With Less Footing Than a Stork, She Fights to Deliver in the Home By GEORGE JUDSON
In the room where a state hearing officer was taking testimony, little girls played quietly, babies slept and more births seemed imminent. Ms. Vidam is a midwife, and she was surrounded by her clients.
This time, though, Ms. Vidam's clients had come to stand by her, health officials had accused her of practicing midwifery illegally. She is a lay midwife, one who came to the birthing room by apprenticeship, rather than by university training, and who specializes in home birth. As states have increasingly recognized midwifery as a health-care profession, many, including Connecticut and New York, have imposed licensing requirements, making midwives like her illegal.
To the State Department of Public Health, the case is simple: Ms. Vidam, a 42-year-old massage therapist from East Hartford, is not a nurse, does not have a nurse-midwife license as re- quired by state law and so cannot practice midwifery.
But to Ms. Vidam (pronounced vih-DAM) and her supporters, it is not just she who is being prosecuted, but the idea of having a baby at home. While most licensed nurse-midwives do not assist home births, lay midwives specialize in them. To bar them from practicing, they say, is to bar home births.
"If they say we are unlicensed and illegal, they are essentially forcing hospitalization," said Ms. Vidam, who began her midwife practice in 1986, three years before Connecticut required nurse- midwife licenses.
State officials say the issue of home births is irrelevant. Their concern, they say, is to protect the public by insuring that anyone assisting a birth is qualified.
While home births are legal in Connecticut, women do not have an absolute right to one, in the absence of a licensed nurse- midwife or doctor, "any more than they have a right to have brain surgery at home," said Stanley K. Peck, the Department of Public Health's director of medical quality assurance.
The hearing officer, Catherine A. Hess, is to hear more testimony before making a recommendation to the Commissioner of Public Health, Stephen A. Harriman. If he rules against Ms. Vidam, he will then issue an order barring her from practicing midwifery. An appeal is likely if the case goes against her.
Few women choose to give birth at home. In nine years of practice in Connecticut, Ms. Vidam, one of about a dozen lay midwives in the state, delivered 175 babies, a modest yearly total for an obstetrician. In 1993, according to the National Center for Health Statistics, about 11,000 babies were born at home nationally out of more than 4 million births.
But the very idea of giving birth at home defines midwifery for both lay midwives and their national organization, the Midwives' Alliance of North America, and sets them at odds with the medical professionals from whom they need acceptance.
For the Midwives' Alliance, midwifery is the art and craft of seeing a woman and her family through pregnancy and birth. It is not medicine, midwives say, because pregnancy is a natural body function. The goal is to enable a normal healthy woman to give birth naturally without the intervention of medical technology, and home is the natural place for it.
"When you go to a hospital, there is always some level of intervention," Jenny Adee, a client of Ms. Vidam's, said during a break at the hearing. "It's a very empowering experience to know that your body is capable of doing this on its own."
National training standards for lay midwives set by the North American Registry of Midwives reflect the focus on home birth. To be certified by the registry, whose exam is accepted by 13 states, midwives must assist at 20 or more births, at least 10 of them home births.
"What we are specialized in is home delivery, and nurse-midwives are not specialists in that," Ms. Vidam said in an interview.
Obstetricians and gynecologists generally agree that a normal pregnancy, the only kind that even nurse-midwives are allowed to care for, is not a medical emergency, or even a medical event. Doctors acknowledge that studies show that babies born at home after normal pregnancies are as healthy as or healthier than similar babies born in hospitals. Many praise the intense personal care of midwives and the value of a comfortable set- ting.
But that care and comfort, they say, is best provided in a hospital, because there is always the potential that something could go wrong. That potential, for most doctors makes a lay midwife, who lacks medical training and works outside the medical system, too big a risk.
"There's no question that the vast majority of the time, pregnancy and labor and delivery are uncomplicated and it almost doesn't matter who's there " said Dr. Joshua A. Copel, the director of maternal fetal medicine at Yale-New Haven Hospital. "But if something goes wrong, even if your house is only a few miles from a hospital, you're talking half an hour, and that's a real long time if the problem is acute. The whole idea of home birth is potentially unwise."
In New Jersey, state officials charged two lay midwives, Alice Sammon and Marina Smith, with practicing without a license in 1992 after two infant deaths in home births they assisted. They settled the charges by agreeing not to practice until they got licenses, but Ms. Sammon later challenged New Jersey's licensing law in Federal court. While New Jersey does not require midwives to have nursing degrees, a 1923 law does require 1,800 hours of classroom in- struction, and no lay midwife has ever earned a license under it. In September however, the United States Court of Appeals for the Third Circuit upheld the law, rejecting Ms. Sammon's challenge.
In Connecticut, Ms. Vidam, the first Connecticut midwife to receive certification from the North American Registry of Mid- wives, also became the state's first lay midwife charged with practicing without a license after a client, as a statement of her satisfaction, submitted her S1.550 bill to a health insurer. The bill was less than a third of the typical cost for care by obstetrician and delivery in a hospital. Insurers do not pay for home births by uncertified or unlicensed midwives, and so clients pay them directly, even though many have insurance that would pay for a hospital delivery.
This woman’s insurer reported Ms. Vidam to the state, and officials sought a cease-and desist order against her in March.
“My understanding was that I was not illegal,” Ms. Vidam said. “We know it was a gray area, we knew there was the possibility of something like this,, but we believed we were legal. We weren’t hiding.”
Accused of practicing nurse-midwifery without a license, Ms. Vidam says she is not a nurse-midwife, does not want to be a nurse-midwife and is not practicing nurse-midwifery. She is a midwife, she says, which Connecticut’s law does not address.
She and her supporters say tat doctors’ concerns about lay midwives would be put to rest is Connecticut followed the lead of Florida, Tennessee and other states and recognized lay midwives who meet the standards set by their national registry, just as all 50 states recognize nurse-midwives graduated from programs accredited by the American College of Nurse-Midwives.
In Florida, for example, a midwife can have primary responsibility for a healthy pregnant woman, but the state requires the woman to see a doctor at the beginning of her pregnancy and specifies the situations when a midwife must turn over care to a doctor.
In states like Connecticut, where lay midwives have worked in a legal gray area, some have relationships with friendly doctors and hospitals, and so that kind of backup is available. Ms. Vidam, for example, said she recommends that her clients be examined by a doctor, though it is their decision. "In essence," she said, "the physician is backing up the client, not me."
Other midwives, however, operate so independently that when complications develop during labor, a woman may simply be dropped off at an emergency room, where she may encounter hostility from medical personnel who view home birth as akin to child abuse.
The Midwives' Alliance says states like Connecticut have created problems by Imposing standards for nurse-midwives on all midwives. It offers, instead, its own national standards that it says will assure women and doctors that lay midwives are properly trained.
"Realistically, all of us believe that if and when lay midwifery is regulated by the state, it's not going to be carte blanche," said Priya Morganstern, a former midwife who is president of Friends of Midwives in Connecticut. "Not just anyone will be al- lowed to practice midwifery."
But in states with recent legislation, results are mixed. In California, licensing was opened to lay midwives this year by recognizing other education besides nursing. But in New York, no lay midwife has received a license under a similar law, and midwives complain that its education requirements cannot be met by traditional lay midwife training.
The executive secretary of the New York Board of Midwifery, Lawrence H. Mokhiber said the law opens licensing to midwives who are training outside of nursing programs. But it requires education, not just experience, he said.
"The bill," he said, "does not at any time anticipate someone who has simply gone out and delivered babies getting a license."