The MacNeil/Lehrer Report; "Midwifery And Home Births: How Safe, How Sound, How Necessary?"

(Film of pregnant woman undergoing medical examination.)

ROBERT MacNEIL: Two days ago the mother you see here gave birth to a seven- pound, seven-ounce girl. The baby was delivered by a nurse midwife, who cared for the mother from the start of her pregnancy. The birth took place in a hospital bed, but not an operating room, in Concord, New Hampshire. In the words of the mother, the birth was beautifully normal. Mothers who choose midwives, not doctors, to deliver their babies are part of a growing trend nationwide.

Good evening. There are an estimated two thousand nurse midwives delivering babies today in the United States. Ten or twenty years ago there would have been far fewer, and they would have been found mainly in poor rural areas. But today midwives are practicing in major urban centers, and with middle- class women as their patients. Many of those women do not want an obstetrician or a hospital delivery room. They want a midwife, and many want to have their babies at home. Tonight, midwifery and home births: how safe, how sound, how necessary? Jim?

JIM LEHRER: Robin, they call midwifery the second oldest profession. It`s been around a long time, since Old Testament times for sure, and probably even before that. Its history here in the United States has been a spotty one. It was widely practiced here until the 1920`s, when it began to taper off. The main reason given at that time was the high death rate, both among mothers and their infants. And just about everybody began to have their babies only in hospitals and only delivered by doctors.

But now there is a swing back to midwives. The death rates are down, there`s a shortage of doctors in many areas, plus there is an apparent desire on the part of some parents for a more human, less institutionalized approach to giving birth. There are now twenty-two centers around the country to train registered nurses in the art of midwifery. They`re the certified nurse midwives, who either perform the delivery in a hospital or assist a doctor in doing so.

The other part of the new movement is the so-called "illegals," lay midwives who do it all by themselves at the mother`s home. Robin?

MacNEIL: The growth of the natural childbirth movement and the renewed desire of women to give birth at home -- or at least in a more familial surrounding -- has prompted some hospitals to establish nurse midwife programs. Rebecca Newton of Public Television Station WJCT reports on one such program in Jacksonville, Florida:

REBECCA NEWTON, WJCT-TV, Jacksonville: University Hospital here in Jacksonville is one of some 160 hospitals across the country that are bringing back the mid wife. The six nurse midwives at University Hospital are all registered nurses. After a year of practice in the field and rigorous specialized training at the University of Mississippi Medical Center, they were certified by the American College of Nurse Midwives. They perform functions that nurses cannot perform, like prescribing certain drugs, and delivering babies in medically directed settings.

All six nurse midwives keep a busy schedule, doing rounds in Ob/Gyn, seeing clinic patients at the hospital and the outreach clinics, teaching, and attending labor and delivery. They delivered over 720 babies last year. If a woman is normal, she may never see a doctor.

A highly trained nurse midwife will care for her through pregnancy, deliver her baby, and follow her for six weeks after delivery. If complications do develop, an obstetrician, who is a surgical specialist, will co-manage the patient.

Compared to other countries, the rate of medical intervention in the United States is high. It`s estimated that nine out of ten women are given drugs during labor and delivery. As high as twenty percent receive cesarean sections, and up to seventy-five percent have episiotomies. By comparison, most normal babies in Holland are delivered using no drugs at all. The rate of Cesarean sections is under four percent; episiotomies, eight percent.

The women argue that these procedures are used to make the delivery quick, convenient and predictable, rather than to protect the well-being of the mother or the baby. They point to the infant mortality statistics. Holland has the second lowest infant mortality rate in the world, while the United States ranks sixteenth.

(Film of birth carried out by nurse midwife.)

VOICE OF NURSE MIDWIFE: Well, the traditional delivery, as everyone knows, is with the bright lights and the clanging and the room is cold so the person doing the delivery doesn`t get too hot. Most of the deliveries are done under these conditions, but things can be done to make it a little more pleasant for the baby, and things like making sure the delivery is slow so the baby`s not traumatized immediately; holding the baby close to the body so the baby stays warm; drying the baby right away, which is also massaging the baby, so the baby doesn`t get cold; and then wrapping the baby and giving it to its mother.

I usually lay it across the baby`s chest on the left so the baby can hear the mother`s heartbeat, which quiets them instantly, and they feel secure; and then they usually stop to open their eyes and look around, instead of squirming and grimacing.

MacNEIL: Well, let`s talk to a woman who`s had an experience something like that. Patricia Jontow is a middle-class Manhattan housewife., She had her first child the traditional way, in the hospital with an obstetrician, but chose a midwife and a so-called "childbearing center" for her second. Mrs. Jontow, why not a hospital the second time?

PATRICIA JONTOW: Well, having my son in the hospital and then having my second child, being pregnant with my second child -- it was a family decision. It wasn`t just, I was carrying this baby and I was going to go have another baby. My son was very involved in the entire pregnancy. He was in attendance at the time that my daughter was born; that`s something that I don`t think any hospital would have allowed.

MacNEIL: So probably the reason was so that your small son could go and watch -- and your husband.

JONTOW: Yes. Also, I had received drugs when I entered the hospital, having Joshua, the first time, never having explained to me why these things were happening to me. I was put on a fetal monitor; nobody told me why I was on a fetal monitor. That was a bit intimidating at the time. My husband had to leave the room at certain points during labor; he was my support person, and I couldn`t understand why he was being led out of the room. I had an episiotomy the first time; I did not at the center, which is wonderful, because I suffered for four...

MacNEIL: Which is the cutting that requires stitches.

JONTOW: Yes, and I suffered for four weeks after. This time I was able to sit down the following day. It was a wonderful feeling. In general it was just really sort of a gut feeling. I knew I didn`t want to go back to the hospital. I wasn`t ill. Also, at the childbearing center here in Manhattan you go home within twelve hours.

MacNEIL: Let me ask you this: what did a midwife give you that the obstetrician didn`t?

JONTOW: More than just moral support. She was available twenty-four hours a day; I could call at any time with the silliest question, and it was answered; involving the whole family. I had access to my charts up at the center; that`s something that I don`t think a hospital would have allowed. It was my responsibility to weigh myself, take care of my urine when I arrived. In general, she became part of our family for nine months.

MacNEIL: Didn`t you worry at all about any possible complications in the birth?

JONTOW: Definitely.

MacNEIL: You did.

JONTOW: Yes. When I first decided to go to the center I went to my orientation meeting and I had questions that I wanted to have answered -- they were answered pretty well. Still, after having decided that I would go to the center, for about two months I was still a little bit nervous. And it was only after I had been going there a while that I realized that the nervousness just disappeared; I don`t know why it disappeared, I just became very much at home in my surroundings there, and

I knew that these people were looking out for my best interest and that by no means would anything go wrong, that it would probably be discovered before the time of labor, and even in labor if anything were going wrong I`d be transferred out.

MacNEIL: To a hospital.

JONTOW: Exactly.

MacNEIL: Would you have a baby at home?

JONTOW: I`ve thought of that. I don`t know; I really don`t think so. I think the only way I would have a baby at home is if I could provide the same equipment that the center had, and I probably couldn`t do that. And the center was so wonderful that I really don`t need to do it at home. I would go back to the center and have those people involved in my baby`s birth. We all became a family; it was very nice.

MacNEIL: Thank you. Jim?

LEHRER: Now to a practitioner of the art of midwifery and to Laudine Appel. She`s a lay midwife who works with a doctor in the Baltimore Columbia area of Maryland. She is one of the founders of Birth at Home, an organization favoring home births. Ms. Appel, first of all, how many babies have you delivered in the twenty-one years that you`ve been a midwife?

LAUDINE APPEL: Over 1,500.

LEHRER: Now, you are in favor of having babies at home. Why?

APPEL: Because of the couples who are having the babies. They feel that it`s a much warmer experience; they very definitely have more control-- over the labor itself, the management of the labor, the protocol, choices involved in the actual manner in which the baby is born; to do an episiotomy, not to do an episiotomy; to hold the baby immediately upon birth; to breast feed it immediately when it`s born; the father cutting the umbilical cord, which is not allowed in hospital...

LEHRER: Now why in the world is that important?

APPEL: It`s very symbolic to men. The woman has literally pushed the baby out of her body at birth, and she who has introduced the baby into the world from the threshold of her body -- now this is where the father of the child comes in and literally makes this a person in their own right by symbolically cutting the cord and saying, here you are, the world is yours.

LEHRER: All right. What about the safety aspects of having a baby at home?

APPEL: The women are very, very carefully pre-screened by obstetricians. We will not train anyone for home delivery, nor will we agree to attend anyone in a home delivery unless they have been seeing an obstetrician for their prenatal care and the obstetrician does certify that this particular woman is not a high-risk candidate for a home delivery.

LEHRER: Okay, but even with that pre-screening there`s still a danger that an unforeseen emergency could arise, and there you are at somebody`s home rather than a hospital. What do you do?

APPEL: We have what we have dubbed "a flying squad," and this is an ambulance from a private ambulance company wherein the drivers are paramedics -- certified, licensed paramedics -- who have also done additional obstetrical training; and they are sitting there outside the door, on call, so that if there is anything that we need in the way of equipment, whether it`s an ambu-bag, oxygen, ped`s mask or what have you, or we have to get out quickly and get to the hospital, within thirty seconds we can evacuate a mother and/or baby, and we`re on the way.

LEHRER: You work with a doctor. Explain how that works, in terms of what you do and what he does in the course of a normal delivery.

APPEL: During the actual delivery itself the woman will call either myself or the doctor when she is fairly certain that she is in labor, whether it`s very early labor or whatever point of time in labor for her. I`m usually the first to get there. My role is to assess and evaluate the particular type of labor the woman is having, where in labor she is, and to inform the physician so that the physician will know the appropriate time to get there. Mine is very definitely a support role, not just for the laboring woman but for the father as well.

LEHRER: You know some illegal midwives, I`m sure. What is their motivation for what they`re doing, those who do not work with doctors, who are not certified nurse midwives and do it on their own?

APPEL: The majority of these women themselves have had their babies at home, and it`s been a beautiful, beautiful experience for them. They feel that they, their husbands, the members of the family who have been present, have literally been partners in creation, and they want to share this with other women. There`s no other reason.

LEHRER: All right, thank you. Robin?

MacNEIL: The medical profession has watched this new trend with some anxiety, both medical and possibly economic. Doctors in general are opposed to home delivery, but give qualified support to midwife de livery. Dr. Fritz Fuchs is professor and Chairman of the Department of Obstetrics and Gynecology at the New York Lying-In Hospital, Cornell University Medical College. Dr. Fuchs, are you totally against home deliveries?

Dr. FRITZ FUCHS: Yes, I think I would say that because I`ve been through it all. I have been a midwife as a medical student, I have done home deliveries before I came to this country, I have been trained in Den mark and in Sweden -- in Sweden 99.5 percent of all deliveries are now in hospitals, although distances are very long...

MacNEIL: And what is their infant mortality rate?

FUCHS: Well, they are the leading in the world.

MacNEIL: They have the lowest.

FUCHS: Yes. Holland comes two, Denmark I think comes three or four; it`s all in the same range, but it`s a far cry to the United States, for a variety of reasons.

MacNEIL: Can midwives not deliver babies as efficiently and as safely as obstetricians?

FUCHS: Yes, in most cases they can. And the trend towards having more nurse midwives is a good one, in my opinion, because it extends the arms of the obstetrician. The general practitioner is no longer under taking deliveries in general in this country. We have not enough obstetricians to take care of all the deliveries in the country unless their arms are extended by people who have special training.

MacNEIL: Why aren`t general practitioners delivering babies any more?

FUCHS: Well, I think because they are too busy doing other things; they have to spend too much time in the home of the person if they are to attend a delivery throughout the labor, and therefore they also feel that they lack the modern training that is necessary for the obstetrician to really be an expert for all situations.

MacNEIL: Let`s go to some of the complaints that women raise; you heard some of them raised in the report from Jacksonville, Florida, and also Mrs. Jontow referred to some of them. Clearly some women feel negative about the hospital experience -- they think it`s a place for illness, not a normal function. Can we go through their complaints: that there`s too much automatic inducement through drugs; that too much use of episiotomy, too much use of forceps; and to use the phrase that the reporter, Rebecca Newton, used, to make births quick, convenient and predictable. Now, do they have a legitimate complaint there?

FUCHS: Well, I think there is perhaps something to it. In certain parts of the country it`s up to the university hospitals that teach medical students to teach them good obstetrics, which does not include induction over a broad scale but only in selected cases. The amount of drugs that is being used today is vastly less than it was just ten years ago. We have better drugs, safer drugs, and they are for the comfort of the mother; and the more comfortable the mother is, the safer is the delivery of the fetus. The episiotomy is usually done frequently at first deliveries, but when the same mother goes to a childbearing center she may not need it, and she may not have needed it in the hospital either, for the very same reason -- that the second time around there is more elasticity in the opening of the soft parts and therefore another cut is not necessary.

MacNEIL: So in other words, you think the complaints are somewhat substantiated but are exaggerated, is that right?

FUCHS: They are absolutely exaggerated; and what we should strive for is to incorporate the midwives in the hospital service.

MacNEIL: Okay. We`ll leave it there for the moment. Jim?

LEHRER: Another medical view now from Dr. John Harrigan, Director of the Regional Newborn Center at Monmouth Medical Center in New Jersey and an associate professor of obstetrics at Hahnemann Medical College in Philadelphia. Dr. Harrigan, first, how do you feel about home births?

Dr. JOHN HARRIGAN: I think there`s a general increased risk in home delivery, and we who deal in high-risk pregnancy are particularly concerned because we see the risk to the fetus. Now, we`ve come a long way, I think, in American medicine from maternal mortality, where we lost mothers. We`ve come away from the fact where we lose babies. And we come now to quality of product, and I think that`s the important thing. We have a lot of sophisticated methods now of monitoring labor and delivery, and we have no good way of predicting with a hundred percent accuracy which deliveries will be complicated. So we don`t really know who can deliver simply and easily; and that patient has to deliver in a hospital. We can predict maybe seventy-five percent, but we can`t predict the whole hundred percent, and we have to have a ready availability. When we speak of transporting patients in, we speak of a lot of time. The patient arriving at a hospital where the staff doesn`t know much about her, being told about her complication, having to muster their forces then, and the fetus at risk -- at risk from monoxia and destroying brain cells, if you will. So when we talk of quality of product, we`re thinking about eliminating cerebral palsy, mental deficiency, soft neurological signs, all these very subtle disturbances now; we`re not thinking about losing mothers and babies. And we even think, in our large institutions, about start-up time for Cesarean sections and emergencies. We think twenty minutes might be too long from the time we decide to do it to the capability of being able to do it. So I think we`ve come a long way, but I think this whole business of delivering at home is a positive factor in that consumers are becoming more knowledgeable, they`re becoming involved in health care. And certainly the way we deliver the normal pregnancy in the hospital is not ideal; and certainly delivery at home is not ideal, and I think the truth is somewhere in between these two.

LEHRER: I want to talk about the hospital a moment, the same question that Robin asked Dr. Fuchs a moment ago, and that`s the complaints that obviously people have about birth in hospitals. Are they legitimate -- what`s your view of that?

HARRIGAN: I think complaints are healthy. I don`t think any of us would think that we`re perfect; and certainly in any institution there should be complaints, because not everything is going to go right all the time, or to people`s desires. So we have knowledgeable consumers; I think they can be a force in changing the institution. And as you know, the institutions are slow to change, and this is not altogether doctors or hospital administrators; the state and federal regulatory agencies must also change their regulations. One example of that is that in our institution we`re moving to birthing rooms, where patients labor and deliver in the same room. There`s no state regulation in New Jersey which permits this, so we first must change the state regulation. Consumer groups can be very helpful there in changing that.

LEHRER: Doctor, let me ask you this, looking down the road: what do you think that this new interest in midwifery and home births and all these new developments are going to really cause down the line in terms of the way babies are born in this country? Are we going through a significant change, and what do you see at the end of that change?

HARRIGAN: Well, I think we have a constant evolution that has been going on in the way babies are delivered; and certainly, as Dr. Fuchs mentioned, we need midwives -- we need them in the hospital setting to extend the obstetrician`s capabilities because if an obstetrician is running around taking care of normal cases oftentimes he can`t concentrate on the problem cases. So we need a team approach to medicine; I think we`ll see that. I think we`ll see institutions changing along the lines of delivering in a labor room that looks very homelike. We already have family center care, we have husbands and children involved in this whole business, and I think we`ll move patients out of the acute care setting in the hospital, because this is necessary economically, after perhaps one day into a day-stay center of some type where it`ll be very family-oriented. It`ll save health care dollars, and I think that`s the way we`re going.

LEHRER: All right. Robin?

MacNEIL: Let me put this question to all of you, and I`ll start with you, Mrs. Jontow, because you were shaking your head so much when Dr. Fuchs was talking particularly: just in conclusion, is this trend -- and ask yourself this question, personally -- is this trend not putting a greater value on the mother`s enriching experience than it is, in absolute terms, the safety of the baby?

JONTOW: For me personally, no; that wasn`t the case. It was an enriching experience, but that was incidental. My primary concern was the safe delivery of that baby. I think the two just happen to go hand in hand.

MacNEIL: Dr. Fuchs?

FUCHS: Well, I think we must think of the total safety of the baby; we cannot be satisfied with having ninety-five percent safety of the baby. Today, when we have fewer and fewer babies, we have to be sure that they are all optimal at the time of birth. The obstetrician has to be there because something can happen to the five percent. The best thing that can happen is the obstetrician standing with his hands behind his back and have the midwife deliver the normal cases; but he must be there. He is paid for his expertise, not for catching the baby.

MacNEIL: Ms. Appel in Washington, in response to my question, and also a point that was made by Dr. Harrigan, is it not putting the woman`s enrichment before the safety of the baby, this new trend, in your view?

He pointed out that your ambulance might be too late.

APPEL: Our ambulance is not too late. It is there sitting at the door while the woman is in labor. If we suspect that a complication is in the offing, we evacuate -- we go in hospital. But we have been working with a physician prenatally with the woman. The physician is aware the woman is in labor; and in the event that we do have to go in, regardless of what the complication is, the physician has already primed the hospital. They know this woman`s medical history, just as her physician does. They know what`s going to happen when the woman arrives there. Needless time is not wasted trying to find out what is this particular complication with the woman. There`s a continuity there of care. This isn`t an old witch coming out of the woods with bloody hands, wiping them off on her skirt delivering a baby. This is a very, very well-thought-out, carefully planned type of birth movement here at home.

MacNEIL: Thank you, Ms. Appel; we`ll have to leave it there. Good night, Jim.

LEHRER: Good night, Robin.

MacNEIL: Thank you all here. That`s all for tonight. Jim Lehrer and I will be back tomorrow night. I`m Robert MacNeil. Good night.