Licensing and Protocols

While I am a very strong supporter of licensing direct-entry midwives, I am fearful of what this might mean for consumers and midwives too. The benefits of licensing are many. Here are some examples: decreased possibility of arrest and criminal prosecution of midwives; increased ease of locating midwives; increased training opportunities for aspiring midwives; more midwives; increased likelihood of third party reimbursement; and the potential to improve collaboration with other health care providers. (I emphasize potential, because this is not always achieved.)

Licensing, however, is not a win-win situation. While all respectable midwives follow protocols, protocols mandated by law can be too extreme, and thus could eliminate the option of a homebirth for many women who would have previously been able to find assistance from an unlicensed, illegal, direct-entry midwife. Depending on how the law reads, such factors as previous Cesarean section and unusually long labors could eliminate the possibility of homebirth. I recently read an article on homebirth in England. Women attempting home birth were transferred to hospital if they had pre-labor rupture of membranes greater than 12 hours. This protocol is very conservative. Six percent of the women who began labor at home were transferred for this reason. There were many other reasons for women in the group to have their babies in a hospital rather than at home. Only 51% of the women who had requested homebirth delivered at home.^*

Personally, this is of particular interest because of the details of my daughter's birth. Knowing that some of the events that occurred with this birth break many medically established protocols (and perhaps some midwifery protocols as well), I am somewhat reluctant to disclose them. I am not embarrassed about what occurred at the birth. I am grateful that my midwife facilitated and monitored, so that I was able to stay at home. I am proud of her and respect her knowledge, training and skills which enabled her to provide direction based on my individual needs and circumstances. Without this kind of guidance, I certainly would have had a medical birth. My reluctance to disclose is based on the response I anticipate from my birth story. It's not that I don't enjoy debating homebirth issues. Debate takes on an added, emotional dimension when the factors involved are personal. But for the greater good, here it is. Additionally, I stress that my midwife did not break any of her protocols. She is unlicensed and unregulated.

My water broke with a squish just before 8:00 a.m. on Tuesday morning, and I continued to squish out a bit of water here and there throughout the labor. I had been experiencing mild contractions since 1:30 in the morning. I awoke but was able to go back to sleep until my alarm woke me at 6:30. (At this time, to my husband's surprise, I was contemplating going to work. When my water broke, I decided to stay home.) My labor progressed as expected throughout the day and into the night. The contractions really got serious during the night and I think everyone (me, my husband, my midwife, her apprentice and two close friends) anticipated a birth before dawn. When the sun rose, my labor changed drastically. Contractions slowed from one on top of the other to one per hour. To everyone's surprise, this slow-rate of contractions continued until the sunset Wednesday evening. Then things got serious again. On this second night, my labor progressed similarly to the first night only this time, I had the good fortune of experiencing back labor. The sweet little one must have turned posterior. Fortunately, as the sun rose Thursday morning, Erin was born (6:07 a.m.). Pushing was easy and short and she was born anterior. Go figure. Her one-, five- and ten-minute APGARS were 6, 9, and 10. She weighed-in at eight pounds even.

Evaluation of this labor and birth, reveals prolonged labor (52 1/2 hours if you count from the first signs of labor); prolonged rupture of membranes (46 hours); and contractions which would have likely been classified as ineffective in a hospital. My midwife monitored closely my situation. Since I showed no signs of infection, and there were no signs of fetal distress, I remained at home. In many localities, the state-sanctioned midwifery protocols would have required my transport to a hospital. Perhaps I was lucky that I was assisted by an unregulated midwife.

^* Davies J; Hey E; Reid W; Young G. Prospective regional study of planned home births. British Medical Journal, 1996 Nov 23; 313 (7068):1276-7.