctors “have a more realistic approach,” Plows said. “Nurse midwives have been well-accepted in certain areas.” He pointed to the success of the UCI Birthing Center and the use of certified nurse midwives in various hospitals as examples.

Jeanne DeJoseph, an associate professor at the University of California’s School of Nursing in San Francisco, believes the bill is a crucial step toward addressing the health needs of women and infants in the state.

“Health care for women and families has been seriously limited by a health care system which has become unresponsive to their needs,” she wrote to Killea. “In these times, professionals must act as responsible citizens and put aside turf battles . . . and work together to assure women’s access to (health) care.”

At issue is not only medical procedure, admit those on both sides. Attitudes toward childbirth and non-medical intervention are also at issue. Midwives often cater to women who believe childbirth choices should be completely left up to them. While some midwives work in hospitals and incorporate medical intervention into their practices, others believe strongly in home births. They all see midwifery as a safe and cost-effective option for families.

According to data from the California Assn. of Midwives, the United States ranked 22nd for infant mortality among the top 25 developed countries in the world in 1987. By licensing non-nurse midwives, more women, especially poor women, would have access to prenatal and maternity care, Johnson and others contend.

Plows, a retired Anaheim obstetrician, said the measure would open the doors for many lay midwives who have been practicing underground to “come out of the midwife closet.”

A key question among many in the medical profession in the midwife debate is liability.

“We are concerned that these people do not have medical malpractice insurance,” said former state legislator Gordon Cologne, a lobbyist for California Assn. of Professional Liability Insurers, a group of doctor-owned insurance companies.

Certified nurse midwives who work for doctors generally have malpractice insurance. Under the bill, midwives will only have to disclose to patients whether they have malpractice insurance, and they must name the physician who is supervising them.

Home births are not covered by medical malpractice insurance, and most doctors won’t risk a home delivery or back up a midwife who assists them, Cologne said. “The risk factor is too high.”

“We understand that 90 to 95% of home births turn out fine. The problem is when they are not successful, the damages are horrendous.”

“We are concerned that our doctors not get drawn into lawsuits” that stem from bad birth outcomes by non-nurse midwives, Cologne said. “Doctors don’t want to be (legally) responsible if they are not in control (of the patient’s care).” The supervisory doctor may only see the lay midwife’s patient once, but the physician could end up being sued if the midwife’s delivery ends badly, Cologne said.

In recent years, there have been some highly publicized cases involving midwives.

In one case, Delores Doyle, an unlicensed midwife accused of murder in the deaths of three infants she helped deliver, pleaded guilty to involuntary manslaughter in 1989.

Los Angeles Superior Court Judge Judith C. Chirlin placed Doyle on probation and ordered her to “stay as far away from pregnant women as you possibly can.”

Doyle was charged along with Dr. Milos Klvana, a Valencia obstetrician. Two of the deaths occurred after Doyle and Klvana administered a drug to help the mother’s prolonged labor. Prosecutors contended that they failed to control the dosage.

The third infant died after Klvana and Doyle allegedly saw signs that the infant had ingested his own fecal material before birth, but did not recommend hospitalization even though it is a serious complication.

In another case, midwife Abigail Odam had her nursing license revoked in 1989 after she was accused of negligence in the case of a baby delivered stillborn to a San Clemente woman after almost 24 hours of labor.

The mother of the stillborn baby testified during a state hearing that Odam, a registered nurse who had not received her certification as a midwife, had ignored signs that the baby was in distress during delivery.

Even with the new bill, many midwives remain bitter over the way they say they’ve been treated.

“The medical community opposes us every step of the way. The harassment of midwives has gone on for many years,” Johnson said.

Stephen B. R. Keller, Walker’s attorney, agrees. As a lawyer who specializes in midwife cases, Keller said he has seen the medical community’s hostility toward nurses who act as midwives.

“This isn’t a health-care issue. It’s an issue of a group wanting to monopolize an area of health care for financial gain,” Keller said.

But California Medical Assn. lobbyist Joan Hall says it is “ludicrous” to think that such powerful medical groups as the CMA are in favor of harassing midwives.

“It’s utter nonsense. Our (obstetricians) have more babies than we can deliver. We are crying out for more certified nurse midwives who can help with safe, competent deliveries,” Hall said.

“If you are going to have midwives, you want them to be extremely well trained. We don’t want consumers hoodwinked.”