Grannies and Granolas

Summertown, Tenn. — Pamela Hunt got the call at The Farm around 11 a.m. the morning of April 23. “Lydia’s baby is coming,” the caller said. Hunt knew Lydia well — after all, she had delivered three of Lydia’s children — but she didn’t recognize the voice on the phone. Then she realized the father-to-be, an Amish farmer named Rudy, must have asked an “English” neighbor to call.

Hunt checked to make sure her birthing kit, oxygen tank and scales were in the car, and then took off on the 10-mile drive. “I’ve learned that if I don’t go immediately sometimes I’ll miss the baby,” she said. “We just don’t get enough information in those phone calls to make a judgment.”

Hunt found Lydia in a rocking chair in the living room of the family’s modest farmhouse. She checked the mother’s blood pressure and the baby’s heartbeat.

Two hours later an eight-pound, seven-ounce boy “came out crying.” There was no fetal monitor, no anesthesia, no forceps. Rudy stayed at Lydia’s side throughout the birth.

The newborn spent his first five minutes on the mother’s belly, then was passed to his grandmother to be cleaned up while the placenta was delivered.

“After that I handed the baby back to the mother to begin nursing,” Hunt said. “I never leave until the baby is on the breast and everything is stable.”

Hunt is one of four lay midwives at a clinic run by The Farm, a rural collective that handles home births for the growing number of women seeking an alternative to the high costs and excessive medical interventions of doctor-attended hospital births.

She is also one of the small handful of Southern midwives who are permitted to deliver babies unrestricted. Beginning in the late 1970s, many Southern states either outlawed midwifery outright or imposed licensing restrictions designed to phase out elderly black midwives who have long practiced in impoverished rural areas.

The restrictions worked, forcing many “granny” midwives out of business or underground. But today, a new generation of young, mostly white “granola” midwives are treading in the footsteps of their black predecessors, lobbying for legal status and emerging as powerful advocates for poor pregnant women across the region.

Some of the new midwives have won professional recognition, but most still struggle with legal and bureaucratic obstacles. Despite a wealth of statistics demonstrating that lay midwifery gives birth to healthier infants, many doctors continue to treat the centuries-old tradition of maternity care as a threat to their power — and their pocketbooks.

“Many physicians fear competition — losing patients to midwives because they’re cheaper,” said Dr. B.C. Merkle, who has practiced medicine in Perry County, Alabama for 22 years. “But what I’m concerned about are the people who can’t afford a doctor, who need to be followed and who aren’t at present.”

 

“So Little Brains”

When male doctors first launched their campaign to seize control of the health care industry a century ago, they attacked midwives as backwards and dangerous. Dr. Joseph DeLee, a leading advocate for banning lay practice, blamed midwives for the slow acceptance of obstetrics as a medical specialty.

“Do you wonder that a young man will not adopt it as his special work?” Dr. DeLee wrote in 1895. “If a delivery requires so little brains and skill that a midwife can conduct it, there is not the place for him.”

Despite the assault, “granny” midwives flourished in the South long after they became extinct in other parts of the country. Excluded from modem hospitals by segregation, poor black women drew on the experience of grandmothers to help them give birth. Even after integration, rural black women who lacked the money for a hospital birth continued to rely on the grannies.

Many Southern states, faced with large numbers of poor women unable to receive care, promoted lay midwives in the 1940s and ’50s by establishing programs to train them and issue licenses.

In the 1970s, however, the medical lobby finally convinced states to replace lay midwives with certified “nurse-midwives.” In Florida, for example, a nurse-midwife apprenticed for a time with a granny midwife, who was then pressured to turn over her black bag or “grip” to the younger woman and retire.

By 1980 all but a handful of grannies had been forced to quit. Alabama, Kentucky, North Carolina, Virginia, and West Virginia outlawed lay midwives altogether, and Mississippi and Georgia effectively prohibited them by refusing to issue them licenses. The nurse-midwives who replaced them are closely supervised by physicians and are often forbidden to handle home births.

Ina Mae Gaskin, editor of The Birth Gazette and founder of The Farm midwifery service, estimates there are approximately 2,000 lay midwives practicing nationwide. She thinks the United States could use as many as 200,000.

“England has far fewer people than the States, but has eight times as many midwives,” Gaskin said. “The U.S. and Canada have fewer than any other country.”

Only five Southern states currently have laws that permit lay midwives to practice — Florida, South Carolina, Arkansas, Texas, and Louisiana. In Tennessee, only a “gray area” in the law allows the women at The Farm to run their midwifery service.

In addition to a health clinic and laboratory, The Farm has equipped a maternity center with an incubator, oxygen tanks, and operating lights for high-risk births. Dr. John Williams, a local general practitioner, provided the midwives with medical backup for 10 years and helped them win the respect of other doctors.

“I feel confident in the midwives,” Dr. Williams said. “They know what they’re doing and there are occasions when they need help. It’s part of the ethical responsibility of any physician to provide these people support.”

The statistics are impressive. In the past decade, midwives at The Farm have “caught” 1,723 babies. Seventy-one percent of the mothers did not need episiotomies, a common hospital practice in which the vulva is cut to enlarge the birth opening. Only two percent received Cesarian sections, compared with 20 percent of all mothers who give birth in hospitals. And the newborn death rate was 5.8 per 1,000 births — compared with a rate of 6.9 deaths in Tennessee hospitals.

Linda Holmes, a healthcare worker who spent seven months studying granny midwives in Alabama, said such figures underscore just how “natural” childbirth really is. “The total dominance of medicine in the baby-delivery business obscures the fact that healthy, spontaneous birth is the norm in the overwhelming majority of childbirth cases, with minimum or no technological intervention required.”

 

Failing by 0.1

Unfortunately, midwives at The Farm say, the acceptance they enjoy is an exception in the South. Texas is the only other state in the region with a large number of midwives and an established tradition of lay practice.

The experience of women in Florida illustrates the obstacles midwives must overcome to provide maternity care for poor women. In 1982, the state established two training schools for midwives and issued licenses. Three years later, after heavy lobbying by medical societies, the legislature rescinded its support and limited practice to a small number of midwives already licensed.

Gladys Milton, an elderly black midwife, had been catching babies for 30 years in the Florida panhandle town of Crestview. When she refused to retire, the state health board charged her with incompetence, alleging that she had failed to repair a vaginal tear on a pregnant mother she assisted.

“The girl herself said she’d had no symptoms and that she’d come back to me if she had another baby,” recalled Milton.

At a hearing last year, a judge recommended that Milton be suspended from practice for a year, but the state health board overruled him and revoked her license. Demonstrators, carrying babies Milton had delivered, greeted the decision with picket lines.

“The Lord is using me for his purpose to focus attention on the needs of his people,” said Milton, who is appealing the ruling. The state has also prevented Milton’s 32-year-old daughter Maria from practicing midwifery. Although she graduated from the North Florida School of Midwifery before it was forced to close in 1988, Maria was denied a license after she scored a 79.9 on a state exam. The passing grade was 80.

Maria notes that the test included essay questions that were subjectively graded. “I know it’s foul play,” she said.

Maria is also critical of state officials in charge of the lay midwifery program , saying their real agenda is to phase out midwives. “It’s like the fox guarding the henhouse,” she said. “When you go to look for the chickens they’re not gonna be there: They’ll be eaten up.”

While she appeals the denial of her license, Maria works in a birthing center her family runs. There she helps her brother, a physician, provide maternity care for local women.

Florida Medicaid covers most extremely poor women, but many don’t qualify for public aid. “I call them those who are too rich to be poor and too poor to be rich,” Maria said. She noted, for example, that an unemployed pregnant woman with two children whose husband makes eight dollars an hour will be turned away by a doctor because she doesn’t have $4,000 for prenatal care and a hospital delivery.

The Miltons charge $750 for prenatal visits and delivery. The next closest clinic is 80 miles away.

 

SECRET DELIVERIES

In many Southern states, midwives determined to carry on the tradition have gone underground, delivering babies in secret to avoid prosecution. Experience has made them wary of strangers, unwilling to discuss their practice with anyone outside their close-knit circles.

On the telephone, a woman who asked to be referred to as Jessie Barnes insisted she was not practicing. In a person-to-person meeting in a Decatur restaurant, however, she loosened up enough to talk about her underground midwifery practice in northern Alabama, where lay midwifery is illegal.

Barnes said many of her clients are middle-class women who get “a rude awakening” when they attend childbirth classes at the local community college. “Basically they teach you to be a good patient,” said Barnes, who reported that Decatur hospitals insist on fetal monitors and IVs during labor and administer anesthetics to most women.

“A lot of clients just want to have some say-so in their births,” Barnes said. “If they could get it in a hospital setting they might not seek out midwives.”

But most women in Alabama who go looking for an alternative to the hospital won’t find it unless they know who to ask. Like other lay midwives in the state, Barnes only accepts patients referred by people she trusts. Often the referrals come from instructors of birthing classes or nurses who encounter women unable to afford a hospital birth.

“I like to know who I’m dealing with since our legal status is shaky,” she said. “I probably should take more precautions.”

Barnes blamed physicians for most of the discrimination against midwives. In one case, she said, a certified nurse-midwife in Montgomery drew the wrath of local obstetricians when their paying patients began asking about her. “If midwives only delivered indigent patients no one would ever say anything,” said Barnes.

Barnes trained in Texas — “a midwives’ haven” — and dreams of returning there to practice one day. In her two-and-a-half years in Decatur, she has performed five home births and three labor sittings, in which she monitors women in labor until just before the birth to minimize their time in the hospital.

Asked what she would do if the authorities crack down on lay midwives, Barnes said, “I guess I would just do labor sittings. I can ’t go tojail. I’m not a political activist.”

 

FACING JAIL

Just before Christmas Day 1985, Ana Mary Sikes of West Helena, Arkansas, got a desperate phone call from a neighbor whose wife was pregnant. “Miss Ana Mary you just got to come,” begged the man. He could not afford the $ 1,300 delivery fees at Helena Hospital, and his wife was too far along in labor for him to drive her to another town. Sikes knew she’d be breaking the law if she went to help.

A 73-year-old black midwife, Sikes had been delivering babies since the age of 19. In 1942 she received training from the state and obtained her first permit to practice. “I renewed my permit each year until 1979, when they wrote us a letter saying they weren’t going to use lay midwives anymore,” she recalled.

Sikes, who was ill the day of the phone call, coached the father on what to do. He washed his hands in alcohol and water and caught the baby himself while the couple’s frightened children looked on from the doorway. Then he called Sikes and she came over to cut the cord.

That year, the elderly midwife delivered three babies in similar emergency situations. She handled four others in 1987 and 1988. “One midwife told me, ‘They’ll put you in jail,’” recalled Sikes. “I said, ‘If they want to put me injail they can do it. I’m not going to turn down no emergency case.’” “I believe that poor women are having more trouble now having babies than in the old days when midwives did all the deliveries,” said Sikes.

 

“OUT OF THE CLOSET”

Without Carolyn Vogler, lay midwifery would probably still be illegal in Arkansas. After training in Texas and practicing underground in central Arkansas for a few years, Vogler moved to impoverished Chicot County and opened the Delta Maternity Center in 1982, openly defying the state’s ban on lay midwifery.

She moved to the Delta area because of the need. Infant mortality was high and the closest public hospital where an indigent mother could deliver a baby was in Little Rock, 115 miles away. Vogler charged $300 for a birth in an area where urban hospitals charged $2,000. Within days the State Medical Board filed suit against Vogler, accusing her of practicing medicine without a license.

“I wanted to come out of the closet,” said Vogler. Going to jail would be worthwhile, she felt, but it would prod the state into establishing criteria for licensing midwives.

The suit never came to trial, but the controversy helped push the state legislature to address the issue in 1983. The result was a compromise law permitting lay midwives to practice in six of the state’s poorest counties.

Midwives were not satisfied with the deal, however. Many poor women lived outside the designated area, and some midwives apparently felt obliged to cross county lines to help women in labor.

Two years later authorities in Independence County arrested a lay midwife and her assistant, confiscated their equipment and records, and charged them with practicing medicine without a license. Independence County was not one of the six counties where lay practice was legal.

The trial of Dixie Stone, a midwife and a part-time nurse, and her assistant Terry Davis was a watershed event, generating daily media coverage and scores of letters to local papers in support of the two women. Eighty-five percent of people polled by the ArkansasDemocrat said midwifery should be legal.

Dr. Joe Verser, secretary of the State Medical Board since 1949, took the stand for the prosecution to reject the notion that midwives can handle normal births. “I don’t think there is any such thing as a normal delivery of a baby,” he said, adding that he considered cutting the umbilical cord a surgical procedure.

The trial ended in a hung jury, but it was widely viewed as a victory for the midwifery movement. In 1987 the state lifted its six-county limit and established licensing for lay midwifery statewide.

 

Anti-Trust Doctors

Yet the legal status proved to be only a partial victory. To receive a license, a midwife had to have the signature of a physician committed to backing her up. But the rift between midwives and doctors was deep, and few physicians were willing to risk the censure of their colleagues by supporting midwives. Defiant, the midwives vowed to continue practicing without state licenses.

“Doctors are required to treat anyone who needs them in an emergency,” Vogler pointed out. “The same is true for us when a pregnant woman needs care.”

Weary of the battle, the state health department finally conceded last year and agreed to require an emergency back-up plan instead of a physician’s signature. Midwives were jubilant. “ We’ve been kind of like the health department’s Vietnam,” said Vogler.

The ruling, however, came too late for Vogler. She was forced to close her maternity center in 1988 when her three backup physicians withdrew their support after she filed for approval as a Medicaid provider. She has filed an anti-trust suit against several local obstetricians, charging that they intimidated her back-up physicians to protect their Medicaid business. The suit, she hopes, will set a precedent establishing the right of midwives to practice.

Despite the gains made by lay midwives, many believe it will take a revolutionary change in the American medical system before midwives gain the universal acceptance they enjoy in Europe. “It won’t happen until we have a national health plan in which midwives play an integral role,” said Ina Mae Gaskin, the founder of The Farm in Tennessee. “I’m looking for the South to take the lead in that. It’s here where the tradition has been kept alive the longest.”

“And it won’t happen,” she added, “until women understand that much of their power resides in motherhood.”