Her home-birth battle
Determined to avoid 'overmedicalized' labor and deliveries, more Massachusetts women are choosing home births. Doctors oppose the practice. The state doesn't regulate midwives. Now one brave – and unlikely – advocate is fighting for change.
Jenifer Holloman hadn’t been doing many chores on her farm in the past few weeks on account of the sheer size of her belly. But that evening, she had to tend to a ewe that had given birth a few days earlier. The lamb wandered off in a snowstorm and died of exposure. Now the ewe’s teats were heavy and swollen with milk, and there was no lamb to relieve her. Everyone who heard the story lamented the loss of the lamb. Holloman agreed that sometimes animals’ lives on earth are too short. The only thing she, as a farmer, has control over, she told them, is the quality of care she provides them.
That’s how Holloman found herself sitting on a crate in a snow-covered field one February evening, negotiating her arms around her massive belly to milk out the ewe. As the light faded rapidly around her, her neighbors pulled up, rolled down the window, and hollered “Where’s that baby?” into the cold evening air as they drove past. They meant Holloman’s baby, not the lamb. It seemed everyone was
ready for Holloman to go into labor, including her husband, Jason Beetz, a first-time father, and Holloman herself, 41 years old and pregnant with her second child. She had spent hours in the week and a half since her due date had come and gone walking the wintry beaches of Cape Cod trying to jump-start her labor.
Later that evening, Holloman felt a rush of warm water and knew it was time. Beetz called the midwife to tell her to come down to South Dennis from Cambridge. In their home, amid the trappings of a family-to-be – the changing table, the co-sleeper, the stroller – they settled in and waited for labor to start. Holloman, like an increasing number of women in Massachusetts, had decided to deliver her baby at home, in the care of a midwife, a practice not regulated in 23 states, including this one, though some home-birth advocates here and across the country are stepping up efforts to change that. Advocates who support a bill gaining momentum in Massachusetts say that regulating midwives would improve the safety of home births, which should be an option for women and families who want them, even though the medical establishment strongly opposes the practice. And after Holloman’s home-birth experience, she has emerged as one of the bill’s most passionate, if least expected, supporters.
Home births have been on the rise in the United States since 2004, says Eugene Declercq, a Boston University professor of public health who researches the issue – the first period of increase since the government started counting in 1990. The number of home births remains very small, at just 28,357 babies in the United States in 2008, the most recent year for which numbers are available, or .67 percent of births. In Massachusetts that same year, 337 babies were born at home, or .44 percent of the total, up from 241 births and .31 percent in 2004. Data on how many of the Massachusetts home births were planned – as opposed to babies who arrive before the mom-to-be can get out of the house – are not publicly available. But for the 25 states where the numbers are available, 87 percent of home births were planned, says Declercq.
There’s a lot of noise around these tiny numbers. Where a mother gives birth and who attends are at the center of a new reproductive rights debate in this country. Unlike other reproductive rights debates, however, this one puts two usual opponents – conservative Christians and liberal feminists – on the same side, and they’re duking it out with the medical establishment. What these seemingly mismatched groups share is a conviction that the natural process of birth has been hijacked by a medical system that is more concerned about reducing legal liabilities than about the evidence showing what’s best for babies and mothers. Meanwhile, most doctors in the debate argue that giving birth anywhere but a hospital or a birth center is putting a baby’s life at risk. Some have said that women who choose home birth are putting their desires for a meaningful experience ahead of the best interests of their babies.
Research shows that many of the women who choose home births do so because they want to avoid the ever increasing possibility that their labor will end in a caesarean delivery, says Melissa Cheyney, an Oregon State University medical anthropologist who studies midwifery (and is a licensed midwife as well). Some are first-time moms, but another subset has had caesareans and doesn’t want to repeat them.
In 2009, 33 percent of Massachusetts births were C-sections, just above that year’s national average and a remarkable 69 percent rise from 1996. Between 1996 and 2008, the rates of so-called VBACs (vaginal birth after caesareans) dropped from 34 percent to 8 percent of births among women with a prior C-section. While the American Congress of Obstetrics and Gynecology says that VBACs are safe for most women and that their rates have indeed dipped in part because of liability concerns, most hospitals in the United States have either an explicit or de facto ban on VBACs, according to surveys done by the International Cesarean Awareness Network. This trend may, in turn, be driving the home-birth numbers up, Cheyney says. “Some of these women don’t even want home VBACs; they want hospital VBACs and can’t get them. They choose home birth because they don’t have another option.”
In 1987, Holloman had a daughter, delivered via C-section after a long labor. In her first career, she worked as a teacher in the Boston Public Schools. Once her daughter graduated from high school, she and her husband moved to the Cape, where Holloman had grown up. She quickly attended to two of the items on her “bucket list,” becoming a farmer and a doula. She so enjoyed her work as a doula that she started studying to be a midwife. Soon after, she achieved another goal on her list: getting pregnant again.
Perhaps it seems obvious that someone like Jen Holloman would choose a home birth. She was studying to be a midwife, she wanted to maximize her chances for having a vaginal birth this time around, and she believed maternal care in the United States had become overmedicalized. Still, there was another, even more important reason Holloman says she and her husband, a carpenter, were interested in home birth. They didn’t have insurance, couldn’t afford the $179 monthly premiums for Commonwealth Care, and felt strongly about paying their way for their birth and not “being a burden” on the state by falling into the uncompensated-care pool for the delivery. Holloman says the midwife’s fees were $3,300 plus mileage, but she was willing to take Beetz’s carpentry and remodeling work as barter instead. They also wanted concurrent prenatal care with an obstetrician and used state safety-net coverage for visits with a nurse practitioner at the Hyannis obstetrics and gynecology offices of Dr. Richard Angelo.
When Holloman met Deborah Allen, she knew she’d found the woman she wanted to be her midwife. She was at once kind and professional. Allen had attended hundreds of births. And unlike other midwives Holloman knew, Allen didn’t see her previous
C-section as a barrier to a successful home VBAC. Holloman says they really just clicked.
Holloman says she was aware that some people view home births as dangerous, but she also believed much of it was based on myths. “People think midwives work out of the back of their cars or something,” Holloman says. Allen “had an office in Cambridge, near Harvard. She was doing the same prenatal protocols I was getting at the nurse practitioner. She’d check my urine for proteins, palpate the baby, listen to the heart tones, and talk to me to see if I was feeling well. It is not like she was using snakes or had feathers and incense all over her office.”
Holloman and Beetz figured that with one foot in the world of midwifery and another in the world of obstetrics, they had a solid plan. At her last visit to the Cape clinic, a couple of weeks before her due date, Angelo told her he couldn’t condone a home birth and explained that VBACs carry a small but potentially deadly risk of uterine rupture, according to Holloman’s medical records. (Holloman allowed her lawyer’s office to show her records to the Globe for this story.)Familiar with the perspective of many obstetricians on home birth and VBACs – it was the same as some midwives – Holloman was not surprised. According to Holloman and Beetz, Angelo didn’t give her any other reasons, based on records from her prior delivery or current pregnancy, that she shouldn’t pursue a home birth. Holloman said she would go to the hospital if any problem arose, and Angelo said her records would be waiting there for the on-call obstetrician.
When Allen and her apprentice arrived at Holloman’s house on February 7, 2009, the night her water broke, Holloman’s contractions had still not begun, so the midwife, her apprentice, and Beetz went to sleep. Holloman watched Amy Sedaris videos until she finally drifted off at around 5 a.m. She says she was still sleeping when Allen woke her up at 9 that morning. Labor had not begun, so Allen and her apprentice went back to Cambridge. Allen called that afternoon to check how Holloman was doing and came back down the next day before heading back to Cambridge again. At 1:45 a.m. on February 10, Holloman’s labor finally began. When her contractions started coming closer together, Allen and her apprentice returned to the Cape, arriving at 11 a.m. It was showtime.
Holloman abandoned herself to her contractions and recalls that through the lens of her single-minded focus, time seemed all but suspended. But not for Beetz. “As the day wore on, I got more and more concerned,” he says. “On numerous occasions I asked Deb, ‘Is this normal?’ She’d say, ‘Yeah, it’s normal.’ I started getting texts and calls. People were starting to worry. I was starting to worry.”
By late afternoon on the 10th, Holloman entered the final phase of labor. Each time she pushed, Beetz says, he thought he was about to meet his baby. But each time, there was nothing. “At 5:30, I was nervous,” he says. “At 7:30, I was really nervous. At 8, I was terrified, and I didn’t know what to do.”
Allen had been checking the baby regularly, Holloman says, but at 8:40 p.m. she couldn’t find a heartbeat. (Allen’s charts show it was 9:35 p.m.) Holloman says she didn’t panic because heartbeats can sometimes be elusive if the baby is very low. Surely her baby was low, because it had to be close to being born. Allen moved her and tried to find the heartbeat again. The medical charting all but stops by this point, but according to what Holloman and Beetz recall, Allen told them that the monitor must not be working. She reached in her bag for new batteries and changed them. Still no heartbeat. Allen picked up the phone and called the hospital. Holloman started screaming.
“I needed someone to know I was not OK. Deb had to put her finger in her ear to hear what he was saying,” she says. “What he was saying was ‘Put her in an ambulance.’ ”
Nonetheless, they didn’t actually leave the house for at least an hour, according to Holloman and Beetz, and they drove themselves to the hospital. (Allen’s chart isn’t clear about the timing, showing 11 p.m. as either the time they left for or arrived at the hospital.) Holloman says Allen first suggested they take a car instead of an ambulance, and then that they stay home. “I remember looking at her and saying, ‘Deb, I want a full medical intervention,’ ” Holloman says. Allen and her apprentice packed and got ready to go to the hospital. “I picked up the telephone and called Cape Cod Hospital myself. I said: ‘My name is Jenifer Holloman. I am having an obstetrical emergency. I’m coming in.’ ”
Countless women have given birth to healthy babies at home in the care of midwives. But these are not the home-birth mothers obstetricians see. The ones they see are those who wind up at the hospital because things aren’t going well. Obstetricians see only the home-birth babies who come into the world and go straight to the intensive care unit; most midwives never have that experience. These two very different realities explain many of the reasons why, in the United States, doctors and midwives, and their camps of patients, so strongly disagree about the appropriate venue for childbirth.
When you have a pitched battle of competing anecdotal evidence, rigorous scientific studies can often settle the disagreement. But this is not really possible in the case of home birth. The gold standard for medical evidence is a randomized, controlled clinical trial. But researchers cannot randomly assign women to give birth at home or in a hospital for the sake of research, so the ultimate study on home births may never be done. In the meantime, a handful of non-random studies have been done in the United States and around the world. But because there are so few home births, and even fewer infant deaths, the statistics simply don’t have sufficient power to lead to any hard and fast conclusions. And so each side chooses the studies that support its viewpoint, and the debate rages on.
The American Congress of Obstetricians and Gynecologists believes that the home is not the appropriate setting for giving birth. It says studies show that home births result in a two- to threefold risk of death for the baby. Critics say some of the studies that indicate this elevated risk contain the significant methodological flaw of counting planned and unplanned home births together. A home birth with a trained midwife is quite different from a 911 dispatcher giving a frantic father directions on how to deliver his child on the bathroom floor, the argument goes.
Meanwhile, midwives cite studies that show the chances of a low-risk woman losing a baby in a planned home birth are the same as in the hospital. But home-birth critics say the largest, most rigorous of these studies were conducted not in the United States, but in places like the Netherlands, for example, where 3 out of 10 women give birth at home attended by experienced, educated midwives and with a high level of cooperation from hospitals. What these studies appear to demonstrate is that home birth can be as safe as hospital birth.
The United States has a different context for home births. In the 27 states where home-birth midwives are licensed or otherwise regulated, the midwives who attend the births are almost always certified professional midwives (CPMs). That means that their training, education, and knowledge meet the standards of an accrediting body, the North American Registry of Midwives. CPMs are not required to be licensed nurses. (Certified nurse-midwives, on the other hand, are registered nurses with special training from programs accredited in midwifery; most work in hospital obstetrics.) In the states that don’t license or otherwise regulate home-birth midwives, including Massachusetts, it’s something of a free-for-all. There are 37 certified professional midwives practicing here in addition to a handful of so-called lay midwives, women who don’t have that accrediting body’s certification. While that doesn’t mean they aren’t competent, it means that there is no third party saying they are. In the United States, certified and lay midwives rarely have close working relationships with local hospitals, and in some unregulated states, midwives have been arrested when transferring patients to the hospital. In the worst of cases, this can discourage a midwife from making a timely transfer. In the best of cases, it can result in less-than-optimal transfers of care.
When Holloman, Beetz, and Allen pulled into Cape Cod Hospital, they rushed into the ER. Up on the labor and delivery floor, everything happened at lightning pace. Nurses swarmed around Holloman, slapping a fetal heart-monitor strip onto her belly. Within seconds, she and Beetz heard a thumping sound. “There it is,” they both exclaimed, relieved to finally hear the baby’s heart.
Dr. David Elmer was on duty that night. He raced into the room and used an ultrasound machine and a fetal scalp monitor to check the baby. Within minutes, he put his hand on Holloman’s arm and said the words that no one expects to hear: I’m really sorry, but your baby has died.
The information didn’t quite compute at first. Hadn’t they just heard the baby’s heartbeat? They learned the terrible truth that what they had heard was the mother’s heart pushing blood through the placenta. Their baby’s heart had stopped beating hours before.
At her request, Holloman was put under general anesthesia so she wouldn’t be awake when the baby was pulled from her via C-section. When she awoke, she found out she had had a boy. They named him Emmet. Weeks before, in preparation for the birth, they had put together a list of e-mail addresses of their family and friends. After Holloman awoke, she pulled up the list on her laptop and sent out an e-mail announcing the death of their son.
When a baby is born at home, one of the perks is that you get to spend so much time in the place where such a joyful event occurred. When Holloman was released from the hospital, she and her husband went home to the place their baby had died. “Everywhere I looked, all I could see was that I didn’t have my son,” says Beetz. Still, they rarely left the house, because venturing out was just as painful. Everywhere they went people asked for the baby. The lady at the bank, the people in the supermarket, visitors at the farm. They started doing their shopping a half an hour from home, where no one knew them.
“It was the longest, saddest year of my life,” recalls Holloman. “The weird thing about losing a baby is that time stops. It stops at the baby shower. And that baby is a baby forever. Emmet is a baby forever.”
The official cause of death was chorioamnionitis, a condition caused by a Group B strep infection. A mother infected with Group B strep can pass the infection to her unborn baby once her water breaks; sometimes, this is deadly. Holloman says Allen never offered her a Group B strep test, nor advised her of the risks testing positive entailed. Though it is common practice for women planning home or hospital births to be tested late in pregnancy, Allen’s charts contain no evidence that the test was ever offered. At the time in the pregnancy when the test would have been done, Holloman was no longer going to the clinic. If she’d had the test, she could have had prophylactic treatment during labor at home, could have decided to have the baby at a hospital, or could have chosen to transfer from home to a hospital earlier.
Twenty-four hours after the water breaks, the risk of infection – any infection – rises, and that is why doctors usually induce labor before 24 hours if it hasn’t already begun. Home-birth midwives routinely take a blood sample between 18 and 24 hours and have it checked for signs of infection. According to Allen’s charts, Holloman had chills and was running a low-grade fever after her water broke but before her labor began. Holloman told Allen she was worried that it was a sign of infection. “I said it’s probably labor beginning,” Allen wrote in her chart.
Deborah Allen declined to be interviewed for this article. Her lawyer, Stephen Lyons, was unwilling to go into the details of the case, the play by play of what happened, though he did say that Allen had informed Holloman about Group B strep. He explained, too, that lay midwives provide a different model of care than doctors or even certified professional midwives and that Holloman knew exactly what she was signing up for, including the risks. He said if Holloman wanted lab tests, she shouldn’t have been seeing a lay midwife. “There was nothing that would have indicated to the mother or anyone in attendance that there was anything wrong,” he says. “Sometimes these things aren’t anyone’s fault.” He said Allen has delivered more than 800 babies in her career. She continues to do so. Last year, she attended the home-birth delivery of Tom Brady and Gisele Bundchen’s baby.
After Holloman and Beetz’s baby died, Allen agreed to undergo a peer review by several local certified professional midwives. Had she been a CPM herself, a peer review would have been the first phase of the process that could have ended in stripping her of her credentials. In Allen’s case, since she isn’t a CPM, the process was nonbinding. The review found numerous failures in the care Allen provided, including not getting Holloman’s informed consent, especially with regards to risks associated with extending a pregnancy that far past her due date or about Group B strep testing. They also found she “demonstrated negligence and the inability to practice safely” by not monitoring Holloman’s temperature or, once her water had broken, getting her blood tested for signs of infection.
“A better-trained midwife would never have allowed what happened to transpire,” Holloman says. She and Beetz wanted their case to be investigated by an entity that could, if appropriate, sanction Allen and prevent her from delivering more babies. Holloman went to the police, the district attorney, the attorney general, the Department of Public Health, the Board of Nursing, and the Board of Medicine. “No one could do anything. They told us she’s neither fish nor fowl in the eyes of the law,” Holloman says. Last year, she and Beetz filed a lawsuit in Superior Court against Allen alleging negligence. “We didn’t want to sue anyone,” Holloman says. “This is the last house on the left for us.”
Jen Holloman still supports home births and a woman’s right to choose them. But she does believe that home births need to be made safer. She has become an activist, working to support a Massachusetts bill that would regulate midwives’ practices. It’s been languishing in one form or another at the State House for years, but appears to be gaining momentum with the recent addition of the American Civil Liberties Union and the League of Women Voters as bill supporters. If it becomes law, midwives who want to continue practicing in the state would need to be recognized by the state as competent, and the scope of their work would be regulated by a state committee on midwifery, which would determine practice guidelines. (In New Hampshire and Vermont, for instance, where midwives are licensed, the state regulates the kind of pregnancies they can take on, including VBACs for some patients, and the services and information they must offer – including telling patients about the risks associated with Group B strep.) In regulated states, if a patient believes a midwife acted with negligence, she can seek an investigation and sanctions from the state. If the Massachusetts bill passes, lay midwives working in the state, including Allen, would have to meet state requirements or cease practicing.
Obstetricians oppose the bill. Dr. Erin Tracy of Massachusetts General Hospital is the chairwoman of the legislative committee for the Massachusetts chapter of the American Congress of Obstetricians and Gynecologists. She believes that the issue isn’t whether certified and licensed or lay midwives should attend home births; as far as she’s concerned, neither of them should. She points out that certified professional midwives don’t even have to have a college degree. Before getting certified, they attend a fraction of the births obstetricians-in-training do, and their curriculum, she says, is woefully inadequate in the sciences. “Licensing them won’t improve their training. It will only give them the state’s stamp of approval.”
Holloman has testified at the State House in support of the bill and has lobbied representatives directly. Two weeks after Holloman made one of these visits in late 2009, her neighbors – the ones who called out to her, asking about her baby, that night in the field before her water broke – brought her some sad news. Their niece, who also resides in Massachusetts, had just lost her baby in a home birth. She had also been attended by a lay midwife.
“I don’t know what they are waiting for. Two babies died with lay midwives in 2009,” Holloman says. “We regulate mixed martial arts in this state. Representative Vincent Pedone, who opposes the midwifery bill, wrote a bill to regulate veterinary techs. But we have people attending human births in this state without any license. My head hurts just thinking about it.”
Holloman is in the painful, and unique, position of having been sharply criticized from both camps in the debate. She says there are some people in the home birth community who want her just to “shut up and go away” for fear that her talk of dead babies will ultimately do more harm to midwifery than good. Some home-birth opponents, including one obstetrician she’s spoken to, have criticized her support of regulated home-birth midwifery, saying that by choosing a home birth, she caused her son’s death. She says she asks herself whether she isn’t telling herself some sort of vital lie, but does not believe she is; she doesn’t think home birth caused her son to die, but rather the care she received from Allen. She says she will continue to lobby representatives to regulate home births. And she is scheduled to testify at the first hearings this session on the bill, set to start in just over a week.
Holloman has also decided to resume her own midwifery studies, keeping open the possibility that she might eventually become certified. She and her husband continue to grow their herd of sheep and goats. And their family. On April 19, 2010, Holloman drove herself to the hospital. Beetz met her there. Hours later she gave birth to a healthy baby girl.
Catherine Elton is a writer in Belmont. Send comments to firstname.lastname@example.org.