Appointments

Published on 05-16-2010

Source: Guardian

As residents of the world's consumer capital, New Yorkers can have anything delivered to their door at any time. They can have their hair cut in the living room, have champagne and caviar rushed to them on a whim, enjoy a shiatsu massage in their own bed or invite a clairvoyant to predict their future from Tarot cards laid out on the kitchen table.

But there is one thing that is currently unavailable for delivery to those who live in this most can-do of metropolises. Women can not legally give birth at home in the presence of a trained and experienced midwife.

This city of more than 8 million people, with its reputation for being at the cutting-edge of modern urban living, now lacks a single midwife legally permitted to help women have a baby in their own homes. "It's pretty shocking that in a city where you can get anything any hour of the day a person cannot give birth at home with a trained practitioner," said Elan McAllister, president of the New York-based Choices in Childbirth.

The collapse of New York's legal home birth midwifery services has come as a result of the closure two weeks ago of one of the most progressive hospitals in the city, St Vincent's in Manhattan. When the bankrupt hospital shut its doors on 30 April the midwives suddenly found themselves without any backing or support.

There are 13 midwives who practise home births in New York, and under a system introduced in 1992 they are all obliged under state law to be approved by a hospital or obstetrician, on top of their professional training.

St Vincent's was prepared to underwrite their services, but most other doctors and institutions are not, and they now find themselves without the paperwork they need to work lawfully.

Miriam Schwarzschild, one of the 13, is now in the invidious position of either abandoning her clients or operating illegally. "Apparently by taking a woman's blood pressure I am committing an illegal act," she said. She has no doubts about what she will do: she will stand by the six to eight women she helps in labour every month, law be damned. She said she intends to "fly under the radar", but is anxious about what would happen should she be reported to the state authorities. "At any time a nurse or doctor could report me, and once that happens they could go after my licence and shut me down."

Jitters are spreading among the tiny community of home birth midwives. The rumour has circulated that one of them has already been shopped to the authorities by an obstetrician at a hospital where she transferred one of her clients in need of medical attention.

The crisis of home birth in New York city is an extreme example of a pattern found across America. Fewer than 1% of babies are born at home in the US, and in New York that figure is as low as 0.48% - about 600 babies every year out of 125,000. That compares with a rate of about 30% in the Netherlands.

In much of Europe, midwives play the lead role in assisting most low-risk and healthy women to give birth, handing over to a specialist doctor or surgeon only when conditions demand. In the US, that relationship is reversed.

Obstetricians, who are trained to focus on interventionist methods and often have never even witnessed a natural birth, are in charge of about 92% of all cases. As a body, they are fiercely resistant both to midwives - who under the private medical system in America are their competitors - and to women choosing to remain at home.

In 2008 the American Congress of Obstetricians and Gynaecologists put out a statement effectively instructing its members to have nothing to do with the "trendy" fashion towards home births. Yet despite Acog's stance, and despite the fact that the US spends more money on pregnancy and childbirth-related hospital costs than any other type of hospital care ($86bn a year), the country has the unfortunate distinction of having one of the highest rates of maternal mortality in the industrialised world. Its rate stands at 16.7 maternal deaths per 100,000 live births, compared with 7.6% in the Netherlands and 3.9% in Italy. Britain's rate is 8.2%.

On top of that, about one in three pregnancies in the US end in a caesarean section - a product, critics say, of the highly interventionist approach that includes frequent induced labours and epidurals. Amnesty International recently dubbed the US record on childbirth as a whole a "human rights crisis".

Knowledge of these statistics, and of what is now happening to New York midwives, makes Julie Jacobowitz-Kelly see red. She is one of Schwarzschild's clients and is preparing to give birth to her first child, a boy she and her partner have already named Benjamin, whose due date fell today.

She said the current illegal status of the home birth midwives was "a travesty, it's absolutely ridiculous. It angers me that experienced midwives like Miriam are in jeopardy."

That is a view shared by some senior New York politicians, including Scott Stringer, Manhattan borough president. "There are 600 women who are going to give birth in the next year who want midwives with them at home, and to take away their rights and choices is so backwards it's embarrassing," he said.

Midwifery organisations are scrambling to persuade other hospitals to take over St Vincent's role by signing the so-called "written practice agreements" the midwives need to be legal. So far 75 hospitals have been approached; not one has replied.

Meanwhile, a bill is sitting before the New York state assembly that would scrap the system of practice agreements and allow the midwives to offer their services free of the control of obstetricians. But the bill may not be put to a vote at all this year.

"At the end of the day, hospitals are for sick people, and I'm not sick," said Jacobowitz-Kelly. "I'm going through one of the most natural processes women can go through, so why do it anywhere other than the most natural setting - my home."