For Expecting Moms, Doctors Or Midwives?

Virginia midwife Karen Carr was recently convicted of two felonies following the death of a baby she tried delivering. Carr's story has rekindled debate over whether it's better for a woman to use a doctor or midwife when giving birth. In this weekly parenting segment, host Michel Martin speaks with Tell Me More contributors and moms Jolene Ivey and Leslie Morgan Steiner. Also joining the conversation are Dr. Manuel Alvarez, head of obstetrics and gynecology at Hackensack University Medical Center, and Dr. Randi Epstein, author of Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

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MICHEL MARTIN, host: I'm Michel Martin and this is TELL ME MORE from NPR News.

They say it takes a village to raise a child, but maybe you just need a few moms in your corner. Every week we check in with a diverse group of parents for their common sense and savvy parenting advice.

Today we'll talk about the tough choice many women face when they're preparing to give birth. Should they deliver in the hospital or at home? Should they use a doctor or a midwife? This is on our minds because of a recent story in Virginia where midwife Karen Carr has been convicted of two felonies after a baby she delivered later died.

The mother had been turned away by other midwives because she had a high-risk pregnancy. She was 43 years old and the baby was a breech position. Carr took a plea agreement, received a suspended four-year sentence and was also banned from delivering babies in the state of Virginia.

The story has revived a longstanding debate of the use of doctors versus midwives and hospitals versus births at home. The latest numbers from the Centers for Disease Control say that while non-hospital births are still few, less than one percent of all deliveries, there is growing interest in them. They're up 3.5 percent in the last period measured.

But delivering children has become increasingly risky for everybody. The American College of Obstetricians and Gynecologists reported that from 2006 through 2008 6.5 percent of doctors stopped practicing obstetrics because of concerns about liability insurance, and eight percent stopped because of fears of litigation.

With us now to talk more about all this is Dr. Randy Epstein. She's the author of the book "Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank." She's a doctor. She's a mom of four and she joins us from our bureau in New York. Welcome.

Dr. RANDY EPSTEIN: Thanks for inviting me.

MARTIN: Also with us is Dr. Manuel Alvarez. He's known as Dr. Manny. He's the chairman of the department of obstetrics and gynecology at Hackensack University Medical Center in New Jersey. He's also the face of the website AskDrManny.com and a father of three. And he joins us by phone from his office. Welcome to you, Dr. Manny.

Dr. MANUEL ALVAREZ: Yes, hi.

MARTIN: Also with us, two of our moms regulars. Jolene Ivey is a Maryland state legislator, the mother of five boys, and she's one of the co-founders of the Mocha Moms, a parenting support group. She's here in our Washington, D.C. studio, along with Leslie Morgan Steiner, author of the book, most recently, "Crazy Love," and a mom of three. Thank you all for joining us.

LESLIE MORGAN STEINER: Thanks, Michel.

JOLENE IVEY: Thank you.

MARTIN: Jolene, I'm going to start with you, because three of your five boys were born at home, four of them with the help of a midwife. Why did you choose that option?

IVEY: Well, you noticed that the first one was born in the hospital with the help of a doctor. And it just wasn't the experience I wanted. There was the threat of Caesarean just hanging over me the whole time I was there. And that threat was there because of the interventions that they'd already done, including giving me an epidural, which seemed to decrease the baby's heart rate.

So because of the things they did to me, the baby was in distress and they were about to give me a Caesarean. So I did manage to get him out in the nick of time, but I didn't want to go through that again.

MARTIN: And when you things that they did to you, you definitely felt you were not a partner in care, you felt like you were not at the center of the thing.

IVEY: When they strap you with devices and keep you on the bed and keep you from moving around, that keeps you from being able to labor effectively. And then withholding food and water and those kinds of things. It just seemed ridiculous to me. You know, you'd never ask a man to run a marathon and say you can't have anything to drink. What kind of sense does that make? But it's the same kind of physical exertion involved.

MARTIN: It all worked out well for you.

IVEY: In the end, yes.

MARTIN: With all of them. OK. Leslie, you think that's nuts.

STEINER: Well, yes, I do, although I respect Jolene a lot. Childbirth, although it's not a medical operation like open heart surgery, can be very dangerous to mother and child. And my mother's first baby died during childbirth. So I've always been conscious of the reality that childbirth can be lethal.

MARTIN: And so you feel, what - if the medical expertise is there, why not use it?

STEINER: I just, you know, I feel that having a baby at home without access to immediate emergency medical care is reckless. I think it's on par with denying a baby or a child medical care when they're sick or have a broken bone. It's simply not fair to the baby. I think it's - it's selfish.

MARTIN: Hmm. OK. But nothing but love here between the two of you.

(SOUNDBITE OF LAUGHTER)

MARTIN: Good to know. Dr. Manny, let's bring you into the conversation. Is this a debate that you find patients wrestling with?

ALVAREZ: This is a debate that every morning when I wake up I think twice about being an obstetrician. I understand that women absolutely need to be part of the decision making. I get it. You know, I trained under midwives and they told me a lot, absolutely - made me a better doctor. But at the same time, what has happened over the last, let's say 20 or 25 years, is that the expectation is one thing but the outcome is another. The reality of a delivery, it's a natural process. Yes, I know women all over the planet give birth in fields and in huts. I get the whole thing. But there's a realistic expectation. There's, you know, if somebody gets a vaginal tear during the delivery or fourth-degree laceration in the delivery, here in the United States that becomes a reportable complication. But all of these things now become litiginous(ph) and complaining things that makes the whole process very adversarial. You know, you have...

MARTIN: Mm-hmm.

ALVAREZ: ...the whole relationship has been broken down.

MARTIN: Hmm. Dr. Epstein, your book is about the history of childbirth, and you have some fascinating insights on, you know, what used to be preferred versus what's preferred now. Could you talk a little bit about this whole doctor versus midwife debate, if you would?

EPSTEIN: Well, you know, this is a debate that goes way, way back. It's not just a debate of modern times. I mean in ancient times or even not ancient times, hundreds of years ago, birth was an all-girls affair. You know, your mom helped you, hopefully a grandma with experience, your friends - and men were not allowed in there. It was obscene to come in the room.

When doctors started to get in the business as what they called themselves, man midwives, the intention wasn't just how it sometimes is portrayed, that these male experts were trying to take over the turf. In some ways they were, but they came in thinking well, we're going to medical school, we're learning about the human body, we think our expertise can help save lives. But go back to the 1800s, 1700s, and midwives were claiming that doctors were too interventionist then, using forceps too much, not washing their hands, and they were responsible for a lot of the deaths.

And, on the other hand, doctors were saying these midwives, they don't have any training. They're just - some have experience, some don't. They're responsible. And the fights back then actually, before we got into all this political correctness now, were a lot more vitriolic than they are today.

MARTIN: If you're just joining us, I'm Michel Martin and this is TELL ME MORE from NPR News. We're talking about the debate over where and how to deliver babies, with a doctor or a midwife, in a hospital or at home. With us are, Dr. Randi Epstein. She's written a book about the history of childbirth. Also with us, Dr. Manuel Alvarez; he's known as Dr. Manny. He's the chair of the Department of Obstetrics and Gynecology at Hackensack University Medical Center in New Jersey and our regular contributors, Leslie Morgan Steiner and Jolene Ivey.

Jolene, when you heard the story about this midwife who was prosecuted for - in the wake of a bad outcome, did that send a chill up your spine or did you feel perhaps she just didn't do her due diligence?

IVEY: Well, I thought that it was a tragedy. It's a tragedy that could have happened in a hospital. I don't know what would have happened if they'd been in a hospital; I can't tell you. I can tell you that I had a pregnancy along the way where I planned to have the baby at home and there were some things that happened. The baby became breech, and the midwives I was using said if the baby's like that, you can't have the baby at home; we won't deliver it. So they sent me to a specialist and the specialist, you know, talked me through it and said that he could deliver me vaginally in the hospital, but - and it would be breech, and there'd be risks involved, but it definitely wouldn't happen at home. I was just very grateful that he did not have to deliver that baby and the baby did manage to flip in the correct position in time and I was able to have him at home. And it really made me sad at the time to think, oh my god, I could end up in the hospital after all this, because I had fought my insurance company to get them to cover the home birth, which was something that they didn't want to do at the beginning.

MARTIN: You know, it seems like the key to this is people communicating with you because, you know, I, as you know I have twins and so...

IVEY: That wasn't an option.

MARTIN: It was not an option. It was not an option and I had, you know, wound up having a Caesarean and I discussed that with my doctor. And when - I wound up being very grateful that the opportunity existed to deliver via Caesarean in the hospital, because the truth of the matter is 50 years ago I probably wouldn't be here and my - at least one of my children would not have survived. So I found myself being really grateful for all the medical expertise that now exists.

But I'm interested in how we can resolve these, the adversarial quality of our discussions around this between doctors and patients. How does it get bridged? Jolene, do you want to start?

IVEY: I really feel like you're right, communication is the key. The reason why midwives aren't really sued so much and doctors have to worry about it all the time is because midwives spend a lot of time communicating and building a relationship with their clients.

When I was having my last pregnancy and I had a lot of complications and I was home on bed rest forever, the midwife came to my house to check me. She said if I sent you home to lay on the couch, I don't want you to get up and come in to be checked. I want you to stay on the couch. Now, no doctor has, would do that.

And so, anyway, I think that because I had such a great relationship with her, if something had happened - and I can't really see it happening, only because she was very meticulous and if there'd been any danger at all she would have transferred me to the hospital. But I feel that we had such a great relationship, how can I sue someone I love, whereas I did not love the doctor who delivered my first baby.

MARTIN: Oh, Dr. Manny, I think it's time to go to you on this. What do you think? What would...

(SOUNDBITE OF LAUGHTER)

MARTIN: I'm sure she would've loved you if she had had you.

ALVAREZ: I'm sure.

IVEY: Not if I get seven minutes a visit.

ALVAREZ: Well, listen, I, I understand what everything that is being said but, you know, it's almost impossible to change anybody's mind. One thing that has been said here is that, you know, at least, you know, if there is an intelligent patient that just like when, you know, the midwives told you that the baby was breech and you did not meet the criteria for a home delivery and they, as good midwives, realized that indeed this is not one of the things that should be done at home, they - that's very reasonable planning and that's, I think, is the key to this whole thing for patients that want this kind of setup.

Unfortunately, you know, you know, again, we obstetricians just get this terrible rap. And I know that there's a lot of doctors that spend a few minutes with the patient and they tend to get very mechanical, they see a lot of people in their office. You also have to remember and again, unfortunately, but it's the reality of fact, that the, that a doctor's, you know, responsibility insofar as the staff that they have to pay in their offices, the space that they have to rent, the malpractice premium, you know, I'm paying $125,000 a year in malpractice. Malpractice of a midwife is just a fraction of what an obstetrician pays - a fraction. And therefore, they can afford to have more selective patients. They, of course, can have more time in their hands to make sure that they do home visits.

Now that doesn't take away the fact that they do a much better job building that relationship with the patient. I get that. And for doctors that do not build that relationship yes, they're going to have more angry patients when things do go wrong as compared to people that have a better relationship.

MARTIN: Leslie?

STEINER: You know, I feel like we're trying to be so politically correct here.

ALVAREZ: I know, right? What do you want me to do?

(SOUNDBITE OF LAUGHTER)

STEINER: And talking about communication and respecting women's different needs and, you know, the tricky thing about childbirth is that it's impossible to be sure in advance that your birth will be low-risk and I never wanted to take that chance with my child's life. And I agree that women should be more empowered and that doctors should listen a lot more to what a mom wants.

But, you know, in my experience, my first child was born with a cord so short that every contraction cut off his blood supply and there was no way to know this in advance. This was a low-risk pregnancy but it turned high-risk in the matter of a couple of minutes. And we discovered it during labor only because of the technology and fetal monitoring available in the hospital that's not usually available at home births.

And I got to tell you, I never could have forgiven myself if he had died or suffered brain damage because I wanted to give birth in my home instead of a hospital. And the thought of it still brings me to tears now 14 years later. And even if there was the tiniest increase in risk of my baby dying, I don't care what they do to me in a hospital. I don't care if they strap me to a table. If I come out healthy and the baby is healthy, to me that's all that matters.

MARTIN: But Dr. Epstein, I'm going to go to you because I'm wondering if there's a way to reconcile these points of view because maybe the whole thing is that midwives should be in charge until something goes wrong. I mean maybe it's just the whole structure doesn't work anymore. What do you...

EPSTEIN: Well, we are grappling with it. It's interesting, I was speaking with some midwives and obstetricians at Yale University and they're not the only place to do this, but they're the one I'm most familiar with, they have a school of midwifery at Yale. They also have medical residents going into OB/GYN. They've made great strides in recent years to do things together. And yes, it sounds sort of old-fashioned and kind of hokey, but they feel that midwives in training and OB/GYN in training shouldn't wait till they're in practice and they're entrenched in what they're doing, but start talking now as students together.

What I keep hearing from everyone is fear of lawsuit, everyone here, and also this lack of control. And I found throughout looking at the history of childbirth when women feel this lack of control or that they're not being listened to, they kind of want the opposite, we become very rebellious. So you look back in the early 1900s when doctors were pushing natural childbirth and no one was listening to women when they were saying gosh, you know, it kind of hurts to give birth. Women started pushing to be knocked out. So, and women were, it was a kind of opposite fight but it all started with this feeling of women not being able to speak up.

MARTIN: Hmm. All right, final thought. Dr. Alvarez, I know we have to get back to patients, speaking of which...

ALVAREZ: Right.

MARTIN: But, if you had to go into obstetrics and gynecology again, would you do it? If you were starting your career now, would you do it?

ALVAREZ: Yes. I would. You know, I, to me, you know, despite the fact that, you know, yes, I talk about all sometimes all the resentment, you know, there's nothing more that I would, that I like to do. Sometimes I have terrible days and when I deliver a baby, it sort of, you know, it cheers me up because I feel the spirit of this child that I have brought into the world just kind of erases some of the negative energy that I might have for one reason or another during my day. But, yeah, I wouldn't change the whole thing.

I have, you know, I got married late and I have three beautiful children, as you said. One of them is autistic, by the way, and, you know, and what I really wanted to focus on is, you know, every morning I wake up and I open the bedroom doors of my children, I look, they're sleeping, they're healthy, they're home. That's all I wanted to do.

Yes, you can get mad at me because I strap you down or I put you in the monitor, or I start an IV, or I recommended an epidural, or I said, you know what, there's something going on here. I don't feel comfortable and I want to do a Caesarean section. And you could argue that sometimes maybe I never gave you the experience that you thought you wanted. But the experience that I wanted is for you to see a child who is thriving, who's healthy and who's going to be part of your life forever. And, yes, I would do it again.

MARTIN: Dr. Manuel Alvarez is chair of the Department of Obstetrics and Gynecology at Hackensack University Medical Center in New Jersey. He's the face of the website AskDrManny.com and he joined us by phone from his office. Okay. Get back to work.

ALVAREZ: Thank you. Goodbye.

MARTIN: Okay.

(SOUNDBITE OF LAUGHTER)

MARTIN: Also with us, Dr. Randi Epstein, she's the author of the book "Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank." And she joins us from our bureau in New York. Also with us, Leslie Morgan Steiner, author of the memoir "Crazy Love." She's also editor of the book "Mommy Wars." She has three children and she's a regular guest in our Moms discussions. Jolene Ivey is also one of our regular Moms. She's a Maryland state legislator and the mother of five boys, and they were here in our Washington, D.C. studios.

Thank you all so much for joining us.

STEINER: Thank you, Michel.

IVEY: Thanks, Michel.

EPSTEIN: Thank you.

(SOUNDBITE OF MUSIC)

MARTIN: And that's our program for today. I'm Michel Martin and this is TELL ME MORE from NPR News. Let's talk more tomorrow.

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