November 2004 | Cover Story
Difficult Delivery
Obstetricians are fleeing the state in record numbers due to insurance costs. Midwives, who fear being prosecuted, are following their lead
by Luli Buxton
Women have been giving birth since the dawn of time, but for women in Illinois the choices of how and where to give birth are dwindling. Not only are obstetricians fleeing the state in record numbers because of skyrocketing insurance costs, but midwives are following their lead, in part because of confusing regulatory actions and a recent Illinois Supreme Court decision that may encourage the prosecution of midwives.
The issue really began to heat up in the 1990s, when local midwives began receiving phone calls from a woman who called herself Vicki Sloan. She said she was pregnant, and was interested in finding a midwife to attend her home birth. Shortly afterwards, eight midwives were sent cease-and-desist orders from the Illinois Department of Financial and Professional Regulation, accusing them of practicing midwifery without a license.
One order named Sloan as an undercover investigator for the agency, according to Valerie Vickerman-Runes of Arlington Heights, who had been helping women give birth at home since 1983.
“I had no idea I was such a dangerous criminal,” said Vickerman-Runes, who had professional midwife’s certification from the North American Registry of Midwives, and also was a licensed nurse at Provena St. Joseph Hospital in Elgin. In 1998 and again in 2000, Vickerman-Runes received cease-and-desist orders regarding her midwife practice. As a result, she said, she quit delivering babies at home, was fired from her job as a labor delivery nurse and her nursing license was indefinitely suspended last February.
“Ironically, I had been promoted to charge nurse three weeks before my termination and even those hospital administrators who testified at my hearing before the nursing board admitted that they had no problem with my nursing skills or my actual functioning within the hospital,” she said.
Provena St. Joseph Hospital Human Resource Manager Wendy Daniel declined to discuss the case explaining it was against the hospital’s policy to comment on former employees. Many Illinois midwives who were issued cease-and-desist orders were unsure how to proceed. They were accused of practicing medicine and midwifery without a license. But since the State of Illinois does not issue licenses for midwives, there wasn’t much they could do, except leave their chosen calling or the state. Several said they were nationally certified as professional midwives by the North American Registry of Midwives. Many left to work in one of the 35 states where attending home-births is legal.
At the time, there was no Illinois law governing the practice of direct-entry midwifery, which does not require a nursing degree and involves home-births. Women who attended home-births were under the impression that since there was no law in Illinois expressly allowing or forbidding their practice, it was legal. Direct-entry midwives are different from nurse-midwives who have a nursing degree, are licensed in Illinois and typically limit their practice to hospital births.
“Illinois is probably the worst state in the country for midwives,” said Marie Campbell, who asked that her real name not be used because she still attends home births in Illinois. “It was the last state to license nurse-midwives and still doesn’t allow birthing centers.”
Although Campbell has not received a cease-and-desist order, she said, “I think about quitting all the time. I’m not naive about it, I know that I order health tests, fill out birth certificates. If you practice for any length of time your name is out there.”
The fear and midwife drain in the state meant that Jacque Shannon-McNulty, the president of Chicago Community Midwives, had to call in a midwife from California for her second pregnancy. When Shannon-McNulty was six months pregnant with her first child in 1997, her midwife had received a cease-and-desist order. Until then the issue had not received much media attention.
But then in 2000 Yvonne Cryns, a direct-entry midwife from Richmond, Ill., attended an at-home-birth in Round Lake Beach. The baby was born breech, and died shortly after delivery. Although the baby’s parents supported Cryns, she was indicted on charge of manslaughter and one charge of manslaughter of an unborn child. She was acquitted of the latter charge, but the jury remained deadlocked on the other count. Her case was up for trial again but on Sept. 6 she accepted a plea bargain for a misdemeanor charge of reckless conduct and was sentenced to 18 months probation.
Cryns had already agreed to stop helping women give birth in July, 2003, following a ruling against her by the Illinois Supreme Court in a civil case brought by Leonard A. Sherman, the director of professional regulations for the Illinois Department of Financial and Professional Regulation.
While there still is no law prohibiting its practice, the Illinois Supreme Court decision in Sherman vs. Cryns stands as a precedent, so that women who attend at-home births now risk being prosecuted.
The court ruled that direct-entry midwifery fell under the jurisdiction of the Advanced Practice Nursing Act, which identifies nursing as including “the assessment of healthcare needs ... the promotion, maintenance, and restoration of health ... counseling, patient education, health education, and patient advocacy.”
Vickerman-Runes believes this definition is broad enough to include all kinds of alternative healing and educational methods. “It could include doulas, lifeguards, health food stores,” she said. “If I’m teaching a childbirth class am I violating the law? The law has an obligation to be specific, so that people of ordinary intelligence can tell what laws they’re violating.”
The Illinois Department of Financial and Professional Regulation’s “main purpose is to protect the consumers of Illinois ... We strictly regulate all of the financial industry and we hold the professional industry to the same standards,” said agency spokeswoman Clare Thorpe, who added nine cease and desist orders were issued.
Obstetricians Fleeing the State
This ruling comes at a time when there is an increasing demand for birthing services. Many Illinois obstetricians have stopped delivering babies or have left the state to practice elsewhere because of soaring insurance costs. According to a report by the Illinois State Medical Society in 2003, an obstetrician who performs high-risk procedures gets sued approximately every 18 months, and liability premiums for obstetricians in Illinois average about $140,000 while the average in Wisconsin is about $40,000. The report states that “Illinois physicians are leaving the state in alarming numbers” and “attracting new physicians to Illinois is next to impossible.”
“Obstetricians are one of the most frequently sued in the medical profession, and their insurance is among the highest,” said Danny Chun, a spokesman for the Illinois State Hospital Association. “Obstetricians are dropping high-risk pregnancies and moving to other states,” where caps on malpractice rewards keep insurance premiums lower.
According to Dr. James Milam, who has a private obstetrics practice in Illinois and is on the board of trustees of the Illinois State Medical Society, “the saddest part of doctors leaving is that they are giving up something that they are called to do. ... People don’t like to say that they have to give up what they love.”
Despite the risks, Milam continues to practice obstetrics. “Ever since that first delivery when I was a senior in medical school I knew there’s nothing like the miracle of birth. That’s how I feel every time I deliver a baby,” he said.
A survey conducted in March by the OB/GYN Crisis Coalition found that 11 percent of obstetricians and gynecologists in Illinois have stopped practicing obstetrics because of medical liability concerns, resulting in the loss of more than 46,000 office visits. More than half of OB/GYNS said they are considering stopping obstetrics entirely, and 80 percent indicate they will see fewer high-risk patients. Almost 90 percent of OB/GYNS said they believe Illinois is in a state of crisis.
Midwives could provide a valuable alternative.
Studies show home birth to be as safe as hospital birth, sometimes safer, according to Debbie Pulley, director of public education and Advocacy for the North American Registry of Midwives, based in Lilburn, Ga.
Midwives are the primary care-givers of pregnant women in many European countries, said Pulley. The World Health Organization studied birth trends in the Netherlands, where 30 percent of women give birth at home. It found that for low-risk women giving birth to their first child “a home birth was as safe as a hospital birth,” and for low-risk women giving birth to consecutive children “the result of a home birth was significantly better than the result of a hospital birth. There was no evidence that this system of care for pregnant women can be improved by increasing medicalization of birth.”
In 1999, the British Medical Journal wrote, “No evidence exists to support the claim that a hospital is the safest place for women to have normal births.”
Milam said there are studies in the United States that show women who have a doula or a nurse-midwife in the hospital have required less pain medication and had “a less psychologically intense labor and delivery experience.”
Diane Bajus-Abderhalden is one of the few certified nurse-midwives who attends home births. She said she knows from having worked in a hospital that a healthy woman is safer giving birth at home. “I saw a lot more complications in the hospital than I ever did at home,” she said.
Shannon-McNulty thinks the hospital is no place for a healthy pregnant woman. “As a healthy woman going in to experience a normal healthy function of my body I didn’t want to go into a place full of sick people,” she said. In fact, some studies show that many medical interventions performed routinely at hospitals can be harmful to infant outcome.
“Most of the decisions have little to do with what’s best for mothers and babies,” said Jo Anne Lindberg, founder of the Birthlink Network, a birthing consulting company. Lindberg said that half of the couples who consult her are interested in home birth, and the most common reason is to avoid interventions. She said obstetric procedures such as cesarean sections, labor induction, epidurals, episiotomies and electronic fetal monitoring are often used primarily for the convenience or legal protection of doctors and hospitals.
Such procedures are the most common type of surgical procedures performed in the U.S., more than 6 million, mainly on healthy women during some 4 million births a year, according to the National Center for Health Statistics.
The stress caused by the sterile and unfamiliar environment of the hospital can set off what the World Health Organization (WHO) calls a “cascade of intervention,” which otherwise would be unnecessary.
Many obstetric interventions, according to Shannon-McNulty, “are actually protecting the doctor. I don’t think it’s because they are bad people. I think it’s because they have their hands tied by their malpractice insurance.”
Record Number of Interventions
Over a quarter of births (26 percent) in the United States are by cesarean-section. This is a 68.4 percent increase since 1989, and is an all-time high in the U.S. The WHO says an acceptable cesarean-section rate is 10 to 15 percent.
In August, 2003, a study published by the American College of Obstetrics and Gynecology found the odds for maternal death to be 3.9 times higher for cesarean section versus vaginal deliveries.
The most common complaint in medical malpractice lawsuits is that the doctor did not perform a cesarean section, according to Milam. But the risks of cesarean section continue to be controversial, as does the use of electronic fetal monitoring, which accompanies 85 percent of all hospital births.
Milam said that electronic fetal monitoring can also be unreliable. When the monitor says the baby is bad, there are studies that show they are wrong 25 to 40 percent of the time,” said Milam. This misdiagnosis can lead to unnecessary cesarean-sections.
An epidural can prohibit the mother’s creation of endorphins that act as a pain reliever, give the mother energy, and help her bond with her child, according to Shannon-McNulty.
Campbell said if a mother uses an epidural, then she needs to have a fetal monitor, which will restrict her to lying flat on her back. “She might not even feel her contractions and know she has to push,” said Campbell. If her contractions slow down, the doctor may induce delivery, but it’s possible the “body is not ready to give birth, it’s called a failed induction, and she gets a cesarean,” said Campbell. In the United States, more than 20 percent of births are induced, twice as many as the WHO recommends.
Do these medical interventions lead to a better infant outcome? Not according to the 2002 infant mortality rate, which is seven deaths per 1,000 live births, according to the National Center for Health Statistics. This is a 0.2 increase from 2001, the first rise in infant mortality in the U.S. since 1958. Most of those deaths were concentrated in the neonatal period, particularly within seven days of birth.
That figure, according to the Central Intelligence Agency World Factbook, places the United States behind 39 other countries that have lower infant mortality rates, including Cuba, Malta, Slovenia, and the Czech Republic.
Luli Buxton is a Chicago freelance writer, activist & documentary filmmaker.
![[Send]](http://consciouschoice.com/sendlink/send.gif){kind=small}
Recommend this page to a friend
Top Ten pages recommended to friends:
