By Tamara Braunstein
When undocumented workers Miguel and Norma first migrated from Monterrey, Mexico, to the United States with their two children in 2003, their only experiences with prenatal care and birthing was in hospitals.
Now, as the couple, whose last names have been omitted to because of their immigration status, look toward welcoming twins in June, they find themselves in unfamiliar territory, and not just because they don’t speak English.
Miguel and Norma are part of a growing movement in the country to rely on midwives for health care during and after pregnancy and childbirth.
Despite cultural and economic differences though, the pair seem split in their approach to the new experience.
Midwives “don’t really exist where we’re from,” Miguel said. “You can’t really compare them. This is a clinic. It’s not a hospital.”
But that doesn’t really matter to Norma, because she feels comfortable with her caregivers.
“It would be better if they could actually come to the birth,” she said.
Norma’s concerns underscore the battle currently being fought by the Manassas Midwifery and Women’s Health Center, a non-profit clinic that caters to uninsured or underinsured patients.
The center, which opened on Aug. 3, 2009, is headed by Certified Nurse Midwives Sheila Mathis and Kathleen McClelland. Mathis and her husband, Derrick, founded the operation after she noticed that a portion of her community – namely, minority females – were not receiving the health care it deserved, she said.
“Predominantly, the women that we serve are women who would have a hard time finding help elsewhere,” McClelland said. “Not even the health department was providing care for women with Medicaid.”
Since the facility opened, it has been operating steadily at maximum capacity levels for its small staff, mostly because of word-of-mouth from patients, said Erika Hernandez, a medical assistant and Spanish-English translator.
McClelland said about half of the clients speak only Spanish.
“A lot of them come in scared because they don’t know if there’s going to be someone who speaks their language … but since I’m here they feel more comfortable,” Hernandez said.
Norma agreed. She said she’s nervous about being in the hospital, without the translations system she’s used to.
The center currently has a working relationship with Prince William Hospital, located across the street, which requires the midwives’ patients give birth at the hospital.
But the midwives are not permitted to accompany their patients during the birthing process.
“The hospital administration needs to know that’s what the patients want,” Hernandez said.
The center’s primary contact in the hospital, Theresa Post, said she was not authorized to comment about the situation, and other hospital officials did not return phone calls.
Mathis and McClelland are in the process of seeking out special privileges to allow them to stay with their clients throughout the entire birth. So far, McClelland said, the hospital has not given any hint toward that being a possibility.
When she spoke with the Department of Medical Credentialing at the hospital, McClelland said they told her that the hospital doesn’t give midwives credentials. But they do give advanced nurses special credentials in certain situations, “so they don’t really know what to do with us yet,” she said.
The situation is not an anomaly. Across America, opinions are divided regarding midwives’ role during births.
Susan Hodges, president of Citizens for Midwifery, a non-profit organization seeking to make midwife services universally available to all childbearing women, said the medical community is the problem.
“Hospitals are businesses … normal labor is unpredictable and hospitals can’t organize staff and resources in a cost-efficient manner to deal with it,” she said.
McClelland has experienced first-hand the fallout of this debate. About 10 years ago, she was employed by a major hospital as one of four certified nurse midwives on staff. They worked nights, weekends and holidays for almost four years, she said, when the obstetricians were off duty. Then, the hospital laid them off with just a couple of weeks’ notice.
“I guess they felt they could save money by having private [obstetricians] take turns with our shifts … if there was another reason, it wasn’t made known to us,” McClelland said.
Hodges said that she has heard from many nurses over the years who admit that when working in a labor and delivery unit, it is not uncommon to be told that their job is to get as many women as possible to have an epidural.
Midwives promote the exact opposite.
“We seek to make women central in the care we provide … they make the decisions about their needs,” Mathis said.
When in labor then, midwives encourage mothers to deliver naturally, meaning no drugs and no surgery.
“Left to their own ability to labor, women deliver their babies just fine … that doesn’t mean they should deliver unattended; even other countries have people go to homes to help monitor births,” Mathis said.
So, Hodges, said, the major question in the debate should be who decides what options mothers have and how those decisions are made.
“Right now, there’s no accountability,” she said.
As an example, Hodges said it is extremely difficult for midwives in the state of New York, where she is based, to practice home births right now.
“It’s a little bit like forcing Ford to get permission from General Motors to open a showroom,” she said.
To give expectant mothers a better idea about the issues in the midwife vs. doctor debate for childbirth, Mathis and McClelland recommend watching the documentary, “The Business of Being Born.” In the film, executive producer Ricki Lake calls the hospital birth process “a snowball effect” of drug administration, which can create a confusing and frightening experience, rather than the intimate and deep encounter she believes is meant to occur naturally.
Women in the film agree that they were “not allowed” to have long labor sessions in the hospital, which is where labor-inducing drugs like pitocin come in. Often, once pitocin in administered, the patients are more likely to opt for an epidural because of the pain produced from the intensified contractions. But epidurals can counter the effect of pitocin, slowing down the labor process. As the cycle of drugs carries on, the baby can begin to suffer, forcing the mother to deliver via emergency cesarean section.
As a result, the United States ranks poorly in maternal and perinatal mortality rates, the rates at which mothers and babies, respectively, die during the birth process.
In March 2010, Amnesty International published a report “Deadly Delivery: The Maternal Health Care Crisis in the USA,” which found that “maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006.”
Often, when patients first arrive to the clinic, they rely on Hernandez to communicate their needs for them to the midwives, she said. But, in the hospital, their experience can be rushed and less personal.
“The fact that our hospitals are businesses can really create a conflict of interest,” Hodges said. “Organized medicine has long taken a stand against any form of medicine by a midwife without supervision because they believe it’s more dangerous. They don’t have studies or reports to back it up, they just put that viewpoint out there.”
Mathis said many women go through with surgery because of fear related to the birth process. ”With C-sections they can schedule them, it’s a short procedure, so they feel it’s a better option,.”
By disallowing midwives to accompany their patients in the delivery room, the fear is that the birthing experience becomes mush harsher and options are not fully discussed, McClelland said.
Even if they were granted access to the delivery rooms though, the certified nurse midwives would still need a doctor to agree to supervise the births.
Some hospitals might opt to only allow doctors to administer the births though, because of the predominant preference in the medical community for doctors, Hodges said.
“These positions are not based on any scientific evidence … there’s this attitude that ‘well, we went to school for 89 years …’ but that doesn’t mean they have the experience,” Hodges said.
A hospital receives the same amount of insurance payment regardless of how long it takes a patient to deliver their baby, she said. That creates an incentive to get as many patients through the process in as little time as possible, and the added services, drugs and surgeries, can increase costs, she said.
“I’m not accusing any hospital of deliberately adding on services … but the fact of the matter is there’s an incentive,” Hodges said.
With midwives encouraging their patients to deliver naturally though, Hernandez said, they can actually save hospitals money.
“It’s cheaper for a hospital to have a midwife on staff because they’ll encourage [patients] to go natural, and recover at home. That takes the burden off of the nursing staff,” Hernandez said.
While Mathis and McClelland would love to be able to accompany their patients for that reason and for their patients’ comfort, there seem to be a lot of issues to work.
“We haven’t gotten as far as really pressing the point … we’re trying to first meet the basic needs of our patients,” McClelland.
More than health care
If Mathis and McClelland are unable to gain the credential privileges they hope for, they’re also looking at the possibility of starting a birthing center, to continue their practice without the rules and constraints of the hospital, McClelland said.
“I honestly think if we opened a birthing center it would scare the pants off the hospital … about 99 percent of our patients would just skip the hospital,” Hernandez said.
But, she also hinted that if Mathis and McClelland can get their access permissions for the labor and delivery unit, the idea of a birthing center might fade away a little bit.
“If they’re nice and friendly and let [Mathis and McClelland] in there, we might opt for hospital births,” Hernandez said.
The birthing center would be a viable extension for the clinic, which operates more as a care center for women, at discounted rates.
“We have a lot of walk-ins,” said Janika Ellis, an office assistant at the clinic. “In the end, I think they realize the cost difference … we had a lot of patients looking at the costs like ‘oh my gosh, one of [another doctor’s office’s] labs is $1,500,’ and our whole cost is $2,000.”
The fees for the clinic include pregnancy check-ups from the time the woman finds out she’s pregnant, but many women come to the clinic to start their care considerably late in their pregnancies.
“The reason isn’t because they don’t want prenatal [care], it’s because of the system,” Hernandez said, referring to the costs and insurance issues that many undocumented workers face with health care.
“They just don’t know that help is out there … you don’t want patients to forgo exams, so why make them a-la-carte?” she said.
Since the clinic recently acquired non-profit status, so it can receive grants — like the one it received from March of Dimes to begin offering Centering Pregnancy, a new model prenatal care in a group setting — the staff hopes that a birthing center could also become a reality.
“The sense of community has been broken in this area … so many of our women come from transient families, so their immediate family members are not available to support them,” Mathis said.
A birthing center, in combination with the centering pregnancy classes, could help restore that supportive community aspect not only between the mothers but also between the patients and their care providers.
“We know that none of us will get rich, but we want to provide the best care … this [clinic] belongs to the community,” Mathis said.
Hodges said there is often a significant overlap between a birth center and a home birth, so patients might feel more comfortable giving birth in a center than in a hospital.
In the past, licensed birth centers could accept Medicaid patients, but Medicaid would not pay the facility fee related to the birthing center. It did pay a facility fee to hospitals for their births. As a result, it was much more difficult for birthing centers to accept Medicaid patients, who tend to be low-income patients, Hodges said.
With the new health care bill though, Medicaid is required to provide a facility fee for birthing centers. And nurse midwives will make the same amount of money that obstetrician-gynecologists make.
“I had a home birth with a midwife who had a legal service in the state of New York, but insurance wouldn’t cover it,” Hodges said.
Now, since insurance would cover more of the cost involved with birthing centers, and since birthing centers can provide a comparable experience to a home birth, there may be more incentive for women to opt for a center instead of a hospital.
“The quality of prenatal care outside of a hospital is superior and is the most important factor to preventing problems during birth,” Hodges said. “Hospitals’ nurses have high case loads so they can’t give the same care.”
When it comes down to it, Hodges said, it’s important for women to do their homework and figure out what kind of care they’ll get from different providers.
“In the hospital the physicians really call the shots,” she said.