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Many physicians may not approve of midwifery, but proponents say licensed midwives serve two very different populations in Arkansas: those with access to healthcare who prefer home births for idealistic reasons, and those for whom a hospital birth is not a viable financial option.

Little Rock resident Hannah Halfhill decided to explore home birth after being fascinated by a water birth she saw on television. Although she and her husband, Andy, were excited about their decision, there were some family members hesitant to buy in.

"I don't think anybody loved the idea. I very much picked and chose who I told," she said. "I was surprised that people were not more openly supportive. Women have been having babies for generations and generations, but there's been a lot of fear generated in us over the last 90 years."

Halfhill said she still receives mixed response when she reveals that her two-year old son, Micah, was delivered at home. "What's frustrating is people's comments now," she vented. "People seem to think that I think I'm 'better' because I didn't use drugs…and I've heard all kinds of stories like my baby could've died or been wrapped in the umbilical cord. I don't think people realize the implications of what they're saying."

Although they met hesitant acceptance of their decision from the start and continue to endure odd reactions, the Halfhills say that they found great reward in the bonding they experienced during the home birthing.

"One benefit of having my baby at home is that I was able to rely on my husband to help me through it. When I was doing exercises, squatting, and walking the night of the birth, he held me up. He showed such great strength and courage. And now we can say 'we did this.'"

While Halfhill represents one population—married mothers with access to proper health care—using home birth as an option, proponents of midwifery argue that another population in Arkansas desperately needs the services provided through the midwifery model of care, a team approach placing the mother at the center. This population includes mothers, married and single, without access to proper health care—mothers who would have their babies at home with or without a midwife attending.

According to Dr. Richard Nugent, MD, MPH, chief of Family Health Branch in the Arkansas Department of Health (ADH), this population underlines the importance of licensed midwifery to the state.

"Some women do not have enough money to go the hospital," he explained. "These are women that would stay at home whether or not the state supported midwifery. It may be better to have a trained attendant present at the birth.

"In Arkansas, we accept national certification by the North American Registry of Midwives, or, in its absence, satisfactory completion of a state test. All licensed midwives must pass a test of their knowledge of the state regulation."

In 2005, the midwifery rules were updated following extensive conversations with representatives of the midwives, with the Arkansas State Board of Health, and with the General Assembly. These revisions clarified many aspects of the program including documentation of midwifery training, the definitions of the conditions that require referral, and the manner in which midwives report the pregnancies and deliveries they attend.

Historically, physician groups have been at odds with lay midwives, often seeking either to ban them from practicing or require physician oversight. In June, the Missouri Supreme Court threw out a challenge by four physician groups—the Missouri State Medical Association, Missouri Association of Osteopathic Physicians and Surgeons, Missouri Academy of Family Physicians and St. Louis Metropolitan Medical Society—to new legislation that allows certified midwives to practice in the state. Midwives are now able to practice in Missouri.

Also in June, the American Medical Association adopted a policy supporting state legislation calling for physician and regulatory oversight of midwifery practice.

"Everybody thinks that doctors hate midwives or that we have something against them, that it's competition, but I don't think the majority of doctors feel that way. Our concern is just what is safe for the patient, what's safe for the baby," said Amy Buckner, MD, an obstetrician from Pine Bluff who serves on the Arkansas Medical Society board of directors.

Buckner said that while master's-level midwives once practiced with her at UAMS, where a resident was always available for crises births, those measures proved to be less cost-effective than using residents alone and were discontinued. Lay midwives, by contrast, are more problematic she said.

"I think midwives can be appropriate and very good options for low-risk pregnancies at a hospital or birthing center, but when lay midwives are delivering babies just out there at home, it's a gamble," Buckner said. "Most births will go smoothly, but 5-10 percent of births will have problems and serious complications and all a lay midwife can do when there's trouble is to call an ambulance. By the time a problem occurs and they get to a hospital, it's usually really bad."

Currently there are 31 licensed midwives in Arkansas, one of 26 states that allow licensed midwifery.

Arkansas licensed midwife Ida Darragh, LM, CPM, believes the future of midwifery lies in having a legal avenue for midwives to practice in every state.

"It is essential that midwives are licensed as independent, autonomous practitioners," said the 26-year practitioner. "The American Medical Association has taken a position against home birth by any practitioner, and against any midwives who are not directly supervised by physicians. That attitude just serves to widen the gulf and to decrease birth options for most women. We need midwives who can serve normal, healthy women in homes, birth centers, and hospitals, and we need medical specialists for the few who are high risk. That kind of cooperative arrangement works well in the rest of the world, and we need for it to work better here."

In the last year, ADH documented 120 Arkansas midwife deliveries at home. Nugent reported that this number has tended to decline in the last five years.

"One factor we can point to is that Medicaid has increased its financial eligibility for pregnant women, and now covers the 'unborn child' for women newly immigrating to the United States," said Nugent.

These changes became possible by the State Child Health Insurance Program, through the Centers for Medicare and Medicaid Services.

Buckner pointed out that although midwifery rates are significantly lower than obstetrician's, every county health department provides free prenatal care and anyone in labor will be treated at a hospital regardless of their ability to pay.

Mary Alexander, RN, LM, owner and founder of BirthWorks—a Little Rock-based midwifery and doula center—has been a practicing midwife since 1977. She echoes Darragh's assertion that there needs to be a more "cooperative arrangement" between midwives and physicians in Arkansas. She says that some physicians misunderstand their practice.

"There is a difference between the midwife approach and the medical approach to birthing," she acknowledged. "The OB doctor is trained to be the authority. The midwife puts the authority back into the hands of the mother. We 'advise' but we do not declare ourselves to be the authority. When some physicians see the way we manage a birth they think we're not doing anything. But we are—we are giving the power back to the woman."

Buckner said that while hospital birth may be less comfortable than a home birth, it is worth it.

"Do we sometimes over-medicalize obstetrics? Sure, but it's only because of the catastrophes that can happen," she said.

Alexander also acknowledged the issue of liability as a primary reason why there may not be more coordination between the two approaches. "We are safe and liability is not a true issue," said Alexander. "But I can understand why some doctors may be concerned, since the only side of home birth they may see is when we take one of our mothers to the hospital for failure to progress. I think they feel quite put upon, when in reality we only have about an 8 percent transport rate."

Alexander said that her ideal solution for getting more interface with physicians would be to meet with them in a summit-type setting. But she says that a more realistic start may be pointing physicians to an issue brief recently published by the certifying arm of the profession.

"I believe this may be a first step (see sidebar) to building our rapport with doctors. If doctors read this brief validating our education and the safety of our profession, they may begin to understand that we are a good option for low-risk births."

"Mothers will be better served if we all work together to provide a wide spectrum of birth options," echoed Darragh.

"I don't think you'll ever find anybody on the medical side say they are in favor of home births," commented Buckner. "There are just too many things that can go wrong."

In Arkansas, the licensing program for Lay Midwives is operated according to state regulation promulgated by the board of health and reviewed and approved by the General Assembly. The rules have the effect of defining the scope of practice for Lay Midwives to include normal pregnancies and deliveries, but require referral to doctors and hospitals when the midwife becomes aware of a complication or high risk factor.

The rules require midwives to refer their patients to a health department prenatal clinic or to a doctor for a risk assessment early in pregnancy, and again at 36 weeks. They also require midwives to obtain certain tests and make specific measurements that will identify important risk factors. If any are found, or if the woman goes into labor before 36 weeks she is strongly advised to seek medical attention. During a mother's labor and delivery at home, the midwife also looks for problems and sends mothers to the hospital for delivery if progress is not as expected.

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