Between the Lines

Between the Lines By David Lias The women at Saturday's legislative Cracker Barrel meeting in Vermillion offered what they hoped were convincing arguments for allowing lay midwives to practice in South Dakota.

Some of their points are irrefutable. Yes, for hundreds of years, including much of the early years of South Dakota's statehood, women typically gave birth in their homes, with midwives in attendance.

And the birthing process likely would seem less clinical and perhaps more relaxed and natural if done in a home setting.

What the midwife proponents didn't talk about is what easily can go wrong in a women's pregnancy. According to the American College of Nurse-Midwives of Washington, D.C., two of the most common medical problems during pregnancy are high blood pressure and gestational diabetes. In both cases, the mother usually returns to her pre-pregnancy good health after birth, but both can be serious during pregnancy, and require close supervision for the safety of both mother and child.

About 7 percent of all pregnant women develop some form of elevated blood pressure, once called toxemia, which could put the fetus at risk of not receiving enough oxygen. In mild cases, known as pregnancy-induced hypertension, the woman is told to get extra rest and a doctor is generally consulted. If the situation is not extreme, a nurse-midwife may remain the caregiver. But if blood pressure rises dramatically or early in pregnancy, the physician will likely take over the woman's care. If blood pressure continues to rise and is accompanied by other signs, a condition known as pre-eclampsia, bed rest may be suggested. If this occurs near the end of pregnancy, as is most common, a physician may decide to induce labor.

Gestational diabetes, an inability to metabolize sugar appropriately, is also frequently treated by a nurse-midwife or co-managed with her consulting physician. Once detected, it often can be controlled through diet and monitored with frequent blood tests. Some nurse-midwives refer women with gestational diabetes to doctors because the condition may engender other medical problems; others may keep a physician apprised of the woman's condition while monitoring her. A nutritionist may also be consulted. If gestational diabetes advances to the point that a pregnant woman must take insulin, she should go into the care of a physician.

Other problems that may occur include:

* Multiple births: When a pregnancy turns out to be twins, some nurse-midwives remain involved in the care; others refer the woman to an obstetrician. If a nurse-midwife participates in the delivery, it is with a physician present.

* Breeches: Breech babies are not automatically transferred prenatally to a doctor for cesarean. Usually a midwife will give the baby time to flip into the head-first position. If the baby is transverse (lying sideways in the womb) near the end of pregnancy, it is standard to call in a doctor for a cesarean delivery. Other breeches are sometimes delivered vaginally.

* Early and late babies: When labor begins before the 37th week of pregnancy, a nurse-midwife generally calls in the consulting physician. The same is true if a pregnancy continues beyond 42 weeks.

According to the American College of Nurse-Midwives, in practices where a doctor and midwife work together, women with these conditions are likely to be co-managed; after a visit with a doctor a woman may return to the care of a midwife, who is to keep the doctor informed of status. In other practices, it may be necessary for women to switch completely to the care of a physician.

The comments of the women at Saturday's Cracker Barrel meeting, however, didn't strike such a cooperative chord with the state's medical establishment. They are associated with South Dakota Safe Childbirth Options, a grass roots organization that supported a bill that would have created a Board of Certified Professional Midwives. The board would be appointed by the governor and would establish qualifications needed for professional midwifery based on core requirements established by Midwives Alliance of North America.

The bill was deferred to the last legislative day by the House State Affairs Committee Jan. 25. That means its only chance of survival is if it gets "smoked out" for debate by the S.D. House, and that doesn't seem likely.

What was troubling about Saturday's meeting is the communicative tone of the bill's proponents. It made it difficult to determine if the legislation's supporters truly want to expand the number of lay midwives in the state because it would heighten the degree of prenatal care and the birthing process for women in South Dakota. Unfortunately, the women often bitterly referred to a "medical monopoly" that exists in South Dakota that they claim is in opposition to any attempt to expand the number of midwives in the state.

That indicates that the South Dakota Safe Childbirth Options group may resist cooperating with physicians, even when, as the American College of Nurse-Midwives notes, that cooperation is warranted.

Rep. Scott Eccarius, R-Rapid City, a physician and surgeon, said in a news report he had problems dealing with the fact that in many cases, midwives are not trained medical professionals. Midwives go through training, some of which is formal book-learning and some of which is on-the-job training, but the philosophy is different than the scientific approach advocated by the medical profession.

We think our own District 17 Rep. Judy Clark best expressed the goals that South Dakota should strive for in offering prenatal and maternity services.

"I personally would rather see us have better medical care in the rural community so you wouldn't have to depend on midwives," she said Saturday.

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