While pregnant with her first child in Portland, Oregon, Bangor resident Marie Schramke sought a birthing environment that was private, supportive and personal. She ended up having a physician-supported home birth. So when it came time to have her second child in Bangor, she looked into similar options and settled on another home birth, but this time overseen by a certified professional midwife, Chris Yentes.
“It was a very personal and intimate thing for me and I wanted someone who had a personal relationship with me,” Schramke said. “The other piece of it was really about control in a sense, I wanted to be able to walk around, bounce on a ball or eat a piece of toast during labor if I wanted to.”
In Maine, midwives like Yentes are not required to be licensed by the state which means they are limited in what types of medicine they can prescribe and how much access they have to routine medical procedures such as ultrasounds and blood screens. That may change within the next year.
A group of midwives and other labor and delivery professionals are spending the better part of the coming year hammering out a licensure structure and next year plan on proposing a legislative bill that would require midwives to be licensed by the state.
For now, a concept draft of the bill, LR 1132, An Act To Ensure the Safety of Home Births by Licensing Certified Professional Midwives, has been submitted to the state by state Sen. Amy Volk, R-Scarborough. Volk said the legislative committee has the year to create the bill’s language, and is working with a professional facilitator to ensure the final language addresses concerns from both those in favor and opposed to licensure.
Midwifery in Maine
For the most part, midwives in Maine fall into two categories — certified professional midwives who attend home births and certified nurse midwives who practice in and out of hospitals.
This is the second time in recent history a bill to license midwives has been proposed. In 2008, a voluntary licensure bill was introduced and while the original bill failed in the senate, at the final hour a new proposal was passed that did not create licensure, but gave midwives access to five medications.
The five medications midwives are allowed to administer are oxygen, lidocaine, Pitocin, vitamin K and an eye antibiotic. It means they are the only non-licensed healthcare providers in Maine that have legal access to drugs.
Currently there are no regulations in Maine regarding who can attend births and call him or herself a “midwife.” However, about half the states in the country have laws around licensing home birth midwives including neighboring Vermont, which has required midwives get licensed by the state for 15 years. Two states — Nebraska and Alabama — prohibit home births attended by certified nurse midwives.
According to the American Congress of Obstetricians and Gynecologists, approximately 25,000 births in the US per year occur at home, and about one fourth of these are unplanned or unattended.
A delicate relationship
Despite a common, and sometimes accurate perception that midwives and obstetricians do not work well together, many OB/GYN offices in Maine have midwives at their practices.
Dr. Paul Smith, of Bangor OB/GYN, said his partnership with the midwife in his office allows him to offer his patients options.
“My goal is to provide choices for my patients,” he said. “Some patients want a different style of management at the bedside … it’s all about offering choices.”
Smith added Midwife Stephanie Cole, who brings years of both professional and personal experience he couldn’t offer like lactation consultation and stories of her own birth.
“She brings a level of credibility and just a different perspective that enhances my practices and what I offer my patients,” he said.
However, Smith is insistent that midwives like Cole should have a physician like himself backing them up because of the risks associated with birth.
“You never know,” Smith said. “You can think things were fine and it can change in an instant.”
He would not comment on his opinion about the bill specifically but said he has “faith in the legislative process and [is] confident that the outcome will emphasize full disclosure and safety for the patient and her unborn child.”
Because home birth midwives are not licensed by the state, they cannot administer ultrasounds without a physician. Certified Professional Midwife Laura Donnelly said some are more willing to help than others.
“Doctors are as varied as other people,” she said. “Some are vehemently opposed to home birth, others are really supportive.”
However, she said, there is some hesitation.
“Most tolerate homebirth midwives, but they aren’t actively hostile or actively helpful,” she said. “Liability concerns and differences in philosophy keep many doctors from having a good working relationship with homebirth midwives.”
One reason could be the philosophical difference between obstetricians and midwives.
Donnelly said midwives approach pregnancy and birth as a normal, healthy process and operate under the assumption that things are going well until they aren’t. Some doctors, on the other hand, may only consider birth normal after it’s complete and nothing has gone wrong.
Studies show both sides of the equation. Most say there are several specific conditions best managed in a hospital setting including fetal growth restriction, a baby who is breech and premature labor. However, others show that otherwise healthy women and babies are at no greater risk birthing at home than in a hospital.
“The well-done studies show that a home birth is just as safe from a mortality and safer from a morbidity standpoint,” Donnelly said.
She always talks with her patients about risks associated with birthing at home.
“What I say to my clients is there are risks to having a home birth that you do not face in a hospital, but there are risks to a hospital that you don’t have at home,” Donnelly said. “Neither option is risk-free so the question is: Which set of risks do you feel more comfortable with?”
For Schramke, the risks were outweighed by her desire to birth at home. However, that isn’t true for everyone.
Bangor mother of two, Carolina Rave said she didn’t consider a midwife birth for her first daughter and when pregnant with the second, ultimately decided a hospital birth was the better choice for her family.
“I wasn’t very familiar with the midwife and homebirth option when I had my first baby, and for my second one, I decided to just do what I knew by then — same doctor, same birth plan, same process,” Rave said. “If I had known better, maybe I would have considered the midwife alternative.”
Envisioning the future
In the coming year, a group of birthing professionals including Certified Professional Midwives, doctors, nurses, nurse-midwives, and lobbyists from the Maine Medical Association and the Maine Association of Certified Professional Midwives, will draft a licensing bill together, Donnelly said.
One of her hopes is that licensure would increase the number of medications midwives could administer including antibiotics for Group B streptococcus, more anti-hemorrhagic drugs and Rhogam which is given to Rh-negative women.
Donnelly also hopes the bill will include language that would recognize women’s rights during pregnancy and birth.
“Midwives fill an important gap in maternity care and women have the right to make an informed decision about where, when, how and with whom they will give birth,” she said. “Women should have access to a complete range of options.”
But Smith has a different hope. He hopes the licensure debate leads to a different idea — a low risk birthing center in Bangor
“This town needs a birthing center,” he said. “I don’t know that licensing midwives is the answer, but a birthing center that is midwife-managed, physician-supported would give women choices that would make their birth more like what they imagined.”