MIDWIVES 
and Kentucky’s health care 
industry

Kentucky is home to Frontier Nursing University, the country’s oldest and largest nurse-midwifery program, but is unsupportive of midwifery with outdated laws lagging behind neighboring states like Ohio and Indiana.

A little over five years ago, Sarah Holland had a huge decision to make. How would she give birth to her first child, a ninth-generation Kentuckian? Sarah, an attorney who lives and practices in Paducah, remembered her college years at Transylvania University, where one of her religion professors commenced a discussion about midwifery and water births. She recalled learning about this topic at an influential age, when she was concerned about her body and overall health and wellbeing. Sarah, curious about midwifery as an option for her birthing experience, turned for more information to a documentary that was then newly released,  “The Business of Being Born,” by Ricki Lake.

The documentary highlights the fact that the United States is the most prosperous nation in the world but has the second-highest infant mortality rate of any industrialized nation. It presents a medical and historical perspective on how and why obstetricians deal with childbirth the way they do. Looking for another birthing option after a traumatizing hospital experience with her first birth, Ricki Lake sought to understand why midwives preside over the majority of births in Europe and other countries, but fewer than 10 percent of American births. Exploring the history and function of midwives, a strong case is presented that many common medical practices may be doing new mothers more harm than good.

Sarah decided, after watching this documentary and doing some research of her own, that a home birth with a midwife would be the best choice for her. She remembered, “I didn’t feel safe in a hospital. Hospitals are a place people go when they are sick or dying. I wasn’t sick, and I wasn’t dying.” She felt that the philosophy of most obstetricians was that pregnant women were somehow sick. She would wait to see her doctor 30-45 minutes after her appointment time and always left feeling rushed and as if she was doing something wrong … she didn’t gain enough weight, she needed to eat more or less of something. Her experience with a midwife was much different, a completely different model of care. She recalled, “My midwife was really involved. My appointments with her were an hour to 90 minutes each time. She spent a lot of time getting to know me and my habits. She knew how much I ate or drank. She got to know me so well that she could notice if I was stressed or depressed. If it wasn’t for this, if I had gone through the medical model of prenatal care, I believe I would have ended up with postpartum depression.” She continued, “My midwife was emotionally supportive and aware of my life, which gave her clues into things that could be a potential issue as the pregnancy progressed. She allowed my body to progress naturally during birth and didn’t rush me. It was a phenomenal experience.”

Although Sarah’s experience with her midwife was noteworthy, many times she has heard of women having dramatic birthing experiences that have diminished their desire for more children. She stated, “The birthing experience affects people’s mothering and whether or not they want more kids, and it doesn’t have to be that way.” She even noted two friends who traveled to Cincinnati seeking midwife-assisted births in a hospital and public policy environment that were supportive to midwives. She reported being frustrated Kentucky law was so far behind and unsupportive of midwifery. Sarah, now a mother of three, believes that women should be able to choose how they give birth, encouraging Kentucky women: “Know your options. People are scared that something bad could happen during a home birth, but people forget that bad things happen in the hospital too.”

Kentucky Births by the Numbers

Maternal-fetal health statistics provide a clear picture of birthing outcomes in Kentucky. In 2012, 12.7 percent of the live births in Kentucky were considered preterm birth, in which the child was born before 37 weeks gestation compared to 11.5 percent nationally. From 2010-2012, the highest rate of preterm births existed among mothers over 40 years old (18.5 percent of births) and mothers under 20 years old (13.9 percent of births). Particularly telling is the rate of caesarian births. In Kentucky, in 2010, 35.4 percent of all births were caesarian. In 2011, there was a slight increase to 36.3 percent and in 2012, 35.4 percent of births in Kentucky were caesarean. Louisville’s caesarean rate in 2012 was slightly better than the rest of the Commonwealth at 34.7 percent of all births. Nationally, in 2012, however, the caesarean rate was 32.8 percent. Women in Kentucky are experiencing more caesarean deliveries than women in the rest of the United States, a procedure that, no matter how common, is a major abdominal surgery.

Midwifery

Midwives are health care providers for mothers and infants, professional practitioners who are trained with knowledge and skills to care for women across the reproductive lifespan and specifically through the pregnancy and postpartum periods. They are trained to assist women to maintain healthy pregnancies and have optimal births and recoveries. Midwives provide women with individualized care for the mental, physical and spiritual needs of each woman. Midwifery is unique in that it is a woman-centered empowering model, one that treats pregnancy and childbirth as normal bodily processes that women can manage with minimal medical intervention while in partnership with, and receiving emotional support from, a midwife. The international definition of midwifery as endorsed by the International Confederation of Midwives is as follows: “The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.” According to the 2013 National Vital Statistics Reports, in 2012, 94.9 percent of certified nurse-midwife and certified-midwife-attended births occurred in hospitals, 2.6 percent occurred in freestanding birth centers and 2.5 percent occurred in homes. Certified midwifery encompasses a full range of primary health care services for women from adolescence beyond menopause. These services include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life and treatment of male partners for sexually transmitted infections.

World Health Organization statistics show that births attended by midwives have lower infection rates, lower cesarean section rates, fewer complications and healthier outcomes — thus, lower overall medical costs than physician-attended hospital births. In addition, there is no difference in infant mortality between midwife-attended and physician-attended births for low-risk women. Countries such as the Netherlands, Sweden and New Zealand, which have the best birth outcome statistics in the world, use midwives as their main maternity care providers.

Although the term, “midwife” is used loosely by the public, there are several different types of midwives functioning in Kentucky and around the United States: certified nurse-midwives, certified professional midwives, certified midwives, direct-entry midwives and lay/traditional midwives (see sidebar). Due to the many types of midwives, it is imperative that a licensure process exists. Just like in other health-related fields, this allows regulations to be put in place and guarantees license revocation and other consequences if a midwife is practicing in an unsafe manner.

Kentucky: The birthplace of Nurse-Midwifery in America

The Frontier Graduate School of Midwifery was started in 1939 by the Frontier Nursing Service (FNS). The school began as part of a project and plan to care for women and children in rural Kentucky. In 1925 in the United States, midwifery training was not easy to come by. At that time, training could only be secured for American nurses by sending them to Great Britain.

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Mary Breckinridge, the founder of this movement, viewed nurse-midwifery as central to health care. She believed that midwifery presented a much needed service to the women of Kentucky. During World War II, American nurses could not continue to travel to Great Britain for study. The FNS immediately put into operation its plan for a graduate school of nurse-midwifery. The Frontier Graduate School of Midwifery, now Frontier Nursing University, enrolled its first class in 1939. The Frontier Nursing University has been in continuous operation since that time and was recently ranked the #1 Nurse-Midwifery program in the United States by U.S. News and World Report.

In essence, the most prestigious training program for nurse-midwives is located in Kentucky, but graduates are forced to leave the Commonwealth to be able to practice to the fullest extent of their licensure. Kentucky trains the best and the brightest midwives and then sends them away to boost the economy and maternal-child health in other states.

In Their Own Voice: Kentucky Midwives

Midwives practicing in Kentucky have their own perspectives on the importance of their practice as well as the legislation needed in order to give women more options in childbirth. Two local midwives shared their insights on these topics. Damara Jenkins is a certified nurse-midwife and the first midwife ever hired at the University of Louisville’s Center for Women & Infants at the UofL Hospital. She is a graduate of Frontier Nursing University. Aundria Radmacher is a certified professional midwife serving a 60-mile radius of Louisville. She currently practices at Visitation Birth and Family Wellness Center.

Both midwives were in agreement that women should have access to birthing options outside of the hospital. When asked why it was important that women have access to other birthing options, Damara responded, “Our present health care model really just has one option, which is hospital-based care.  This only is needed for a small portion of the population. We (hospitals) are over-treating and unnecessarily exposing women to interventions that they don’t need.” Aundria continued, “Women and families are ultimately the ones that should make the decisions about childbirth. It’s their families and their lives. Women are so much smarter than the medical model gives them credit. The reality is, when we give families the risks and benefits and a clear picture of what their health looks like, they are always going to make the best decision that they can.  That is what midwifery does. Midwifery says, ‘You are responsible for your health; you are responsible for your baby; and you are ultimately the decision-maker. I am here to be in consult with you, to give you my professional experience, to give you the risks, to give you the benefits and to give you education. You are the one that is responsible for making the decisions.’ And that is powerful.”

They agreed that pregnancy and birth are normal physiological conditions that should not be treated like medical problems.  Beyond this, Aundria notes, “We spend more money on the birthing process per woman in the United States than any other industrialized nation.” According to Damara, this is partly because of the increased rate of caesarian deliveries in the United States. She stated, “C-sections are the number one surgical procedure in the country. Midwifery practice has less than a 10 percent caesarean rate.” Both midwives note the importance of educating women about the different options they have in birth and the risks and benefits of each prior to a woman making her final birthing-option decision.

Each midwife had her own definition of midwifery. Aundria described it philosophically, stating, “Midwives use a high-touch, low-tech model of care. We spend a lot of face-to face time. We minimize interventions and it works. High-touch, low-tech. Let me be with you; let me be present with you. Let me witness with you. And I don’t need to do a lot because your body has got this. There’s over 7 billion people on this planet and every single one of them got born.” Damara continued, “We are the guide. We partner with women to help them craft their best birth, to help them make the best decisions to keep themselves and their families healthy. You get much better outcomes when you teach someone how to fish than give them a fish. It’s the same concept. So I can walk in tell you what to do, but if I don’t help you understand why and help you understand the best way to do it, and help you understand the reasons, you’re not going to then leave my office and put them into use.” The midwives described their practice as a partnership that empowers women to make the best decisions for themselves and their families. When asked why a woman should choose a midwife-assisted birth over a hospital, physician-assisted birth, Aundria responded, “The research across the board says midwives are cheaper, we have better outcomes, and we use fewer interventions. That’s the point. There’s very little research out there that doesn’t support that. The medical model is about institutional relationships. It’s about a product, a treatment and a goal, and birth doesn’t work that way. It just doesn’t. When we acknowledge that we can’t institutionalize birth, the results are dramatic. The results are that individuals are treated with respect and dignity and compassion, and that’s how we work. Birth is a sexual experience. There’s no way around it. And we don’t do that, as a species, under bright lights and in front of a crowd. Birth is an intimate act of a family and if you put it in an institution, our bodies, our brains and our primal beings don’t function the way that they are designed to function.”

Addressing the barriers to midwifery practice in Kentucky, Aundria stated, “Home births are not illegal in Kentucky. There is no way to legislate where people have babies, but the laws can make it easier for women to determine how they have babies.” Currently, Kentucky hospital regulation 902 KAR 20:016 states that a physician must “assume full responsibility for diagnosis and care” for hospitalized persons seen on an in-patient basis. As written, this regulation denies autonomy to independent health care providers, and supporters of midwife-assisted births would like to see the law updated.”

In many states, midwives care for pregnant women in birth centers. But there are no birth centers in the Louisville area, and only one in the state of Kentucky (The Birthing Spa in Stanford), leaving residents, particularly Louisville residents, to seek access to midwifery services in Indiana. Both Aundria and Damara expressed concern that in Kentucky, in order to build a birth center, a Certificate of Need must be presented and approved through a hearing in which hospitals often oppose them. These midwives — along with the Kentucky Coalition of Nurse Practitioners and Nurse-Midwives — have been advocating for a modernization of the Certificate of Need program so that this barrier is removed, presenting Kentucky women with the option to choose how they want to give birth. When Sarah Holland’s children seek to bring their family’s 10th generation of Kentuckians into this world, they should have the option to choose their own style of birth.

Correction: The original version of this article incorrectly stated that “there are no birth centers in Kentucky.” The article has been amended to clarify that “there are no birth centers in the Louisville area, and only one in the state of Kentucky (The Birthing Spa in Stanford).”