Births attended by midwives, especially those not regulated by the state, are increasing in Oklahoma, state Health Department records show. In 2007, 2,127 births in Oklahoma were attended by midwives, a 10 percent increase since 2004. Certified nurse midwives accounted for 85 percent of the midwifery births in the state in 2007. Certified nurse midwives are registered nurses who have completed a nurse midwifery program accredited by the American College of Nurse Midwives Division of Accreditation and are regulated by the state of Oklahoma. But births outside of a hospital attended by other, non-state regulated midwives, increased 54 percent from 2004 to 2007, records show. The increase comes as some in the medical community are voicing concerns about out-of-hospital births. "In obstetrics, if everything goes well, it’s not a hard job, but you spend your life training and practicing for the emergencies,” said Dr. Gena Gray, with Tulsa OB-GYN Associates in Tulsa.Comments
Complication concernsGray said there have been at least Tulsa two cases in the past year where women with high risk deliveries attempted home births, but ended up at a hospital when complications developed. "My concern is somebody delivering at home or at a birthing center doesn’t have adequate medical care if something goes wrong,” Gray said. But others say midwifery is safe and Oklahoma midwifery births’ growth is not unique. "I think it’s a trend across the country,” said Susan Moray, with the Midwives Alliance of North America, referring to an increase in out-of-hospital births attended by midwives. She credits a 2008 documentary produced by Ricki Lake, "The Business of Being Born,” with igniting interest in out-of-hospital births. "I think also women are educating themselves and seeing the likelihood of a Caesarean if they go in to the hospital because the Caesarean rate is going up nationally,” Moray said. Caesarean sections are increasing. Caesarean section births increased from 22 percent to 34 percent nationally, according to data from the Centers for Disease Control and Prevention. In Oklahoma, one in three births in 2007 were by Caesarean section. To avoid Caesarean sections, women look at other options and "out-of-hospital births is the main option,” Moray said.
Numbers fallMeanwhile, as Caesarean sections have increased, the number of women with prior C-sections who subsequently delivered vaginally had been decreasing in Oklahoma, largely due to restrictions imposed by insurance companies. In Oklahoma, the number of vaginal births after Caesareans, steadily decreased each year since at least 2000 from 784 cases to 2005 when there were just 228. But in recent years the number has begun to increase slightly. Caesarean section prohibitions placed on doctors by some insurance companies have resulted in women "making other choices,” Moray said. States take a mixed approach to regulating midwives, Moray said. Some states regulate all midwives while others, including Oklahoma, regulate only certified nurse midwives. Other midwives, called direct-entry midwives by the industry, have training that can range from a national certification program to no formal program training. Direct-entry midwives are not regulated or licensed by Oklahoma. Ten states, including the District of Columbia, prohibit direct-entry midwives, Moray said. Kim Glazier, executive director of the Oklahoma Board of Nursing, said while state law permits the agency to regulate only certified nurse midwives, it often receives calls about nonregulated midwives. "Usually it’s when there has been a negative outcome that we are being called,” Glazier said. "Because they are not regulated, it falls to the public making an educated decision, which is difficult for the public.” Glazier said she believes the public may be confused by variations in training and experience. Other states, but not Oklahoma, regulate where certain births can take place. "In many states a woman who has had a previous Caesarean cannot have a birth at home” with a professional midwife attending, Moray said. "The concern about (vaginal birth after Caesarean) in and out of the hospital is uterine rupture,” Moray said. "If a uterus ruptures in the hospital it’s easy to access emergency services and do a fast Caesarean. In out-of-hospital (births) you have that transport time and it puts the mom at more risk.” And that’s one of the concerns for Gray. "These women are putting themselves at risk,” she said. "They may know they are putting themselves at risk and they may know they can die there and their baby can die there and they may say they are willing to do that, but I would seriously doubt that.”
National standardsMoray said the Midwives Alliance of North America favors adopting one national standard for direct-entry midwives. She said she would also like to see the U.S. move to the Dutch model where hospitals collaborate with midwives who attend out-of-hospital births.