Midwifery is Messy

Jennifer Braun

I'm a midwife in Boulder, Colorado. The kind of midwifery I do, the extremely focused, one-on-one, homebirth kind, fancies itself spiritual. Ina May Gaskin wrote a book called Spiritual Midwifery in 1976, and it became something of a bible. Events that were considered medical were examined through another lens entirely. Women were offered a completely different image of what childbirth might be. It is a rare "spiritual midwife" these days, however, who is familiar with the fact that Ina May's doctrine -- what she meant by "spiritual" -- included that the midwife not be paid. That particular detail has fallen away.

In Boulder, the notion of spirituality encompassing birth can reach the extreme. I have met families with the most amazing concepts of what their birth might look like: the lighting, the décor, the music, the ambiance, the over-attachment to delivering the baby in water. I personally understand most of it as a simple desire to be in control of an essentially chaotic experience. In this environment of birth plans and blessing ways, the job of the midwife becomes idealized, not by every member of a community, however, and certainly not by the obstetric association. But among families that choose midwifery care and homebirth, the midwife becomes something of a celebrity. In truth, midwifery is messy. Most of the time, most midwives are not catching a baby. Those moments are fleeting. Of the hours spent at a birth, I typically spend some substantial portion doing laundry and scrubbing the bath tub. Certainly though, there has been a lot of Mission-from-God time.

As this story begins, I was having strong feelings that something was terribly wrong with childbirth in America -- that things were not as they should be. I had a powerful notion, as an anti-war activist, that by making birth less violent we might make less violent people. It seemed worth a try. As a young woman in Boulder, Colorado, I was surrounded by a community that embraced homebirth midwifery, yet the practice was outlawed by the state of Colorado. Midwifery was defined as the practice of medicine, so only physicians were allowed to do it, even though it was a legal and regulated profession in the majority of states. In Colorado, we were practicing medicine without a license.

Homebirth midwives were somewhat tolerated in Boulder and Aspen due to the forward-thinking physicians there, but they were treated as criminals in other areas. There were many instances of a midwife responsibly transporting a homebirth mother to the hospital for care when things moved beyond the scope of homebirth, and the hospital calling the police to come and arrest the midwife. We felt strongly, for many reasons, that the call to the police was not in the patient's best interest.

The state wouldn't consider making homebirth illegal. That would be seen as an infringement on personal liberty, something the Colorado legislature does not care to trespass upon. We have no helmet law here for motorcycle riders, for example, but for a family choosing homebirth to have a qualified attendant was illegal (for the midwife). Consequently, midwives were accountable to no regulatory oversight, and there were no enforced educational standards. Still, objective statistics seemed to reveal that having a baby at home is as safe or safer than having a baby in the hospital, as long as mother has no high-risk factors and has a qualified attendant.

When I joined the community of Colorado midwives, myself all of 19 years old and looking about 14, I was horrified to hear the political perspective of the leaders of the midwifery association. They seemed to believe that if we could convince organized medicine what good girls we all were, then the physicians' lobby wouldn't oppose the decriminalization of midwifery. Their bill sponsor was a woman, a liberal democrat from Boulder, and the strategy was to politely explain homebirth midwifery to the Colorado Medical Society. This seemed to me a recipe for complete failure. The legislature was overwhelmingly Republican, with a particular bias against regulating professions. The bill sponsor was a fine human being, a great human being really, but she was totally wrong for the issue with regard to actually winning. Boulder -- a progressive Democrat town in a largely conservative Republican state -- was not taken seriously by the majority of legislators. The midwives, it seemed to me, should forego pursuing the doctors' lobby, and instead concentrate on winning over the majority of Colorado legislators.

Politics is a filthy business, and the midwives weren't willing to get their hands dirty. I'm certain that I ended up offending most of the Board of Directors of the Colorado Midwives Association (CMA) at the time, acting as though I knew what I was talking about. But being the child of a serious civil rights activist (our house was set on fire when I was in grade school), I did actually know what I was talking about. After the CMA strategy failed in committee in the summer of 1985, it was I who was lit on fire. The need to see midwifery decriminalized and regulated hit me like lightning, along with the absolute certainty that we would succeed.

After that, I was in the vortex, on a quest, on a mission from God. I worked 100-hour weeks. Our little CMA became a well-oiled machine. I learned to be a lobbyist, and I learned how to lead. We had to raise money to pay a professional lobbyist to work with me because that's how it's done -- at least it is when you're fighting this kind of David and Goliath battle.

The first year we ran a bill in the legislature (after years of lead-in work), we made it through numerous House hearings and finally, unbelievably, through the full House vote and on to the Senate. It was here that the opposition really turned up the heat. At the Senate hearing, professional lobbyists from 23 groups turned out to oppose us, and I heard and saw things I can still barely believe. We knew we would lose the first year the bill ran. The dream was to win the next year, but it was tough. It seemed that it was my whole life. I worked as a midwife, and I had a family, but the bill, the battle to change the law, seemed like the most important thing at the time -- not really in a sick way, my family was really supportive and we all still love each other, but in a driven, mission from God way.

At first, I was unable to testify at hearings that I was a homebirth midwife. There was a committee member, Mary Ann Tebedo, who threatened to have anyone who claimed to be a practicing midwife arrested. I took a job at the University of Colorado in the Molecular Biology Department, working in a laboratory. It was a good job, and it allowed me to say that I was a faculty member at CU Boulder -- of course so I wouldn't be arrested, but more to tweak their thinking about just who is a homebirth midwife. The next year I was permitted to admit I was a practicing midwife at hearings. The explanation was that once we had gotten that far, it would look as though they were targeting me specifically as an individual if I were to be arrested. Apparently they are not supposed to do that. It's interesting what "rules" they do and do not follow.

Some of the outrageous things I saw weren't really traumatizing, just funny or awful. Once there was a table about HIV awareness in the lobby of the capitol, it had a basket of condoms on it. One of the senators lost his composure entirely, seized the basket, and went to the microphone in the Senate. He had an enormous outburst about homosexuals and loose morals and children in the capitol seeing a basket of condoms right out in plain view! He was shrieking, shaking the basket and sending the condoms skittering all over the senate floor, freaking out in front of the full Senate. All the lobbyists were rushing to the gallery to catch the outburst -- things this interesting were not to be missed. Then, one of our bill sponsors went to the microphone and called him a Nazi. The focus changed immediately to her gaffe. That was stressful.

At one time the House of Representatives was in quite a state of conflict. They were arguing about a gun bill, some concealed carry thing. They were really angry with each other. Voices were raised, tempers were high. A member introduced an amendment to require midwives to carry guns to homebirths, and that fixed the mood right away.

Once I heard a sub-committee of senators take touching testimony from each other about how expensive and stressful it is to be a legislator. They were discussing a bill to raise their salaries. That same Senator Tebedo complained about the wear on her tires from her commute. They had just, minutes before, killed a bill to raise the minimum wage in Colorado, blaming NAFTA for the request. They did however vote to raise their salaries.

Some things were more frightening, and it was a struggle to avoid cynicism. It seemed like all the things we hear about politics, all the jokes about how bad and corrupt it is. In fact it was much, much worse than that. The sinister element was quite present, and many things did seem to happen after an exchange of cash. Democracy appeared to function, and yet there were always other things happening, actual back-room dealings influencing outcomes and yet seeming not altogether legal. It became almost unbearable at times to contemplate the fact that this really was the process of actual laws being made -- laws that governed real people's lives. It was dreadful.

The amount of inappropriate influence by shadowy figures was particularly weird in light of how small a fraction of the population homebirth midwives serve. We received a huge amount of negative attention from the medical lobby, and they got out the big guns to shoot us down. The policy of not permitting home birth midwives to practice is not a matter of good public health policy; they were fighting a turf war. But we were such a tiny opponent, and they had a vast capacity to outspend us.

One moment that stands out in a very personal way is when I realized my phone was tapped. There were two of us on the board of the midwives association who had thrown our entire lives into this legislation. I was the front person, the lobbyist, the one who was at the capital all day. Jan backed me up in a million ways, but she did not testify in front of committees. Her nose would bleed. One night, while we were strategizing on the phone, we thought there was an intruder in her home. We were hearing strange sounds, we thought a phone was off the hook in her basement and the sounds were coming from there. We discussed what I would do if I heard her challenge an intruder, and she braved the walk downstairs. There was no one. The sounds we heard over the line were coming from somewhere else.

It took a few days for us to accept that our phone calls were being listened to, and a few more days for me to decide to go to our house sponsor, a member of the Colorado House of Representatives. I'm not much of a conspiracy theorist. I was self-conscious and embarrassed raising the issue with him. But when I told him that I thought that someone was listening to my phone calls, he became very angry. He didn't ask me why I thought that, he just said that he'd "take care of it." He was clearly furious. The strange sounds stopped the next day.

I have a friend who was in Viet Nam. He explained to me that while I was working in the legislature, I was at war. I had seen things that I shouldn't have seen and done things I might not feel that good about doing, but I did those things and saw those things for the good of the mission. It always seemed to me that the legislature was an altogether different world, not so much like a far away land that I'd gone to war in, but more like Narnia -- a whole different ecosystem where very little was the same as back in my world.

Out in the regular world, a subset of American women were questioning cultural assumptions about childbirth. Many decades had passed since the time when childbirth was quite risky. Women across America were reading Spiritual Midwifery and Immaculate Deception and Special Delivery. Lamaze was no longer enough, women wanted more control over how their deliveries were conducted. They were not satisfied with how they were treated by hospital staffs. Some routine procedures began to seem quite violent. Episiotomy -- the insertion of scissors into the vagina at the time the baby's head is born to cut a larger opening -- doesn't offer any of the benefits it was said to and is in fact risky, and it seemed not far removed from female genital mutilation. What possessed anyone to cut a woman's vagina with scissors at the moment of birth? What woman would ask for such a procedure? Women were tied down during childbirth, with restraints, like psychiatric patients. That finally began to look as weird as it is.

In the midst of this re-evaluation of how they want their births to be, about 2% of American women were giving birth at home with midwives as attendants. Some do it because they want control. Some do it because they believe it's safer. Some are just looking for privacy. Many women tell me they don't want anyone they've never met at their birth. Studies continue to verify (despite some hysteria to the contrary) that home births are an appropriate choice for low-risk women attended by qualified midwives.

I was young, I was idealistic. I wanted to change things for the better, and it seemed to me that the criminalization of homebirth midwifery was a great injustice. It seemed to reach into issues of women's power and autonomy. It seemed to resonate with old fashioned witch hunting. We heard again from Senator Tebedo when she shared with us her suspicion that homebirth was likely caught up in satanic activities, delivering babies at home to sacrifice in rituals. She liked to ask rhetorical questions in committee as to how many babies might be buried in people's yards, victims of demon midwives. During our House of Representatives battle we were accused of specializing not in homebirth, but home abortion. It seemed we rattled the cage at a very fundamental level.

I had my on-fire angry fit and took hold of the midwives association in the summer of 1985. As a result of my predecessors' mistakes, we had to take a side trip to the state supreme court. That took a few years, after which we entered the long and complex process of getting a bill to regulate a new profession to the Colorado Statehouse. The bill ran in 1992, when we lost, and in 1993, when we won. It was hard to have the stomach to go back in 1993, hard to imagine that the system I'd seen was appropriate for regulating my beloved profession. We won for a lot of reasons and against great odds. We won because grass-roots democracy can still work at the state level, which was uplifting to experience. We won because we managed to work together. We won because we were right. And we won on the force of my personality, because I turned out to be a pretty good lobbyist.

Childbirth in the US presents a conundrum of sorts. On one hand, it is extremely rare for a woman to die in childbirth. We have low rates of mortality and morbidity. However, our health statistics are not particularly great for the developed world. The US usually ranks around 28th in the industrialized world for maternal and child indicators. Most women in the US see a doctor for their care, which would be unusual in most nations with better outcomes than ours. Midwifery is the standard of care for pregnancy worldwide. Most women in America have access to regional anesthesia during childbirth, the epidural, and many women use it. Although epidural anesthesia carries substantial risk, many US hospitals have epidural rates of 80 to 90%. In many countries with better outcomes than ours, epidural anesthesia is not available to laboring women. Those women have no belief that they might "need" an epidural. It's simply not part of their culture of childbirth.

So while childbirth is relatively safe in the US, we are told that it is extremely risky and potentially intolerable. We are constantly informed of behaviors that are risky for mothers, what foods must be avoided, what new prenatal testing needs to be conducted. There is a lot we are supposed to worry about, many things to fear during pregnancy and birth. We are told that women should be cared for by obstetricians, specialty surgeons, during their pregnancies. But all this anxiety hasn't improved outcomes when compared to other industrialized nations, and our cesarean section rate is now the highest ever recorded without improving anyone's health. We are simply driving up costs with our beliefs, not improving outcomes.

Lately we are hearing from obstetrics about a woman's "right to choose" a cesarean section with no medical risk factors and no labor -- an elective cesarean with no indications. This "choice" carries enormous risk when compared to waiting to go into labor, and yet obstetrics feels it's a "choice" pregnant women should get to make. At the same time, the American College of Obstetricians and Gynecologists has a position paper against homebirth. Although homebirth has much lower rates of complications than does elective cesarean section with no indications, having a homebirth is a not a choice that obstetrics feels pregnant women should get to make.

But homebirth is alive and well in Colorado, as it is in most states. Our law is working pretty well. I was afraid for a while, afraid that the rule of law was just too weird to interface with midwifery, which can also be pretty weird. But things have mostly worked out. Now that we have access to reliable data, we know that the outcomes of Colorado deliveries attended by qualified homebirth midwives are completely up to standard, and our law allows for the prosecution of midwives who practice without the necessary qualifications.

It's hard to imagine what will ultimately become of the practice of childbirth in America, but certainly any happy ending includes lots of midwives. By promoting Certified Nurse Midwives (CNMs) as the standard of care for women in the hospital and promoting homebirths attended by Certified Professional Midwives (CPMs) as another perfectly good option, the US could improve maternal/child health outcomes and lower costs. But it will be a long time coming. That turf is pretty well defended.

As for the spiritual aspect, it worked in me completely differently than it looks in Ina May. I don't like to lay any particular trip about spirituality on my clients. There is a wide array of beliefs in this country, and I hesitate to impose what I think is the spiritually correct way to approach birth. I particularly detest notions of how women "should" feel or act in labor. I prefer to try to manifest whatever the individual family is looking for, within the realm of the possible. Spiritual midwifery for me initially turned out to be about becoming the "servant leader" of the Colorado midwives. I worked night and day for our right to do our jobs without fear of prosecution, and it's no longer illegal.

Now the journey has taken me to where I am today, a midwife in Uganda, Haiti, and Afghanistan. Everything I learned from that wild ride in the state legislature seemed only to have gotten me ready for a complete change of perspective and focus. Although I do not doubt for a moment that it was God working through me to tidy up the legal situation for homebirth midwives in Colorado, a profound spiritual experience was to lead me away from homebirth in Boulder and off to Afghanistan.

This essay is part one of a three-part series.

Jennifer Braun is the Program Director of International Midwife Assistance. IMA provides aid to areas experiencing crisis in maternal/child health. Ms. Braun has been a midwife for 26 years and has spent the last few years working in Afghanistan, Uganda, and Haiti. To learn more about IMA's work, or to offer much-needed support, please visit www.midwifeassist.org