Home birth debate readies to ramp up in Delaware

Aledia Brown couldn't wait to see her daughter, Danelle. A week before her projected due date, Danelle was already dancing — kicking up a storm in Brown's belly.

At 22, Brown is a young mom, but she said she knows what she wants and needs when it comes to bringing her little girl into the world. For Brown, having a home birth with a non-nurse midwife in her Magnolia home, without prescription medication or surgical intervention, was preferable.

"Your body knows your house, this environment," she explained. She said she felt the entire birthing experience would be more enjoyable for both her and the baby.

However, that wasn't what Brown got. Under Delaware law, it is illegal for women to have such a home birth.

Two years ago state lawmakers passed a bill that made non-nurse midwifery a felony if the midwife does not work with a licensed physician and have a written "collaborative agreement" endorsing her midwifery practice. Without that understanding, non-nurse midwifery is considered a Class F felony, with a conviction carrying possible incarceration of up to three years and a fine.

Two non-nurse midwives practicing in Delaware received cease and desist orders in May 2013 before the bill was signed into law. One is appealing her case against the Delaware Board of Medical Licensure and Discipline to the Delaware Supreme Court.

Currently, there is one non-nurse midwife practicing legally in Delaware who serves women in the Amish and Mennonite communities.

"The way that you bring your child into the world, that should be a fundamental human right," said Sarah Culver, a Dover-based doula and director of the LightHouse Birth Collective. As a doula, Culver assists a woman non-medically before, during and after childbirth.

She and other home birth advocates attempted to pass counter legislation last year, but it fell flat in the Delaware Senate on the legislature's final night.

"This is a touchy area," says Newark Democrat Rep. Paul Baumbach, who led the counter effort in the House of Representatives last year. "It also is a culture intersection between the Western medicine, sort of patriarchal thinking, to home birth."

There are two types of midwifery distinctions in Delaware. A non-nurse midwife is defined by the state division of public health as a midwife who has completed an accredited midwifery education program such as the Certified Professional Midwife certification, regulated by the North American Registry of Midwives.

Nurse-midwives are licensed by the Division of Professional Regulations' nursing board as an advanced practice nurse and must have a standard registered nursing license as well. They either have a master's or doctoral degree along with their midwifery certification and can deliver in hospitals, birth centers, homes and offices in 50 states.

Baumbach's bill established a Midwifery Advisory Council that reports to the Board of Medical Licensure and Discipline, instead of requiring a written collaborative agreement with a physician. It would be responsible for renewing and issuing licenses every two years, as well as recommending suspensions to the board.

Now nearly a month into the new legislative session, he is working with leaders on the Senate health committee to resurrect the bill. He expects an amended form to be introduced to lawmakers at least by March.

"This is one where there is a lot of learning, meeting, understanding the other side. It's difficult for one side to trust the other," Baumbach said.

Delaware's most recent data on home births dates back to 2011. That year 89 Delawareans had home births, including births attended by the non-nurse midwife practicing legally, births assisted by a partner or family member and may include births assisted by illegally practicing non-nurse midwives, according to Emily Knearl, a spokeswoman for the Delaware Division of Public Health.

By comparison there were 10,454 hospital births. Delaware does not have a specific breakout of newborn deaths in the home and in the hospital setting, but the most recent data shows there were 73 in 2011.

Hospitals and birthing centers are the safest for mom and baby, according to the American College of Obstetricians and Gynecologists. Though the "absolute risk" is low, planned home births can have a twofold to threefold increased risk of newborn death and complications such as seizures compared to hospital births.

However, gynecologists do realize that a woman has the right to choose how she gives birth, says Dr. Nancy Fan, secretary for the Delaware College of Obstetricians and Gynecologists.

Fan was part of a committee that worked through the summer to discuss how to foster better relationships with the non-nurse midwifery community and physicians. She said while the College of Obstetricians and Gynecologists still does not fully support Baumbach's legislation, they are willing to find some "middle ground."

"We really would like to work with everybody on this. The patient is the one who suffers if there's not a collaborative effort," Fan said.

Advocates stress that planned home births should only be pursued for women who are considered "low risk." It is not recommended for women who have had a cesarean section, developed pre-eclampsia (when blood does not filter effectively to the placenta) or have chronic medical conditions such as diabetes or hypertension.

"Not all births belong at home," acknowledged Culver. However, if a woman is healthy and considered low-risk, she should be allowed to have a home birth with a non-nurse midwife, she said.

"There's an element of trust and a real relationship that is present," she said.

Brown had a happy, healthy baby at Beebe Healthcare last Tuesday, but she worked out a birth plan with Culver in the months before her delivery. Instead of working with a midwife, her plan detailed how to discuss medical intervention like epidurals or episotomies with the doctors and how she prefers a natural birth unless a serious complication arises.

Brown said they discussed what would happen during labor as well as how to care for the baby after birth.

"You're in and out," she said of hospital births. "I don't think that that's fair to a new mom. I'm not a cow. What about teaching me about how to change diapers. There are mothers out there that aren't that educated.."

Non-nurse and nurse midwives both provide education on fertility, nutrition, exercise and breastfeeding among other topics, according to the American Pregnancy Association. However, only nurse midwives can medically intervene if necessary with labor-inducing drugs, epidurals (which cut the pain after an injection into the spinal cord) and episiotomies. An episotomy is an incision made near the vaginal opening and anus that helps the baby move through the birth canal.

But regardless of which midwife is heading the delivery, if there are any complications mom and baby would be transferred to a hospital setting.

The possibility that something could go wrong is why a collaborative agreement with a non-nurse midwife is necessary, explained Fan. However, some obstetricians still have been reluctant to give that endorsement since they are not monitoring the baby directly throughout the woman's entire pregnancy.

"I really think it's a big ask for physicians," Fan said. "You really have to know whom you are working with."

Fan works with St. Francis, and says that she trusts the two midwives in her office, but that is not the case for every professional. She said she would need to hear feedback from the midwife on what he or she is comfortable with performing and when to ask for a consultation.

"I really need to know who that person is," Fan said.

She hopes going forward there is room to address those concerns in future legislation.

"There's a cautious optimism for having the conversation," she said. "The wheels of legislation works slowly. I think we want to get it right."

Jen Rini can be reached at (302) 324-2386 or jrini@delawareonline.com. Follow @JenRini on Twitter.