August 1, 1993

Doctors, midwives share common goal, but problems remain

By Pamela Ferdinand, Herald Staff Writer

The goal is staggering: to have 50 percent of Florida's healthy pregnant women giving birth with midwives by the year 2000.

Equally staggering is who set this goal -- not just midwives, but doctors. And not just doctors, but the state health officer, Dr. Charles Mahan, alias The Medical Establishment.

The people who set that goal all belong to the Midwifery Resource Center in Tallahassee, formed last year to research and promote midwifery in Florida. Mahan directs the center.

"We haven't gotten into bed with (midwives) yet, but at least we're talking," said Dr. Paul Gluck, past president of the Florida Obstetric and Gynecologic Society. "We don't feel that we are each other's worst enemies any more."

Attitudes toward midwives are changing, particularly among younger doctors. But the new perspective is not universal.

Some doctors resent the competition. Others are skeptical of midwives' education and competence, reserving particular scorn for direct-entry midwives who are not required to work with back-up physicians.

"There are some doctors who don't even want to say the words (direct-entry) midwife," Gluck said. "And there are midwives who probably look at me and feel it's their job to protect the patient from my evil clutches."

Whether doctors or midwives choose to cooperate or compete, the issues prospective parents must face when choosing between the two remain. And the decisions they must live with:

Do you believe in technology? Do you forgo it in a modern medical era? Whom do you trust -- doctor or midwife? How much can you afford? How important is empowerment to you? What is best for your baby?

One factor is money. Midwifery supporters say the practice, both in and out of hospitals, offers one of the greatest panaceas for health care today: cost-effectiveness.

Dr. Donald Hanft, a Miami obstetrician, charges more than $3,000 for a hospital birth, for example. The nurse-midwife who works out of his private practice, Clarissa Carbo, charges $2,300.

Carbo's clients -- who must be low-risk, healthy women -- are asked to deposit $1,000 less than obstetricians' patients at South Miami Hospital because "they know my patients are going to use less intervention and are going to go home earlier," she said.

Midwifery care also is covered by insurance as part of maternity care benefits. Medicaid reimburses up to 80 percent of midwifery costs.

The main concern among skeptics is not as much the birth attendant as the birth site, Gluck said. Home birth, which most direct-entry midwives practice, is still regarded as unacceptable by many physicians and hospitals.

The American College of Obstetricians and Gynecologists opposes home birth and supports only midwives with hospital privileges and back-up physicians.

"It's essential to have properly trained medical personnel and equipment available," said college spokeswoman Penny Murphy. "Too many things can go wrong during labor and delivery."

Brian Udell, director of newborn intensive care at Broward General Medical Center in Fort Lauderdale, agreed: "When things really go badly, you want the most trained person."

Still, Udell says he helps direct-entry midwives when they must transfer their clients to Broward General.

And as cooperation increases, he, Hanft and others envision a two-tier future where obstetricians take care of high-risk patients while midwives deliver the bulk of normal births.

Given more alternatives, prospective parents will have to make an informed choice and live with the consequences -- in or out of a hospital, good birth or bad.

Janice Heller, a direct-entry Hollywood midwife, says she has taken the memory of a birth that went wrong 13 years ago to every one since.

Brianna Dalnes was born in May 1980 at home with Heller's assistance.

Her father, John Dalnes of North Miami, calls their decision to have a midwife-supervised home birth a result of "the Birkenstock sandal-New Age phenomenon." His wife, Elyse, says she liked that "female-to-female nurturing, positive energy."

The pregnancy went smoothly. The birth did not.

As Brianna's head emerged, it became clear she was suffocating on her own bowel movement. Janice tried to clear her air passages until paramedics restored her breathing with an infant respirator and transferred her to the hospital. Now 13, she suffers severe cerebral palsy.

Janice was not properly equipped, John Dalnes said.

"It's probably wiser to go with traditional medicine than it is to try and do things on your own," he said.

His wife, who almost lost her baby, disagrees.

"As far as I could see, from what I knew, I felt comfortable she was trying the best to do what needed to be done," Elyse said.

Janice said Elyse's heart tones and labor were perfect, with no early sign of danger. A hospital birth would probably have resulted in the same outcome, she said.

The Dalnes have since divorced. Among other factors, the trauma of a damaged baby became too much for their marriage to handle.

"I don't really think that anybody needed to be blamed," said Elyse, who has since recommended Janice to friends. "What happened happened. We're not in charge of life and death."