May 9, 2005
By Robin Ewing

Middle-school teacher Lori Osborn rents a tiny two-room house in central Austin. The kitchen, wide enough for only one person at a time, opens to an outside deck with potted flowers under strings of colored Christmas lights. The cozy bedroom just fits her canopy bed and television, and the rumbling of the window unit doesn’t quite cover the beeps and clangs of construction on the heavily-trafficked street just outside the door.

Though Osborn has been living here with her husband for the last 10 months with no plans to purchase the house, it has been long enough to consider it home, she says. This is where she plans on delivering her first baby in September.

“I wanted a natural childbirth. A midwife just clicked,” 32-year-old Osborn says of her decision. “My only concern is that it’s going to be safe.”

Though Osborn is part of a growing trend of women nationwide who are choosing midwives over doctors, she is one of a dwindling group in Austin.

Travis County lags behind both Texas and the nation in employment of midwives and the number of midwife-attended births. During the last two years, Austin, the only major city in Texas without a hospital midwifery program, lost nurse midwives. This limits birth options for Austin women, says Libba Letton, president of the Austin chapter of Texans for Midwifery, a consumer support group.

“Midwifery is about informed choices and protecting those choices,” says Amy Chamberlain, a board member of Texans for Midwifery. “There is a real need for midwives.

In Texas, there are two types of midwifes: certified nurse midwives and documented midwives. Nurse midwives, regulated by the Texas Board of Nurse Examiners, are registered nurses who have graduated from a nurse-midwifery education program and are certified by the American College of Nurse Midwives. Nurse midwives usually work in hospitals.

Documented midwives, also called direct-entry or lay midwives, must have a high-school degree and have completed one of Texas’ three approved education programs. They are licensed by the Texas Midwifery Board, part of the Texas Department of State Health Services, and deliver at women’s homes or in birthing centers.

The percent of midwife-attended births in the United States has risen steadily to 8 percent in 2002, reports the National Center for Health Statistics. These women are choosing midwives over doctors for a number of reasons, including emotional support and the choice of natural childbirth.

Chamberlain delivered both of her daughters with midwives in the hospital. “It seemed too good to be true that someone will be there for you the entire time – someone you have a relationship with and trust,” she says.

“Throughout time, it’s been a natural female occurrence,” says Cheryl Geovia, a 40-year-old Austin middle-school art teacher who had both of her daughters at home with a midwife. “It’s a false idea that a man who went to college is more experienced than a woman.”

Most midwives in Austin practice the “Midwives Model of Care,” a philosophy of health care and education that says it reduces intervention, such as inducing labor or performing Caesareans.

Julia Bower, a former nurse midwife in Austin, describes the model as treating women as a complete “unit.”

“The care under a physician is so fragmented. Midwives stay with the mother during birth sometimes for more than 24 hours. At a hospital a nurse checks you and calls the doctor and the doctor might not come in until it’s time to push,” Bower says. “A midwife takes care of the baby and the mother and takes care of lactation. An obstetrician doesn’t know a lot about nursing.

“The big difference is that a midwife’s visit lasts an hour. With OB/GYNs the nurse does everything, and the doctor spends five minutes with you,” Bower says.

Osborn initially saw an OB/GYN before deciding to switch to a midwife. “The last time I went, I waited an hour and a half.  I left before I saw him, because I decided that’s not what I want,” she says.

Osborn visited a birthing clinic before deciding on having her baby with a documented midwife at home. Though she is confident in her choice, she calls it a “forced decision.” “You have to have one or the other,” she says.

In the United States, home births, such as Osborn and Geovia, are in the minority. Ninety-nine percent of all births in the United States were in hospitals in 2002. In the 1990s, hospital midwife births more than doubled. Travis County followed suit until 2002, when Seton Medical Center and Brackenridge Hospital cancelled their midwifery programs. In 2003, Travis County nurse-midwife births were down 70 percent, and despite a small increase in documented-midwife births, midwife births accounted for less than 2 percent of total births, according to data from DSHS.

“There are just no job opportunities here,” Chamberlain says. Ninety-seven percent of certified nurse midwives work in hospitals, according to the American College of Nurse Midwives.

Mary Barnett, a nurse midwife, lost her job at Women Partners in Health at Seton. With 22 years of experience, a master’s in nursing and over a thousand babies delivered under her care, Barnett started her own home-birth practice.

“Self-determination is a nice thing,” Barnett says of her year-old business. “Yet I would still like to have hospital privileges.”

Of the six nurse midwives who worked in the hospitals, Barnett is the only one still delivering babies in Austin, and the only nurse midwife in Austin with a home-birth practice.

“I was doing six to eight births a month before (at the hospital). Now I’m doing two to three,” she says. “My pay is a lot less and my pace is a lot slower.”

Outside of starting a business like Barnett, employment for midwives in Austin is limited. Austin has two birthing centers – the Austin Area Birth Center and the New Life Birth Center – which together employ five midwives.

After 25 years in Austin, Susan Wente, a nurse midwife at Brackenridge, moved to Michigan for financial reasons. “She lost her job and was the main breadwinner for her family. Unfortunately she had just bought a new house, and she had to sell it,” Barnett says.

“All of the women working at Seton and Brack were very experienced,” Chamberlain says. “It’s a shame they can’t do what they want.”

Technically, the hospitals, both managed by the Catholic nonprofit Seton Healthcare Network, didn’t cancel their midwifery programs. The implemented hospital policies still allow nurse midwives to practice if they have both a sponsoring physician and a physician in the room during birth. Since no physician is willing to take on the extra liability or spend the time as backup, the midwives can’t get sponsors.

“What doctor is going to want to sponsor a midwife? It’s ridiculous – sort of a Catch 22 situation,” Letton says. “This rule requires an additional physician, in addition to the one already on call. Insurance isn’t going to pay for two professionals.”

“No physician wants to assume that liability and to take that time. Nor should they,” Barnett says. “We don’t need supervision.”

Doctors say the midwifery programs lost money. “At Brack, the reason they kicked them out is because of malpractice insurance. They weren’t generating enough business to justify their existence,” says Dr. Kimberly Carter, an OB/GYN at St. David’s Hospital and a member of the Texas Medical Association. “They weren’t paying for themselves and they couldn’t pay for their overhead, so they let them loose.”

Supporters of hospital midwifery accuse doctors of pushing out the competition. “Physicians who have privileges at the hospital are making the rules. I don’t think that’s fair that a certain profession can make those kinds of decisions because midwives take low-risk pregnancies away from doctors. These are the doctors’ bread and butter,” Chamberlain says.

Chamberlain also points to the high cost of epidurals, about $2,500 she says, and Cesarean sections as economic incentives for hospitals – things midwives can’t provide.

Midwives charge between $1,600 and $3,000 for a home birth, which includes all visits and “catching” the baby. The average price of a birth at the Austin Area Birthing Center is $3,500, says Stacy Jamail, office manager. Carter, an OB/GYN in Austin for more than two years, says she sometimes only gets paid $700 for a delivery. “For Medicaid it’s about $1,500,” she says. However, a Cesarean or labor inducing drugs can run the cost up.

Insurance plans, such as PPO, generally cover the cost of a midwife, though home-births are considered out-of-network. Osborn, however, has to cover the cost out of pocket since her HMO plan won’t pay for a midwife.

Supporters of midwifery point to the Texas Medical Association as a powerful lobbyist against midwives.

Carter, a member of the association, says that she doesn’t object to nurse midwives, only documented midwives. “Certified Nurse Midwives are true professionals and a great asset to medicine,” she says. “Documented midwives are not trained medical professionals. They are dangerous with a complete lack of judgment on their part.

“I have a vivid memory of a woman with 210 blood pressure that came in and she stroked. They let her be that way for 32 hours. That is not a low-risk pregnancy.”

Geovia – who also trained as a midwife apprentice but didn’t finish her studies – specifically chose a documented midwife for her second home birth. “I prefer a lay midwife because she doesn’t inject fear,” she says. “My midwife was a 300-pound, 60-year-old, 5-foot-11 Texas woman from the Valley who had been attending births since her teens. She could have picked me up and run me to the hospital if she needed too.

During the birth of Geovia’s first daughter, the umbilical cord was pulled into the birth canal and the baby’s oxygen was cut off. “The midwife told me to ‘get in the bed and push that baby out now.’ My adrenalin and instincts went into play and it took three pushes,” she says. The baby was born grey, but within 20 seconds of receiving oxygen she turned pink and started breathing, she says.

“If that had happened in the hospital it would have been a very violent Caesarean,” she says. “It was a freak event.”

Two years later, Geovia decided to have her second baby at home with a midwife. “Everyone thought I was nuts to have another home birth,” she says. “But birth in a hospital is too dangerous with a man in a white coat and a bunch of drugs.”

Part of Geovia’s refusal to give birth in a hospital is linked to the growing rate of Caesarean sections in the United States. In 2002, the number of Caesarean births reached an all-time high of 26 percent, according to the National Vital Statistics Report.

“It’s an epidemic of inductions – which leads to a higher rate of intervention like a C-section,” Chamberlain says.

“They think we cut people on a whim and in some hospitals that may be,” Carter says. “But we use good common sense. Twelve to 20 percent of deliveries should be operative vaginal or Caesarean to prevent permanent neurological damage.”

Osborn says not having a doctor available if there is an emergency worries her, but she trusts the judgment of her midwife.

“I trust that my midwife will know if I become a dangerous pregnancy,” she says. “In that case I have no qualms about going to the hospital. I didn’t really want to do it in my small little rent house but for me, having a midwife is more important.”