Story by: Jenni Ciesielski
Graphics by: Callie Riek
When Debra Fiore’s child was born in a hospital in Massachusetts, everything went as it was supposed to.
Forty-one weeks pregnant, her doctor insisted on inducing labor. She gave birth to a healthy boy that day.
But she felt something was missing.
“I was induced with my son,” Fiore said, “And I didn’t feel very empowered by the experience of my pregnancy and my childbirth, and I didn’t feel like I was being listened to. I felt that they were basically treating me as just a vessel for this baby to come out of.”
Soon after, she attended a talk given by a group of midwives at a local community center. She personally connected with the stories of mothers wanting to play an active role in the birthing process. She admired the connections the midwives had with the mothers.
Even though she had a teaching degree, she found a new calling.
She returned to school, got a nursing degree and began practicing as a midwife, working at hospitals in Pennsylvania, Massachusetts and Vermont before moving to North Carolina in 2006.
Now, Fiore is one of approximately 300 midwives practicing in North Carolina and has attended more than 1,200 births. After working in the department at UNC hospitals, she opened Carrboro Midwifery in 2009 so she could perform births at home.
“That’s what was in my heart, that’s the setting that I wanted to attend women in,” she said. “I could have perhaps joined another midwife in her practice, but at the time I only knew of one midwife that was practicing home birth, and she wasn’t looking for any partners and most aren’t.”
Before the 20th century, home births with attending midwives were most common. But throughout the first half of the 20th century, physicians began getting more involved and came up with new procedures such as epidurals that made people more reliant on medicine in the birthing process.
Today, just 8.3 percent of all births in the United States are assisted by midwives, according to the American College of Nurse-Midwives.
The United States is also 47th for maternal mortality rate globally and is one of the only countries to have had rising infant and maternal mortality rates since 2000.
Nine out of the 10 countries with the lowest maternal mortality rates are in Europe, where midwifery is a more common practice.
States with less restrictive laws are likely to have more positive outcomes for newborn babies and mothers, according to results from a University of British Columbia study.
The study showed a positive correlation between states that made it easier for midwives to assist women throughout their pregnancies and healthier birth weights, fewer premature births and fewer maternal deaths.
The study ranked North Carolina as the most restrictive state in the country, with a score of 17 out of 100.
North Carolina is one of 17 states that requires midwives to have a degree in nursing instead of a training certification, restricting Certified Professional Midwives. North Carolina is also one of only six that requires midwives to get their practicing licenses signed by a physician, even if they don’t practice in a hospital.
The latter shocked Suzanne Wertman, who had to get her license signed by a physician when she moved to North Carolina, despite having worked in hospitals in San Francisco and the Virgin Islands for years.
“I mean, what the heck is going on? What do you mean I can’t get a license?” said Wertman, the president of the North Carolina affiliate chapter of the American College of Nurse-Midwives.
A 2018 survey of North Carolina midwives conducted by the Charlotte Observer showed 91 percent of nurse midwives do not want to have a supervising physician’s approval in order to get a license.
These restrictions, both Wertman and Fiore said, can potentially create conflict, particularly for midwives practicing out of homes or birthing centers because they’re competing markets with physicians and OB/GYNs.
“It’s really hard when you start talking money,” Fiore said. “With midwives, if they’re getting independent licensure, opening up their own practices, it’s giving physicians competition for low-risk women.”
Nursing associations have proposed bills to the N.C. General Assembly that would lift the physician supervision requirement.
The 2017 Modernize Nursing Practice Act, which aimed to remove physician supervision requirements for all types of registered nurses in the state, had bipartisan support in the House but was killed in the Senate.
The North Carolina Medical Society publicly opposed the bill, stating that physician supervision is a necessary part of nurses’ training and its removal would diminish collaboration among medical professionals in the state.
“As the entire healthcare system values a team approach to care delivery, this proposal seems to go in exactly the opposite direction,” the Medical Society said in a 2017 statement.
Even if midwives in the state are given these legislative freedoms, it means little if they can’t break through the stigmas surrounding midwifery.
“We’re still outsiders, we’re still doing something that is different, especially since the birth process became more like medicine in the 20th century,” Wertman said.
Although Fiore said she’s felt women in North Carolina have been more open to pursuing home births than in her previous home of Massachusetts, she’s encountered assumptions that women who seek out midwives are “earthy, granola” hippies or are doing so for specific religious reasons.
“I’ve had every kind of woman give birth at home,” she said. “I’ve had physicians, one of my recent clients was a gastroenterologist. One of my first clients, when I started my home birth practice, was an anesthesiologist. I’ve had nurses, I’ve had midwives, I’ve had women who are as young as 18 give birth at home.”
In Wertman’s experiences, she’s felt that North Carolina is “physician-centric,” not considering other options.
“I think that it’s very much hanging onto tradition and there’s that belief that physicians are at the top of the ladder,” Wertman said. “But when we have excellent working environments, we can save lives, we can make sure that moms and babies not only survive but thrive.”
With the medicalization of childbirth, she says, people go into pregnancies thinking delivery is a much riskier process than it actually tends to be.
“It’s as normal as getting your period every month,” Fiore said. “Now can, things happen throughout the pregnancy that will make her at higher risk of not having a positive outcome? Sure. Those are rare. But physicians, the way they’re trained to think is that it’s an accident waiting to happen, and you’re going to need my help in my intervention to keep you safe. We don’t see things that way as midwives.”
Fiore also said she’s had women think going through the birthing process without a physician isn’t an option for them.
But, according to Yale Nursing School, about 85 percent of women have pregnancies that are “low-risk” and can healthily use midwives and not rely on physician supervision.
Fiore acknowledges the process isn’t for everybody; pre-existing chronic conditions like diabetes and high blood pressure create potentially high-risk pregnancy.
Also, when she travels to a home birth, she doesn’t provide any medication or epidurals, making the process completely natural, and, typically, longer.
If somebody wants a quick birth or a Cesarean section, they would be better suited for a delivery run by an OB/GYN.
But with midwives, whether it’s a home birth or a hospital setting, the mother has more of a say in how the delivery goes.
UNC nursing student Alex Hagwood had been assisting many OB-GYN births as a doula before going into her first midwife delivery and was shocked at the amount of control the parents had throughout the process.
“The dad was like, ‘They’re saying I get to cut the cord, and Mom gets to lay in whatever position she wants,” Hagwood said. “In my head, I’m thinking ‘I don’t know who told you that, but you’re wrong.’”
But that’s exactly what happened.
Midwife-led births give women more flexibility and control than most physician-led hospital births, having the freedom to move around, bathe and eat during the process.
The purpose of providing these choices, Fiore says, is to prioritize the experience of childbirth, not just the outcome, and give women the feeling of empowerment she’d missed when she had her first child.
“This is monumental in a woman’s life,” she said. “We care for not just the baby that’s growing inside of her, obviously, but we care for the woman as well.”
“We listen to her and we put her in the driver’s seat. It’s her birth, it’s her pregnancy, and we’re there to safeguard the process for her and make sure that everything stays as normal as it should.”
