Midwives or Doulas and Prosecuters, Oh My!

There's a family in the midwest that is in a terrible predicament...one that is grossly unfair, and my heart goes out to them. The information on their website is that, after giving birth to a healthy child at home, with the assistance of a midwife "they made the decision"...(a few hours later)..." to call 911 just to be safe" because they were "a bit concerned about the mom". In the jurisdiction in which they placed the call, since a child was involved, the police were required to respond as well. The EMS personnel insisted that the baby "needed immediate medical attention", so mother and baby were transferred to the local hospital, both were found to be well and healthy, and after a few hours were released. The police took statements from both the midwife, and the woman's husband.

Two months later however, the family was served with a summons to appear in court having had the charges of child endangerment levied against them. At their most recent hearing, they were offered a plea bargain for the charge of "disorderly conduct", which the family chose not to accept because they feel that they "are not guilty of anything", that "a guilty plea would validate the charges against" them, and that a "guilty plea would give the impression that homebirth is wrong, and possibly open the door for other families to be prosecuted". All noble arguments, but not exactly in their best interests. In fact, despite this family's earnest sincerity (and I do believe they are sincere), I'm not particularly certain that their arguments are even in the best interests of the homebirth community at large.

I agree that this family did nothing wrong. I support their right to give birth in the place of their choosing, with an appropriately trained, skilled, experienced attendant of their choosing; but despite my compassion for this family, and my desire to help them, and my fervent prayer that the charges will be dropped, I have concerns. There must be more important issues for the authorities to be addressing than a homebirth where the outcome was healthy and safe.

Or is there?

Whenever I see "calls for support" go out over the web for midwives or families that are being pursued by the legal system for whatever charges that can be trumped up regarding a homebirth (practicing medicine or nursing without a license, child endangerment, etc.), it is in my nature to question both the reasoning of the local authorities, and the actual story of those who are being charged. More than once I've heeded the call to a "persecuted" midwife only to find out that there may actually have been some questionable management of the situation. It's a sad reality in our culture that, due to the tenuous legal standing of midwives in general, and homebirth and Direct Entry midwives in particular, that the care the family received must be beyond reproach. That is difficult enough to prove, even in the best circumstances, when we've got the machinations of the AMA, ACOG, and sensationalist reporting such as the "Perils of Midwifery" piece recently aired by the Today show swirling around us. It becomes even more difficult to prove when those who are being prosecuted are not being forthright with every minute detail of the situation.

So, quick to my trusty Iphone I went, dialed my beloved friend C., childbirth educator and doula extraordinaire, who also happens to be in regular communication with our local CPMs. It seems that indeed, a small piece of information has been overlooked in the most recent reports of the incident. In initial media reports, the midwife, when giving her statement to the police, identified herself as the family's "doula".

Whaaaat? Now, when a midwife transfers her clients to a hospital, she certainly does cease to become the primary care giver, and steps instead into the role of doula. However, during the incident about which she was giving her statement, she was acting as the primary care provider. That role, as such, places her in a position of responsibility regarding the outcome of the situation. By identifying herself as a doula, this midwife exposed her client to suspicion that they were attempting to give birth unassisted, and I said as much when I questioned the family and their supporters on the informational website.

What I did not point out at the time was that I was not questioning the family's right to give birth any way they chose (I wasn't...although I won't mislead anyone here and say that I am in favor of giving birth without a skilled care provider in attendance, be that physician or midwife...but that is for another post). I was simply pointing out two things that could have a very important impact on the outcome of their case. 1). Those who were telling the story, be they supporters or the family themselves were not being forthcoming with all the pertinent information, and 2). A midwife who identifies herself as a doula, is going to be perceived as someone with something to hide...and so will her clients.

Well, immediately I was accosted by both supporters of (of whom I still consider myself to be among...I just want more information), and members of the family, including the much beleaguered mother. Was I actually insinuating that this family did not have the "right" to an unassisted birth if they chose?; that the charges were valid if there wasn't a midwife present? From there the arguments became not about how best to support and provide for the best possible legal outcome for the family, but a heated discussion, mostly directed at me, about the family's "right" to choose to birth in whatever manner they saw fit. Try as I might, until one post late in the day, I could not convince those who saw red the moment they read my words, that this was not about the family's "rights"...it was about getting all the information in their defense out on the table where it could be considered...and perhaps improve their legal standing. Ironically, that post was from a mother who chose to have several of her children unassisted. She simply pointed out the dominant cultural biases against homebirth, and how being seen as potentially giving birth unassisted were not going to work in the family's legal favor, despite their philosophical "right" to do so.

The mother says that she stands beside her midwife 100 percent.

But is her midwife standing beside her 100 percent, when she identifies herself, not as a midwife, but as a doula, whose role by definition, is anything but midwifery?

The mother goes on to say that "It shouldn't matter that the authorities see homebirthers as irresponsible. They are supposed to enforce laws, not their opinions".

She's right, it shouldn't matter.

But, unfortunately, it does matter. It matters very much in our as yet unenlightened medico/legal culture. Is this family willing to martyr themselves to a cause that their trusted midwife does not appear to be willing to herself? After all, if indeed she is a midwife, she placed herself in the role of "authority"; and now when another type of authority is attempting to insinuate itself (apparently, tragically, and unfairly) into the situation, she recoils from that role? That is abandonment of her client...and that is irresponsible. What would we do if a doctor in similar circumstances said something to the effect of "Hey, don't look at me...I'm just the gardener!". I know I oversimplify...but truly...are we holding midwives to the same standards that we hold other care providers? Or are we, because we are so passionate to advance the cause, allowing them to assume less responsibility for outcomes we would not choose?

If the local authorities believe that a family is behaving irresponsibly, they are going to try to find a law to, if for nothing else, make an example of the family, if for no other reason than to further discourage other families from making a similar decision. In the process, the family in question is placed under great stress, both emotional and financial, at what should be one of the happiest times of their lives.

As often happens, the support discussions concerning this family have evolved, for those who rally around them, more in support of the philosophy of birthing rights than the support of the family (although there is much to commend supporters on regarding the level of financial and other support being planned and given). Of course we have the "right" to give birth in any way we see fit; but legal "rights" are, unfortunately, variable, based on how a judge and/or jury interpret the law. How we present our argument to them is going to have a definite impact on their decision making process, and the outcome of the case.

The mother writes that a part of the charges say that she "gave birth in an unsanitary place and did not seek immediate medical treatment for the baby". Since they (the charges) did not address the presence (or absence of) an attendant, she does not feel that the midwife identifying herself would have changed anything.

But of course it would!

If, indeed, the woman who identified herself as a doula was actually a skilled, experienced midwife, and had identified herself as such, then the defense could point to the safety of midwife attended births in study after study, and it's acceptable practice in nearly half of the United States (let alone many other industrialized countries with much better maternal/infant, and dare I say it, economic outcomes than our own), thereby at least placing a chink in the prosecutions argument; but this would place the midwife in a precarious legal predicament, since the state in which the incident occurred is not one of the more "enlightened" states that provide a legal basis for the practice of midwifery for families giving birth at home.

So now the question becomes...on whose shoulders does the responsibility for the safe health care outcome of this situation rest?

On the Midwife's!...or at least as much as the family's!

Of course a birthing family is responsible for choosing the best possible care for their pregnant mother and unborn child. If they choose themselves as such, then they are responsible for the outcome...and liable should the outcome be not as expected. If they choose a midwife for that care, then the midwife, by the act of attending them, assuming the role of primary care provider prior to transport (if a transport is called for), and in accepting compensation for that role in whatever form deemed appropriate (money, barter, etc.), should accept responsibility for the outcome. Here it seems, only the family is being subject to prosecution, and I want to know,

Where is the Midwife?

Is the family protecting the midwife? Is the midwife going to publicly step up in the family's defense? Of course, if she does so, she assumes the risk that she will be prosecuted as well...but didn't she assume this risk when she chose to be a home birth attendant?

I'll be brutally honest here. I would have loved to trained as a midwife and provided care to mothers giving birth at home; but at the time, I was a single mother with two young children to support. I needed a steady paycheck, and I couldn't afford to risk being arrested and convicted of practicing nursing or medicine without a license, lest I lose custody of my sons. Does this make me unwilling to "put my money where my mouth is"? I guess it does. I decided get a bachelor's degree in nursing instead, and attend mothers giving birth in hospital. That does not mean I think that the hospital is the best place for a healthy, low-risk mother carrying a healthy baby to give birth. I don't; and every shift I work, I struggle with the dichotomy of my belief system while trying to give the best, most compassionate, physiologically appropriate care to my patients that I can. It helps (sometimes), that I work on a unit that accepts many complicated transfers of care, and that the majority of my patients are those who a qualified midwife would risk out anyway; but when a healthy mother in normal labor comes under my care, I struggle. That is my lot in life. I chose it, I live with the spiritual and emotional consequences. I don't have to live with the potential legal consequences that a Direct Entry Midwife has to, but that was my choice. Does that make me a less-valid supporter of a woman's "right" to choose her birthing situation? I still place myself in the position of risking my license if I would harm a patient with a medication or practice error, or by not advocating for her properly should I feel that her medical care provider not be practicing appropriately; and ironically, for all my work to avoid loss of income by choosing a more culturally accepted way to provide care, I've found myself in situations occasionally when providing that advocacy did, in fact, jeopardize my employment. It's not easy being a pro-birth choice nurse in a culture that sees technology and the practice of medicine as the preferable way to give birth; and it's not easy being a homebirth and midwifery supporter who works in the dominant health care system!

This family's freedom, as well as, should she choose to come forward, their midwife's is of paramount importance in this situation; but we need to be careful about how we couch our arguments in the current culture. The reality is that if we're to advance a woman's right to give birth in an environment of her own choosing, we are, again, going to have to hold ourselves to the highest of standards, both of care, and of how we present the appearance of that care to the "authorities". I don't see that happening here.

Again, I have only compassion for this family. I deeply want to see the charges dropped. I'm furious at the waste of taxpayer money being used to harass and traumatize them, for no good legal reason; but I think there is a missing piece of information that someone, somewhere, is unwilling to, for whatever reason, address that could help them.

And I think that information has to come from the midwife.