In December 2004, Teri Stone-Godena and three other midwives gathered in a New Haven home to do what they do best: deliver a baby. The set-up was markedly different from the cramped hospital room most people believe to be the most suitable place for a woman to give birth. Instead of disconnected P.A. announcements, the only background noise was the low murmur of the midwives’ voices. Instead of neutral beige walls and tackily upholstered chairs, the mother-to-be, Arianna Stein, was surrounded by the familiar comforts of her own kitchen. And, instead of lying on a sterile, mechanical bed, she relaxed in the warm water of a birthing pool.
The woman and her husband, Josh, remained in the pool for her entire 12-hour labor. “She gave birth to Gracie in the tub,” Stone-Godena said. “And then she pulled Gracie up—Gracie didn’t remain floating underwater—she pulled Gracie up to her chest and we wrapped them all in a nice warm towel that we’d heated in the microwave.”
This story could be misconstrued to support the notions most people have about midwives: unconventional, placenta-eating relics of a time when medical knowledge was minimal at best and flat out dangerous at worst. And while Stone-Godena cheekily combated the stereotype by posting a sign reading “No, You May Not Bring Your Dog in To Eat the Placenta” on the wall of a birth center where she once worked, today’s midwives serve a larger and more varied group of patients than the general population assumes. Arianna Stein is not a neo-hippie; she is a midwife herself, who wanted to give birth among her own. Her husband is not an uninformed follower of alternative medicine; he is a doctor. And Stone-Godena herself remembered Gracie’s birth from her office at the Yale School of Nursing, where she is a lecturer, blocks away from Yale-New Haven hospital, where she practices the majority of her midwifery.
In the United States, one out of every ten babies is delivered by a midwife. In New Haven, the percentage is much higher—one out of every three babies at Yale-New Haven Hospital is delivered by a midwife. The Yale School of Nursing is largely responsible for this number. It is one of a handful of institutions in the country that offers a nurse-midwife program, and many of its graduates choose to remain in New Haven.
Although New Haven is an extreme example, midwifery is a common phenomenon in the United States. Today’s midwives have little in common with those mentioned in high school history lessons; they are not grizzled old women who attend childbirths armed only with knowledge accumulated through trial and (often fatal) error. Modern midwifery is an extension of conventional medicine; almost all midwives graduate from an institutional program like the one at Yale’s School of Nursing, which trains students as midwives and nurses. Most go on to either work at hospitals or join private obstetrics and gynecology practice.
But in spite of their pervasiveness and qualifications, midwives often find themselves struggling to prove their legitimacy to patients. “It always comes back to that concept of people who don’t know about midwives saying ‘Why would you see a midwife? You have private insurance, you have enough money to see a doctor,’” said Debbie Cibelli, who, along with her business partner Linda Lisk, operates one of the few midwife-owned practices in Connecticut. But while she may be skeptical at first, once a woman begins to see a midwife, whether she actively seeks one out or, more likely, stumbles across one in a physician practice, statistics show that she is unlikely to return to physician care for future childbirths or regular gynecologist appointments. Such women value the unique kind of care that midwives offer, where basic medical techniques used by physicians are complemented by a degree of empathy and personal attention rarely found in modern medicine.
Eight years ago, Alycia Clune experienced what she had believed to be impossible: She became pregnant. Clune and her husband, Tim, had been plagued by severe fertility problems and had resigned themselves to not having children. When she discovered that she was carrying their son, Clune knew that she wanted to take every measure to ensure her pregnancy’s success. Having spent years as a nurse in the obstetrics department at Bridgeport Hospital, Clune was aware of the risks associated with childbirth. But, unlike many women in her position, she did not want her pregnancy micromanaged by physicians, reduced to blood counts, ultrasound images, and amniocentesis results. She wanted a midwife.
“I never wanted the people I worked with to take care of me,” Clune said. She turned instead to Dr. Marshall Holley, the New Haven obstetrician and gynecologist who first diagnosed the Clune’s fertility problems. In choosing Holley, Clune was not simply seeking a doctor outside of her workplace. Holley’s practice employed two midwives, Cibelli and Lisk, who worked with him for over twenty years before establishing their own practice upon his retirement. After observing thousands of babies delivered by physicians, Clune had decided that she wanted a midwife to be the primary attendant at her son’s birth. Having seen midwives in action, she knew that she would be receiving excellent medical care. Moreover, she knew that she would be more comfortable in their hands.
“Everyone tells you that childbirth is normal, but I saw a lot of women in fear,” Clune said. “I just saw that there was something that midwives gave that inspired trust.” The current trend in obstetrics—towards large practices with a multitude of physicians—makes it difficult for patients to forge personal connections. So, when a woman enters the hospital in labor, as Clune had observed time after time, she is often terrified. In contrast, every time Clune had an appointment at Dr. Holley’s office, she saw either Cibelli or Lisk. And during her labor, which was overseen by Cibelli, she knew exactly whose hands she was in.
When Clune finally went into labor, it lasted for 14 hours. She had been admitted to the hospital several days earlier, when doctors became concerned that her pregnancy had extended past 41 weeks. Four days before she gave birth, their concern was heightened by her son’s lack of movement, and eventually he was born with his umbilical cord wrapped around his neck. Though he was completely healthy, Clune’s labor can hardly be characterized as easy. Nonetheless, when she remembers it, her first words are in praise of Cibelli, who oversaw the birth.
“She ran the whole room, but without seeming like she had an ego,” Clune said. “She wasn’t thinking about another patient she had, it was just us.”
“My husband and I were terrified,” she added. “We’d gone through so much. But she guided me, and she guided Tim, and kept him even keel.”
Two years later and against all odds, the Clunes found themselves expecting another son. Once again, they chose to have a midwife attend the birth—this time, Linda Lisk was on call. And once again, complications ensued. Although Clune was ultimately in labor for only two hours and gave birth to a healthy son, his heart rate began decelerating, and an emergency Caesarian section became a possibility. Afraid for her child, Clune panicked.
“I came as close as you can come to freaking out without completely losing it,” Clune said. “I knew too much. At one point, Linda took her thumb and put it between my eyes on the bridge of my nose…Whatever she did with that touch, it worked—I relaxed. It turns out it was just an old midwife trick that she’d learned. I’m a nurse, and I don’t ever remember seeing that in my twenty years of nursing.”
Midwives perform the same blood work, risk assessments, prenatal exams, and ultrasounds as physicians; but their draw lies in what they provide in addition. “Physicians are really educated in the abnormal, and midwives, their education focuses on the normal,” Cibelli said. “We spend much more time talking about nutrition and the psychological aspects of the pregnancy, how it may or may not affect the household or the family or the other siblings at home, if that’s relevant.” Midwives are taught to view pregnancy as a natural condition, not an illness. Thus, they are able to view their patients as individuals, not cases.
One of midwives’ primary aims is to educate their patients. The fear that Alycia Clune observed in women while assisting deliveries is caused by a patients’ lack of understanding what happens in labor and ignorance of their options. For example, many women view epidurals, an injection that numbs the body from the waist down, as harmless and a necessary relief from the pains of childbearing. But epidurals come with risks of their own. They achieve their grand effect because anesthetic is injected into the fluid surrounding the spinal cord, and the procedure carries a small risk of hemorrhage, and a larger risk of infections, sore backs, and headaches. Sometimes, epidurals do not work, leaving a certain area or even an entire side of the body in pain. And most often, the epidural fails to produce the desired numbness that the mother-to-be had expected. This is where midwives’ role as instructors is key.
“We do a huge amount of education before they get there,” Stone-Godena said. “When the women we take care of ask for epidurals, they know what they’re asking for. They don’t just think it’s something they’ve read about in a magazine, the be-all, end-all.” Thus, if the epidural, or any part of the labor, fails to occur as the mother-to-be envisioned, she at least understands why, and is spared the fear that ignorance can inspire.
Midwives also include their patients’ partners in the process of birth. This is most clear in the delivery room itself, where midwives take care to include partners in the process and often find themselves, as Cibelli did with Tim Clune, soothing the partner as well as the mother-to-be. Cibelli remembers one patient whose husband was not pleased that his wife was seeing a midwife rather than a doctor.
“He was very uncomfortable with the whole thing,” she said. But after the birth, the patient’s husband had a radically different opinion of midwifery. “He said to me, ‘This is the first time when I’ve been at the birth of one of my children where I didn’t feel like I was an outsider, that I was encouraged to participate, that I felt like the person really knew my wife and cared about her.”
Midwives’ attention to their patients’ partners does not end at birth. Like obstetricians, midwives carefully screen their patients to see if they are at risk for post-partum depression and keep close tabs on their physical and mental health after the baby is born. And while doing so, they extend an eye to their patients’ partners as well.
“Partners get post-partum depression too, so we have to take care of the whole family,” said Stone-Godena. “I think we sometimes forget, because the woman is bearing the physical burden and the hormonal burden, that sometimes the partner has to be strong. And they get fatigued, and they have a meltdown, and they aren’t able to provide what they need for support either. So we have to be prepared to take care of all of them, or set them up with someone to take care of all of them.”
On some occasions, midwifes simply go above and beyond what could reasonably be expected of any doctor. After the birth of her first child, Alycia Clune developed severe mastitis, an inflammation of the breast that renders breast feeding extremely painful. But, after giving birth to a child against the odds, she was unwilling to relinquish any aspect of motherhood. Her family did not understand. Cibelli did. Rather than refer her to a nurse or lactation specialist, Cibelli drove to Clune’s house to personally assist her with her breastfeeding. Twice.
“What physician would do that?” Clune asked.
In New Haven, midwives are a ubiquitous part of OB/GYN practices. And some doctors do recognize that midwives provide patients with a type of care that, for practical reasons, they cannot. Soon after she began working alongside Dr. Holley, Debbie Cibelli asked him why he chose to include midwives in his practice rather than hire additional physicians.
“He said, ‘I thought my patients were going to get better care if they had that personalized approach and if they actually had someone that they knew with them when they were in labor,’ she remembered. “He said, ‘I’m a physician. I’m not going to sit at someone’s bedside and rub their back and hold the bucket when they throw up. But midwives do that, and I think my patients get better care because of it.’”
Cibelli characterizes Dr. Holley as a “unique” physician, one who genuinely believed that midwifery care would benefit his patients. And while it is true that some doctors are confident in the level of care midwives provide, others are more motivated by economic incentives. Instead of seeing a midwives as a critical source of comfort—stroking a patient’s hair and murmuring soothing words as she vomits—they view them as people who will be spending time with their patient so they can be elsewhere, be it in the financially lucrative operating room or on the golf course. A midwife, who can perform routine examinations and assist in all but the most complicated of births, is a far less expensive employee than another physician. Years ago, a small number of physicians caught wind of this idea, which spread in a domino effect. Now midwives are fixtures in many New Haven OB/GYN practices.
“Whether it’s fortunately or unfortunately, I think that a lot of the time when midwives are hired into physician practices, it’s because physicians see them as an economic advantage, not necessarily because they buy into the philosophy of midwifery,” Cibelli said.
By and large, midwives in the greater United States operate within the same confines as their peers in New Haven: in partnership with a physician. Those striving to operate in less conventional environments often work in alternative birth centers, like those in Danbury and Waterbury, which promise a less intimidating atmosphere than a hospital’s. A select few also participate in home-births. But midwives are limited by their status as nurses, not doctors. They are not qualified to perform procedures necessitated by complicated pregnancies, such as Caesarian sections. Thus, birthing centers and midwives who perform home-births limit their work to low-risk pregnancies, while their counterparts, working in hospitals, always have a physician in the building who they can turn to if a more complex procedure becomes necessary.
As midwifery has become more popular in the United States, the number of midwives has naturally blossomed. But, in the past few years, growth has halted. “There’s a crisis now,” Teri Stone-Godena said. “Midwifery, not unlike nursing as a whole, has become less attractive to people who want to have a life, who do want to make a good income, and don’t necessarily want to be under the threat of a lawsuit for twenty or thirty years after taking care of someone.”
Midwifery has been unable to escape the malpractice maelstrom that has afflicted medicine as a whole over the past decade. Because they participate in childbirths, midwives and obstetricians are at risk for being sued years after the actual event. If a heart bypass is botched, the effects are immediately evident. But damage inflicted by a poorly handled childbirth may not manifest itself for years.
“There may be a birth that seems to have gone okay, but when the child gets to first grade, he or she is not doing very well,” Stone-Godena said. “The parents say ‘Well, you remember it took a little bit longer for him to come out than we thought,’ or ‘You knew there was all this excitement in the room’ and they go back and try to pin down the issue that’s happening with their child.”
“I don’t want to make it sound like I think that’s a commonplace scenario,” she added. “I think there’s a fear that that’s a commonplace scenario.”
In actuality, midwives get sued far less frequently than their physician colleagues, because they tend to care for lower-risk women, and because of the bond they share with their patients. Those midwives who do get sued for malpractice are generally those who operate closely with physicians and, in the event of a suit, get sued along with the physician, the hospital, and every other entity involved in the birth.
In spite of this, it is a logistical nightmare for midwives who are not affiliated with a physician or hospital to obtain malpractice insurance. Debbie Cibelli became aware of this when, after Dr. Holley’s retirement, she and Linda Lisk started their own practice and attempted to become insured in their own right, without being directly linked to a physician.
“One of the most challenging aspects of starting this practice a year ago was educating insurance companies,” she said. Few insurance companies had ever insured a midwife who wasn’t employed by a hospital or physician, and though clients had been seeing Cibelli and Lisk for twenty years in Dr. Holley’s office, some companies were hesitant to insure in their new practice. Others flat out refused.
Rather than give up, Cibelli took on the role of advocate, both for her own practice and for midwifery as a whole. “I had to take each insurance company on individually and educate them that indeed I did not have to be a physician employee to see patients in the state of Connecticut,” she said. Sometimes a conversation wasn’t enough. In those cases, Cibelli quietly opened a book of legal statutes, photocopied relevant pages revealing that she was acting within the confines of Connecticut state law, and mailed them in neatly addressed envelopes to the insurance companies. Her perseverance paid off, and she and Lisk are now healthcare providers under almost every insurance company their patients use. Except one: Aetna.
Lisk and Cibelli have inarguably won a victory for midwives by establishing a precedent for midwives seeking insurance coverage. But the specter of Aetna, the one hold-out insurance company remains. In her initial struggle to win recognition from insurance companies, Cibelli did not vehemently pursue Aetna, regarding it as somewhat marginal. That changed as of January 1; Aetna is now the only alternative to the Yale Health Plan for Yale employees. Aetna’s refusal to insure midwives had previously inflicted a financial burden on Cibelli and Lisk’s patients; since the two have been operating their practice, their patients who are insured by Aetna have been forced to pay out of pocket for their care. But now it is a question of principle: Employees of the Yale School of Nursing, where many of New Haven’s midwives received their training, will not be able to rely on their insurance to cover visits to Cibelli and Lisk. Thanks to Aetna, midwives can no longer rely on their insurance to cover visits to other midwives.
Alycia Clune, who currently works at the School of Nursing, is one of Cibelli and Lisk’s patients who has been affected by Aetna’s refusal to recognize them as valid healthcare providers. She has joined many of the pair’s patients in writing letters to the company championing Cibelli and Lisk’s cause, and plans to continue seeing them, paying out of pocket, if Aetna continues to refuse to back the two. In the years that they have cared for her, they have become far more than just medical support.
“I believe, for me, having a midwife in your life is a gift you give yourself,” she wrote in an e-mail. “Linda and Debbie are my practitioners, but they are so much more. They take the role as mom, sister, counselor, whatever is needed at the moment.
According to Cibelli, Aetna has made a verbal agreement to enroll midwives as providers, but has yet to come through on its promise. “They’re ‘working on it,’” she said, with a hint of skepticism in her voice. In spite of the efforts of Clune and other Aetna-insured patients, the company seems to be oblivious to the bond that these women have formed with Lisk and Cibelli.
“One of our patients called Aetna and said ‘I’ve been seeing these women for years—they delivered my babies!’” Cibelli said. “The person on the other end said, ‘If you’re done having babies, why do you care who you see? It’s just a yearly appointment.’”
In a country where doctors have become so distanced from their patients that, according to a recent New York Times article, by 2011 all new medical residents will be required to demonstrate “empathy” in a role-playing exercise, patient centered-midwifery care is needed more than ever. But in spite of the well-defined niche they fill, midwives still struggle to gain recognition from patients, doctors, and insurance companies. And while it is doubtful that medical school-administered “empathy tests” will make much of a difference in the way doctors interact with their patients, the fact remains that the highest-paid midwife earns less than the lowest-paid obstetrician.
Helen Eckinger, a junior in Trumbull College, is the Research Director of TNJ.