MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. It was a midwife's tale but one that went terribly wrong. A home birth in Virginia ended in the death of the baby. It was a risky delivery by any standards. The baby was breech or feet first. The result was criminal charges for the midwife who delivered the baby. The case has sparked debate on the home birth question -- where and how should women be allowed to give birth? The medical community and midwives have often been at odds over home birth and the midwifery profession itself.

MR. KOJO NNAMDIMidwives and even some doctors say that birth has become far too medicalized with one in three hospital births ending in a Cesarean section, while many in the medical establishments say that home births are too risky when things go wrong. And the training and licensing standards of midwives, if they exist, vary from state to state, something many in the midwifery profession would also like to see changed. And joining us to have this conversation is Mairi Breen Rothman. She is a certified nurse midwife and co-founder of the Metro Area Midwives and Allied Services in Silver Spring. Mairi, thank you so much for joining us.

MS. MAIRI BREEN ROTHMANHi, Kojo. Thanks for letting me be here.

NNAMDIMairi joins us in studio. Joining us by telephone from Charlottesville, Va., is Brynne Potter. Brynne Potter is a certified professional midwife. She's the public relations director for the Commonwealth Midwives Alliance, the state midwifery organization for Virginia. She's also on the board of directors of the North American Registry of Midwives. Brynne Potter, thank you for joining us.

MS. BRYNNE POTTERThank you so much for having me.

NNAMDIAnd joining us from telephone -- by telephone from Washington is David Downing. He is the attending OB-GYN physician at the Washington Hospital Center who works with midwives. David Downing, thank you for joining us.

DR. DAVID DOWNINGThank you for inviting me.

NNAMDIOf course, you can join this conversation by calling us at 800-433-8850, sending email to kojo@wamu.org, a tweet, @kojoshow, or simply go to our website, kojoshow.org. Join the conversation there. Let me start it with you, Mairi. Home births are in the news these days because of the case in Virginia of a midwife named Karen Carr. Can you tell us what happened?

ROTHMANWell, of course, I can't really tell you what happened because I wasn't there, and that's been one of the big problems with the news coverage is that it's a lot of people writing about something when they weren't there. But what it brings up for me that I think is really good about the coverage is that it brings out a lot of issues that need to be addressed around birth and choices and training of providers and safety of home birth and the safety of hospital birth. And it's good that we're having this conversation about it.

NNAMDIThe case, as you said, you didn't witness is -- but as it was reported in the media, Karen Carr is a certified professional midwife. She delivered a baby to a 43-year-old woman who was having her first child. The baby was in the breech position. Most reports say the woman was turned down by another midwife practice as too risky. Breech babies in the feet-first position are considered risky to deliver. Normally, most hospitals will do a Caesarian section out of concern for the risks. But delivering -- according to reports, during delivery, the baby's head got stuck in the birth canal for about 20 minutes or so.

NNAMDIWhen the baby was delivered, he was not conscious. Carr delivered CPR for 13 minutes before calling emergency services. The baby died a few days later at the Washington Hospital Center. So much for the reports. Mairi, this was what was called a planned home birth. Can you briefly describe the options available to a woman delivering a baby with a midwife?

ROTHMANSure. Well, that's, actually, a huge question because there are different kinds of midwives and different choices that women can make in all those areas. But, basically, there are several kinds of pathways to midwifery, all of which are valid ways to become a very excellent professional midwife. And the options that women have in the D.C. are that they can have their baby with a midwife in the hospital. 97 percent of certified nurse-midwives actually work in the hospital.

ROTHMANOr they can have their baby with a certified nurse-midwife in a birthing center, such as the Family Health and Birth Center in D.C. Or they can have their baby at home with a certified nurse-midwife who is a midwife who's had training as a nurse and then has gone to a graduate program in midwifery and sat for boards with the American College -- the American Midwifery Certification Board. Or they can go with a certified professional midwife who is somebody who has sat for boards with the North American Registry of Midwives, which is another pathway to becoming a midwife.

ROTHMANAnd one of the things that causes a lot of controversy is that certified nurse-midwives and CPMs have different laws governing them in different states. Certified nurse-midwives are legal in all 50 states, but they have a huge variety of regulations governing how they can practice. Certified professional midwives are not legal in every state yet, although they're legal in more states than not. And I know Maryland is currently trying to legalize certified professional midwives. In Virginia, certified professional midwives are legal and Brynne Potter can speak a lot more to that.

NNAMDII was about to say, Brynne Potter, can you talk a little bit about what you see as the similarities and differences between a certified nurse-midwife and a certified professional midwife.

POTTERWell, I think Mairi has done a good job of describing...

ROTHMANIt's actually Mairi.

POTTERSorry, Mairi.

NNAMDIMairi.

ROTHMANYeah. Thanks.

POTTERI think Mairi has done a very good job of describing the paths for certification of the nurse-midwives. The path for certification as a CPM is really within a scope of practice of handling childbirth. It does not have a wider scope outside of well woman care within the childbearing year. So the competencies and training are very similar. There's a very distinct overlap of experience in training for childbirth between CPMs and CNMs. But CNMs have a much wider scope of practice. And as Mairi said, they also have extended academic education as part of their certification as well.

NNAMDIA lot of choices. When I was delivered by a midwife when I born in Guyana, South America, there was only one choice, the midwife.

NNAMDIDavid, the Virginia case was a breach birth, a risky delivery. What would you, as an OB-GYN, who works with midwives have recommended?

DOWNINGI would not have recommended a primagravida breach delivery. The scientific evidence shows that there is significantly less birth trauma to a neonate by a C-section route than by a vaginal route. And that's -- there's a study called the breach study about seven, eight years ago and that pretty much put the nail in the coffin for elective breach deliveries.

NNAMDIRemind me. I forgot what primigravida means.

DOWNINGFirst -- I'm sorry. First baby being delivered as compared to a multigravida who's a woman who's had several children already.

NNAMDIThank you very much. Brynne, the midwife in this case, Karen Carr, was prosecuted on several felony counts. How unusual is it for there to be criminal charges in a midwife delivery case?

POTTERI think it's very unusual. I think that NARM's position and really the CPM credential in itself was designed to support the needs of licensure. So certification allows for a level of accountability on the national level. And licensure on the state level allows for local accountability and a process of accountability related to competence and professional conduct. When you don't have licensure and only have certification, your only mechanism for accountability on the local level is through the criminal system. And so that is why it's pretty unusual, because no one -- no midwife and no woman is choosing to have a baby at home thinking and believing that they're putting their baby or themselves at risk. Everyone has the best intentions in every decision that they're making.

POTTERAnd so the general principles of ethics and beneficence that are really at the heart of all maternity care professionals really are at work for certified professional midwives as well. The challenge is that when you have -- as Mairi mentioned, is you have an uneven regulatory playing field across all states and especially in that tri-state area between Virginia, Maryland and the District. It becomes very confusing and not clear how to manage scope of practice issues and how to manage informed consent and autonomous decision-making when abilities and rights really vary when you cross state lines.

NNAMDIWhich is a source of confusion to a lot of people in this case, Brynne, because the midwife in question was not licensed in Maryland, where she lived and practiced, nor in Virginia. And the difference between how different jurisdictions deal with this issue is what, I guess, is leading to this confusion.

POTTERThat's right. And I think that, again, Maryland and the District of Columbia don't offer specific licensure for the certified professional midwives. So what that means is that you do have this lack of clarity around mechanism for legal practice, and you have, historically, the ability to practice without a really clear direction or accountability authority.

POTTERThat's, again, why we really -- we're working towards licensure in Virginia and achieve licensure for certified professional midwives in Virginia because it creates a mechanism of accountability that not only upholds public safety and allows an overview of competency and a community standard, but it also creates a much better mechanism for review of practices of midwives or any health care providers. It puts certified professional midwives up to the same standards that all health professions are under through licensing boards.

NNAMDIMairi?

ROTHMANYeah. I think we're really looking at two basic questions here. One is -- as I think what some of the leaders to this show said is about whether or not a woman has a right to decide how to have her baby. I think the way that it was put was whether a woman should be allowed to make choices about her birth and her baby. And I think that's a, you know, a basic question in our culture, what women should be allowed to do. And I, sort of, object to that way of framing it. The other issue is the safety of birth. And as the famous midwife Ruth Lubic once said, birth is as safe is anything else that we do in life.

ROTHMANIt's just a matter of calculating risks and benefits to whatever decisions you make. And there have been many, many studies that have shown the safety of home birth that it's safe or safer to have a low-risk birth in your home as it is in the hospital, and especially in the D.C. area. I know in my neighborhood, the nearby hospital has something like a 42 percent C-section rate. So if I have more than a one in three chance of having abdominal surgery to have a baby, it's hard to say that it's safer to go there than to stay in my home where I have, maybe, a five percent chance of having abdominal surgery.

NNAMDIHere is Laura in College Park, Md. Laura, you're on the air. Go ahead, please.

LAURAHi Kojo. Thanks for calling. I just wanted to say it's really unfortunate that this particular case of a death of a baby is what's being so popularized and spoken of in the media is it's one really awful case of something that happened. And an unlicensed midwife who took, I believe you said, over 13 minutes to call emergency services. And that when something this terrible happens, of course, it's awful, but it shouldn't reflect the practice of midwifery. And I think it's more a symptom of, like, a guest was saying just a moment ago, of rather ill view of women's bodies in our society.

NNAMDIWell, interestingly enough, many midwives and her former clients came out strongly in support Karen Carr. Mairi, is there a concern that this will hurt the profession as a whole, which is what Laura seems to be implying?

ROTHMANI think there's always that concern when there's a highly publicized bad outcome. And the reason that it makes the news is because it's so incredibly rare. But, you know, we never -- well, are there studies that show that home birth is safe, but we don't say, are there studies that show hospital birth is safe. We don't think about the risks of the cascade of interventions, beginning with an epidural and going through pitocin and surgery and the risks of having repeat C-sections, the risks for the future babies and to the mother's health. We don't think about the risks of nosocomial infections, which are infections that are acquired in the hospital. And...

NNAMDIWe did a show on that recently.

ROTHMANYeah. And the safety of the babies. Babies that are born in the hospital have a much higher incidence of infections in the first month than babies who were born outside of the hospital. We're not saying, where are the studies showing that hospital birth is safe?

NNAMDITime for you, David Downing.

DOWNING(laugh) I agree with everything that's been said so far. I think part of the challenge is in communication and in seeing doctors, midwives, lay midwives communicating with each other. I agree with Mairi in the sense that for a -- for an uncomplicated, healthy, young woman, a home birth is an option. Unfortunately, the ACOG, the American College of OB-GYN does not endorse or support home births because their studies show that there is a higher incidence of potential harm to the baby in home birth.

DOWNINGBut they do support the right of a patient to choose where she has her baby as long as she is informed of the risks and the benefits. And that's where, again, communication with the patient comes in. I agree. Many patients that go -- or many pregnant women that go to midwives are looking for the non-interventional, non-aggressive, more laissez-faire, hands-off approach to labor, which for the healthy, uncomplicated patient is fine and for most patients, I mean, that is, thank God what happens.

DOWNINGBut, you know, there are things that can happen in labor, which are not predictable or are not expected. And in those circumstances, which, thank goodness, are rare, having the resources of a hospital does improve outcomes.

NNAMDILaura, thank you very much for your call. Unfortunately, I do have to take a short break. I'm glad that David Downing mentioned ACOG, the American College of Obstetricians and Gynecologists because when we come back, we'll be talking with ACOG's chairman of the committee on obstetrical practice. 800-433-8850 is the way for you to join this conversation. We're talking about home birth -- home births and midwives. 800-433-8850. I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation about home births and midwives. We're talking with Mairi Breen Rothman. She's a certified nurse midwife and co-founder of the Metro Area Midwives and Allied Services in Silver Spring. How do you pronounce that acronym, Mairi?

NNAMDIMAMAS.

NNAMDIMAMAS. Also with us by phone from Charlottesville, Va. is Brynne Potter. She's a certified professional midwife. She's the public relations director for the Commonwealth Midwives Alliance. Joining us by phone is Dr. David Downing. He's the attending OB-GYN physician at the Washington Hospital Center. He works with midwives. And joining us now by telephone from Saint Louis is George Macones. He is chairman of the committee on obstetrical practice at the American College of Obstetricians and Gynecologists, ACOG.

NNAMDIHe's also a professor and chairman in the Department of Obstetrics and Gynecology at the Washington University School of Missouri in Saint Louis, Mo. Thank you very much for joining us, George Macones.

DR. GEORGE MACONESGreat. Thank you for having me.

NNAMDIWe're hearing a lot about planned home births because of this case. How common are home births versus hospital birth?

MACONESI think they're still pretty uncommon. At least the most recent information would say there's about 25,000 or so per year in the United States. And that's out of a total of four million births.

NNAMDIMany women say they choose home birth because hospital births have become so medicalized and come with their own complications. How do you and how does ACOG feel?

MACONESWell, I certainly think that, you know, a hospital birth is gonna be different than a home birth or in a birth -- or a birth in a midwifery center. Certainly, there are more interventions. You know, C-section rate now is pretty high as you've alluded to, about 30 percent nationally or so. And I think that that's really up for a woman to decide, you know, what kind of environment she wants to be in, whether that's at home, in a hospital or in a birthing center.

NNAMDIWhat concerns does ACOG have about home birth?

MACONESSo, I think, really, the main issue has to do with the fact that there is about a two- to three-fold increase in the risk of neonatal death with home birth, just like we saw with this case that you're discussing today. And it's no surprise that this is a case. You know, obstetrics, I think, as David mentioned, can be a risky business. And when things go wrong, they go wrong quickly. And I think it can be hard to, you know, respond to that at home.

MACONESHowever, I think, if you talk to women about that, with some of the other risks that the other panelists have talked about on the other side of having a hospital birth and a woman chooses to go for home birth, I think that's a reasonable thing to do. I think it's really about communication and informing patients, you know, accurately about risks and benefits.

NNAMDIWhat does ACOG feel about the training of midwives?

MACONESWell, I know there's some debate about this, and I think that the panelists have done a great job with this. But in general, I think ACOG is in favor of people who are certified as certified nurse midwives performing deliveries, both in birthing centers, hospitals and at home. But there's more concern about people who've had not that degree of training and certification by that board.

NNAMDI800-433-8850 is the number to call. Do you make distinctions, George, between risky at-home births, like the case in Virginia, and low-risk pregnancies?

MACONESYou know, I certainly would, and I think that the place for home birth is for much lower risk deliveries. Clearly, this was an extremely risky delivery to take on at home and as David said, this would -- this would be a case for a C-section, without question, at a hospital. And I think, again, the place for a home birth is gonna be a much lower risk case.

NNAMDIWell, we got an email about that on our website from Cindy in Baltimore. Cindy writes, "I found it upsetting to see that Saturday's Washington Post article about Karen Carr failed to include the breech vaginal statistics for Virginia Hospitals that were provided to the reporter. From 2005 to 2009, Virginia Hospitals, in total, perform between 250 and 300 breech vaginal deliveries. I think that this shows that it was not an unreasonable birth choice for the midwife and her clients to pursue a vaginal breech delivery."

NNAMDI"It's important to note that the decision between having a breech birth versus Cesarean is not a risk versus no-risk equation since Cesareans carry their own significant number of risks including a higher risk of dying during childbirth." I suspect that all of you will want to comment on this, so I will start with you, Mairi.

ROTHMANWell, I think that it's important, first of all, to go back to the study that was cited just a minute ago that said -- showed that two- to three-fold increase in deaths in home births. That study included unplanned home births and planned births, both. And everyone knows that having an unplanned home birth is not safe. I think that if you look at the Cochran Review, which did a meta-analysis of studies of home birth, they actually rejected those studies because they skew the results of the analysis by including those unplanned home births.

ROTHMANAnd I think it's also true that it is possible to do a safe vaginal breech delivery. It's also true that any delivery has risks in it, and sometimes bad things happen. Mother Nature is really harsh, and bad things happen in the hospital just the way bad things happen at home. The other thing I wanted to say is that one thing about the ACOG home birth statement is -- their statement on home birth is that they say now that having your baby in a birth center that's accredited by AABC is safe, but having a home birth is not. And I just wanna point out that when I go to a home birth, I bring everything that they would have in a birth center. There's nothing they have in a birth center that creates safety that I don't bring in my car to the person's house.

ROTHMANSo that's -- it's -- what it is is it goes back to the whole communication thing. I totally agree with both of these positions that all of us understanding what is the scope of practice of each profession. What we all can do and what we all can't do is a really important factor.

NNAMDII guess we're talking in terms of the study about the Wax report. Dr. Wax in Vermont being the one who did a survey of studies and found a three-fold increase in neonatal death in home birth. The study were mostly European numbers, because there are many more home births in Europe. What do you have to say about that, Brynne?

POTTERWell, I...

NNAMDIBrynne Potter?

POTTERYes. Thank you. I would like to respond to that that the Wax study really isn't a study. It is a meta-analysis or a review of other studies. And there's definitely been question about the inclusion criteria or which studies were included in calculating the neonatal death rate. At least four of the seven studies that were included were included inappropriately. And as Mairi said, some of them did not exclude for unplanned and planned home birth. And also, some of them did not exclude for congenital birth defects, which certainly would have an impact on the neonatal death rate.

POTTERAnd I think what no one is really talking about -- and I do want to just to say I really appreciate and commend ACOG's new position on home birth, because I think it's a great leap forward in acknowledging that collaboration and integration of home birth into our system is the best way to improve safety. But I think that what no one is really talking about related to the Wax paper is that there was definitely a showing of a decreased morbidity for women, for mothers in childbirth. And I think that to play up on a questionable neonatal death rate really gets to the heart of this implication that the integrity of the mother is sacrificed in order for the benefit of the baby.

POTTERAnd that there really isn't evidence to show globally that that is necessary, that we have the third highest Cesarean section rate in the world, that we have 50 percent of all first-time mothers being induced in the United States really leads us to question what can we do to integrate some of the practices that are successful in home birth into models in hospitals.

NNAMDIDavid Downing, your turn.

DOWNINGYup. And I think, again, I see the model practice as one that gives the woman the greatest number of choices, a model practice where you actually have the time and the capacity on the patient's part to understand the risks and benefits of each of the subsequent choices to have a relatively smooth system, which can transfer from one model of birth to another without extensive delays and then -- and so I think giving the mom the greatest number of choices and having midwives and physicians speaking to each other at the time of either the initial patient's choice for method of delivery or at the beginning of the labor process.

NNAMDIGeorge, you wanted to weigh in?

MACONESSure. You know, I think we're all really saying a lot of the same things, which is about, you know, informing patients accurately of risks and benefits with different plans for delivery. And, you know, while people may look at the study we're talking about, Wax, differently, it's the best that we have. And we have to use the best data that we have. And, unfortunately, on the negative side, it suggests that home birth is associated with an increased risk of neonatal deaths, which may really shouldn't be any great surprise to anyone. And I agree, but on the flipside, there certainly is more intervention on mom with hospital-based birth. So I think you just inform patients of those -- of risks on both sides.

NNAMDIGeorge Macones, thank you for joining us.

MACONESOK. Thank you so much.

NNAMDIGeorge Macones is chairman of the committee on obstetrical practice at the American College of Obstetricians and Gynecologists and a professor and chairman in the Department of Obstetrics and Gynecology at the Washington University School of Medicine in St. Louis, Miss. Onto the telephones again. Here is Brooke in Sperryville, Va. Brooke, you're on the air. Go ahead, please.

BROOKEHi. I just wanted to weigh in because both of my children were born at home. In fact, my second child, my son's birth was on NPR on Daniel's World Link's "Weekend Edition" in 1995. But I had a lay midwife, which was illegal at the time in Maryland. And I just wanted to say that I was so much more comfortable and more trusting with her because, certainly at the time -- I mean, I'm so glad to hear that things are getting better with the medical profession. But their concept of a normal birth is so narrow that interventions are common when they don't need to be happening. And...

NNAMDIBrooke, what's a lay midwife?

BROOKEA lay midwife is a midwife who doesn't have nursing training. Although, you could ask the other people if that's correct.

POTTERI would like...

NNAMDIAnd Brynne...

POTTERI would like to -- I'd like to speak.

NNAMDII'm sure Brynne would.

POTTER(laugh) I think it's a really interesting phrase. I think there's a semantic that it really speaks the heart of history of midwifery, particularly in the South, particularly in Virginia. We have a history of whether we're termed granny midwife or lay midwife that we're actually permitted by the Department of Health in Virginia from 1918 to 2002. These midwives had great outcomes. They had no formal education, which is technically the term.

NNAMDIIt's my understanding that the granny midwives are mostly African-American midwives who had long been caring for poor women who could not afford hospitals.

POTTERThat's exactly right that they were -- they cared for women as -- really the issue of midwifery was one of privilege and race. And that shift really occurred -- even though outcomes were fabulous for these midwives, the shift really occurred in 1976 when Medicaid came into being and started paying for women who couldn't afford hospital birth could now have their birth in the hospital. And I think that the reason it feels sometimes loaded to refer to, sort of, by professional midwives as lay midwives is that we really carry the legacy and honor the legacy of incorporating those time-honored traditions of apprenticeship and community-based learning as our model for hands-on skills.

POTTERBut at the same time, certified professionals absolutely have academic training, verification of skills, testing a national board exam. So to imply that a CPM doesn't have any formal training is actually false. So it's a very different and important distinction that, I think, sometimes the term direct-entry midwife is more acceptable in that, because it's acknowledging that there is midwifery training but you didn't have a nursing degree first.

NNAMDIBrooke, thank you very much for your call. David Downing, every time a baby dies during childbirth in a hospital, it doesn't make national headlines, not even local headlines for the most part nor does it usually end in prosecution, but there are risks. And things do go wrong in hospital births, don't they?

DOWNINGYes, they do. And when that does happen, there is a very extensive process and protocol that are followed to understand why a bad event occurred. It's not completely dissimilar to when an airliner crashes. And the NTSB comes in and starts a thorough investigating to it. It's called a root cause analysis of the bad outcome. That's one of the concerns in the less-regulated or less-supervised -- in the arena of less-regulated or less-supervised medical care. When something bad happens in a hospital, there is a full court inquiry into it.

NNAMDIHere is Amy in Boston, Mass. Amy, you're on the air. Go ahead, please.

AMYHi. I have a question for Brynne Potter about certified professional midwife. I'm wondering why the Midwives Alliance of North America, which is the sister organization of NARM, is hiding the death rates for the 23,000 certified professional midwife-attended home births that they have collected in their database.

POTTEROK. Well, I can sort of speak -- I can certainly speak to that that the MANA dataset that, I think, Amy is referring to is a private dataset that is not CPM's exclusively. It's not certified nurse midwives exclusively. It is simply a voluntary collection of data that is not specific to death rates, but specific to all information. And that information is available. Researchers can apply for that information. But mandated reporting -- and I'm really speaking back to what Dr. Downing was just saying -- mandated reporting review of outcomes really takes places on a state level under licensure and regulation.

POTTERAnd I completely agree with him that one of the benefits of licensure in all 50 states is having the option to create integrated systems in which perinatal review can happen that includes home birth. And it's not just a review of bad outcomes, it's a review of all outcomes. And an opportunity to really know what's going on and what's happening with birth isn't just going to be a benefit to be able to analyze how we can make birth safer, but to optimize what systems of care are gonna give women the most choices.

NNAMDIBut I have to be more specific here, Brynne, because Amy specifically accuses your alliance of hiding the death rate of home birth. How do you respond to that?

POTTERWell, first of all, it's not -- she's referring to the national midwifery organization, the Midwife she's referring to the national midwifery organization, the Midwives Alliance of North America...

NNAMDIOh, I'm sorry.

POTTER...that I don't represent. So I can't really speak to a specific about some assumption of hiding. What I would say is that MANA's -- I know MANA stands ready to meet the needs of any reporting mandate. It is a private data set in which isolated cases of death would only be isolated cases similar to this case that we're talking about today. We wouldn't be able to make any extrapolation of a trend to homebirth. The only place we can do that is from the CPM2000, which was a cohort study that mandated all CPMs to report in prospectively all of their data for one year. And that study was published in the British Medical Journal, and it is absolutely in line with outcomes of all other published studies around homebirth, which is...

NNAMDIMairi?

ROTHMANYeah. I just wanted to go back to what Dr. Downing said. I absolutely agree with what he said about the importance of reviewing poor outcomes, and I can't think of a single midwife that I know that doesn't participate in peer review and looking at poor outcomes.

ROTHMANAnd I also just want to say that it is really great to have physicians like Dr. Downing, who understand the midwifery model, understand our scope of practice and where it intersects with obstetrics, so that when we do have something going on at a homebirth where we're not sure things are going well and we were starting to feel like maybe we need to access medical technology, that we have people like Dr. Downing that we can call and say, here's what's going on, we're coming in, and that we know that we and our clients will be received with compassion and respect and understanding of what has come before, so that we never have to hesitate to bring someone in knowing that they're gonna get that good care. And that is a really important factor in the safety of homebirth.

NNAMDISpeaking of which, David Downing, does the OB-GYN take on the risks of that case when he or she provides backup for a midwife?

DOWNINGYes, but, again, it -- I have to profess, I work in an academic model, which is closely integrated with midwives. I'm actually sitting in a room right now with three midwives and we have a -- they say hello -- we (laugh)...

NNAMDIHello.

DOWNINGWe have a collegial, respectful -- we understand each other's practices and what we can and can't do. So -- and that's sort of unique to an academic medical setting. If you look at a more traditional, private, community-based obstetrical practice, there isn't as much -- my impression is there isn't as much collegiality and integration.

NNAMDIGot to take a short break. When we come back, if you have called, stay on the line. We'll try to get to your call. But in the meantime, if you'd like to communicate with us, go to our website kojoshow.org. Send an email to kojo@wamu.org or a tweet @kojoshow. I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation about midwives and homebirth in the wake of a well-publicized case in the Washington area in which a midwife was prosecuted after a baby died in childbirth. We're talking with Mairi Breen Rothman, she's a certified nurse midwife and co-founder of the Metro Area Midwives and Allied Services in Silver Spring. Also joining us by telephone from Charlottesville is Brynne Potter, she's a certified professional midwife. She's the public relations director for the Commonwealth Midwives Alliance and serves on the board of directors of the North American Registry of Midwives.

NNAMDIDr. David Downing joins us by phone from Washington. He is the attending OB-GYN physician at the Washington Hospital Center. He works with midwives. Directly to the telephones, here is Susan in Silver Spring, Md. Susan, your turn.

SUSAN...for taking my call.

NNAMDIYou're welcome.

SUSANI had a hospital birth four years ago, and I just recently, in March, had a home birth. And I think what I learned from both of those experiences was that the medical industry and society has actually done a really good job at convincing women that they can't give birth on their own, that they need these interventions. And I think one of my concerns about all of the coverage of this particular case in Virginia is that that'll just exacerbate this notion that, you know, women can't do this on their own, when in fact, you know, the human race have survived so far with women doing that.

SUSANAnd the difference for me with the hospital birth was that when I went there, it was all about the hospital and the doctors. You know, I was ready to push and they told me to sit in the waiting room and wait to check in, and it wasn't until I kind of fell down on the ground that they whisked me to a room and then -- only then to tell me, oh, the doctor isn't ready and to hold it in for an hour. It was a little surreal that that's what was happening to me. When I had my homebirth, which in fact Mairi was at -- hi, Mairi...

ROTHMANHi, Susan.

SUSAN...it was a completely different experience. It was all about me and the baby, and I felt completely safe. The whole time I knew, and my husband, who comes from a family of doctors, knew that if anything went wrong, we could be transferred, that they wouldn't wait until it was too late to do something. And, you know, I think for most women who have a healthy normal pregnancy, homebirth is a good option that they need to think about. And they probably have heard or seen in movies something that contradicts that it's safer and it's also cheaper. No one here is talking about the money factor.

SUSANMy hospital birth four years ago, the bill was over $17,000 and I was there for about, you know, two hours before the baby was born and left a day early. And there's a lot of costs that I think people need to think about as a society. We're talking about that ...

NNAMDIAnd we also need to be talking -- and thank you very much for your call, Susan. Mairi, we need to be talking about how insurance covers this, how health insurance covers one process as opposed to the other.

ROTHMANWell, it's interesting, some years ago, Kaiser in California started paying 80 percent for women that chose to deliver in a birth center -- I mean, sorry -- 100 percent for women that chose to deliver in a birth center and 80 percent for women who are low-risk that chose to deliver in a hospital because they knew that they could save money. They knew that it was perfectly safe or as safe as being in a hospital.

ROTHMANAnd I think that in recent years, that was maybe 15, 20 years ago, in recent years, there has been a huge push to re-medicalize child birth with this incredible rising C-section rate and more and more insurance companies are only covering midwives as an out-of-hospital benefit, I'm sorry, out-of-network benefit, so that they cover, say, 80 percent of what's -- they consider reasonable and customary. And, of course, reasonable and customary remains some kind of cosmic mystery. You can't actually find out what that is.

NNAMDIBecause it's my understanding that you can have three women with the same insurance company and get three different reimbursement amounts.

ROTHMANYes, we've experienced that. We once got a check back from insurance company for 2 cents. (laugh)

NNAMDIFor doing what? (laugh)

ROTHMANPre-natal care, labor, delivery and six weeks of postpartum care.

NNAMDITwo cents.

ROTHMANYeah. That -- apparently it was 80 percent of their idea of reasonable and customary. I don't know.

NNAMDISusan, thank you for your call. We got this email from Desiree. "It seems to me that there are some dangers inherent in childbirth. To have the unfortunate death of a child rule out homebirth is ridiculous. Babies die in the hospital and they die at home. I've had a baby in the hospital and a baby at home. My birth at home was incredible, and I would do it again with or without the permission of the state." And then there's this email from Diane. "My daughter is a nurse at a local hospital, where she also gave birth to her two children using a midwife. Suggesting that hospitals are a bad alternative to home delivery reflects an ignorance of all the possibilities using hospitals.

NNAMDI"Nurses can be very hands-off, leaving the delivery to the midwife. But should anything go wrong, you can access emergency help almost immediately. The case suggests a false choice. That notion should be corrected." How do you feel about that, David Downing?

DOWNINGI agree entirely, I think. Again, what I said before, which is that there should be enough choices and that the patient, as long as she's counseled, can make her own choice. I tend to draw the risk line a little bit more conservatively in terms of trying to be prepared for things that albeit are very, very rare, but which are very difficult to handle at home. One that comes off the top of my head is a -- what's called an amniotic fluid embolism. It's a condition where, all of a sudden, some of the amniotic fluid gets into the mother's circulation and can actually cause her to have a cardiac arrest.

DOWNINGThat is very, very difficult to handle in a hospital. It's almost impossible to handle at home. So -- but, again, it's extremely, extremely rare. And -- but that's where I would see some benefit of having more resources for these extremely rare events.

NNAMDIOn to Dea (sp?) in Washington, D.C. Dea, you're on the air. Go ahead, please.

DEAHello. Thank you for taking my call. It's very unfortunate that a baby has to die for this conversation to take place. And what I would like to do is echo what pretty much everyone has said consistently, that communication is key. And I really hope that what we're moving toward is informing women about their choice and informing them in a non-judgmental way. The conversations that I had with midwives prior to my first son being born were extremely judgmental, and really set me up to feel like if I ended up with a C-section, I somehow failed, that it was my job to advocate for myself to make sure I don't end up with a C-section.

DEAWell, somehow, between my last appointment and the time I went into labor, my son ended up in a breech position, so I ended up with a C-section. I cried like a baby because I felt like I failed, and I didn't. I didn't. I had a healthy baby. And then with my second child, I advocated for myself, and I wanted to make sure I had the least amount of intervention possible. But I wanted to do it in a hospital because of what happened the first time. And I was in a very supportive environment, and I had a successful VBAC with very, very little intervention.

DEAAnd since then the conversations I keep having, it's really either or. And I think the information that gets to women really needs to be about all the choices that they have available to them, and not making them feel like they're a failure if, for some reason, they end up in a hospital or, God forbid, they end up with a C-section. None of us -- at least most of us -- don't want that, so.

NNAMDIBrynne Potter, how do you have that conversation without making one seem somehow more morally authoritative than the other?

POTTERI completely agree that this is an issue. And for and those in my practice and in what the CPM and the Midwives Model of Care really puts in, it is that informed consent is a process. It's not a document that gets signed at the beginning of care or at the beginning of a procedure. But it's really a process that, as a core foundation, is based on providing evidence-based information, clinical judgment and expertise without a bias, and clear outlines of risks and benefits and alternatives, including doing nothing in any given situation.

POTTERIn specific answer to your question of how do we mitigate these issues of feeling of failure -- I mean, I've definitely transported women and then seen across their charts failed homebirths, you know, that it's actually -- becomes a term, and we know it's a term, an obstetric failure to progress. So there's no way that we can completely eliminate the disappointment that the birth didn't go as you planned for. But, really, the thing that makes a huge difference in both the sense of satisfaction for women who plan out-of-hospital birth and end up birthing in hospital, maybe end up with interventions that they hadn't hoped to need, but end up needing, really comes down to the relationship between the midwife and the receiving providers.

NNAMDIDavid Downing, I'd be interested in your comments on this.

DOWNINGOh, I can't agree more. And, again, I think most midwives -- at least in this area -- that have established relationships with physicians do present in an unbiased -- this is what's happening. This is where the patient is coming from and what she would like to see happen. And both the midwife and the patient are receptive to the obstetrical perspective of that particular situation.

NNAMDIAnd, Mairi, I wanted to get back to the issue of regulation for a second because we started off talking about it earlier. Only about half the state's licensed certified professional midwives. What's the situation in states that don't have licensed certified professional midwives? In the absence of a law, does that mean that the practice is simply unregulated, or is it illegal, or how is it dealt with?

ROTHMANWell, in Washington, D.C., there is no licensing mechanism for certified professional midwives, but there's also no law against them. So I guess you can say they're A-legal there. And then in Virginia, there's licensing. And in Maryland, there's a law against certified professional midwives in that, in Maryland, midwifery is defined as advanced practice nursing. So if you're practicing midwifery and you're not a nurse, you can be accused of practicing nursing without a license. And that is something that the CPMs in Maryland and the many women who are served by their wonderful care wish to change.

NNAMDIAnd, Brynne Potter, is there a tension -- is the tension between medical doctors and midwives sometimes a gender-based tension? Is it a kind of male-female tension, and could I have a future in midwifery? But go ahead, please.

POTTERThere are definitely male midwives. I think midwife means with woman, so that's really related to the woman who's giving a birth. So I can tell you, you probably will never be able to deliver a baby, but you certainly could help a woman deliver a baby. So, no, I don't think there's gender bias. I think that there is more, as I spoke to before, there are prejudice -- prejudices and bias that relate to hierarchical views by a really a paradigm or model of thinking about how we view birth.

POTTERThose are, I think, where opposition and untenable cultural divides occur between midwifery as a whole and medicine as a whole. I think we're really talking today here about really who is impacted the most when those divides are left hallow, and that is the women who seek services of both obstetricians and midwives for their care.

NNAMDIHere is Sarah in Washington, D.C. Sarah, you're on the air. Go ahead, please.

SARAHThanks for taking my call. I was -- Hi, Mairi. You delivered my baby during Snowmageddon.

ROTHMANYou delivered your baby, Sarah.

SARAH(laugh) Yes. Well, you came to check him out, I suppose. And I was going to say that, in my case, it was much safer to have a midwife-attended birth.

NNAMDIHow come?

SARAHIsaac (sp?) was born during Snowmageddon, so there was, what, three feet of snow on the ground. He was born in 90 minutes from first contraction to holding the baby. And, needless to say, there was no time to go anywhere. And so we -- the baby was born while Mairi was on the phone with my husband. If we had had a traditional OB birth, it would -- he would have been born either in the car, which would have been definitely less safe, or while waiting for the answering service to call back and without even the help over the phone.

NNAMDISo Mairi performed her service by telephone?

SARAHYeah. And then she came about -- she arrived 10 minutes after the baby did and checked him out and helped with the act of birth.

NNAMDIIn the middle of Snowmageddon. Apparently, midwives still take that over the mail...

ROTHMANYes, we do.

NNAMDI...doctors used to.

SARAHI didn't have to go anywhere.

NNAMDI(laugh) OK. Thank you very much for your call. I'm afraid we're just about out of time. Mairi Breen Rothman is a certified nurse midwife and co-founder of the Metro Area Midwives & Allied Services in Silver Spring. Mairi, thank you so much for joining us.

ROTHMANThanks for having me.

NNAMDIDavid Downing is the attending OB-GYN physician at the Washington Hospital Center. He works with midwives. David, thank you and all of your midwife colleagues for joining us.

DOWNINGIt's a pleasure to participate.

NNAMDIAnd Brynne Potter is a certified professional midwife. She's the public relations director for the Commonwealth Midwives Alliance. Brynne, thank you for joining us. And thank you all for listening. I'm Kojo Nnamdi.