I support the idea that women are intelligent, that when educated and given full informed consent they have the right to make the choices that are best for them and their baby.
A Lesson In Naivety: Casa De Nacimiento
by Linda Arnold
Midwifery in an El Paso Birth Centre
Bridging the Gap
THE VISION of Casa de Nacimiento
I founded the birth centre, Casa de Nacimiento in 1985 in El Paso, in the belief that birth is a normal physiological function of the human body, that it should be a family event and that women should have options to choose how, where and with whom they birth. At that time nationwide, choices of providers were generally limited to general practitioners and obstetricians. There were a few women acting as midwives at home births, but education and experience were limited. More women wanted to become midwives, but needed a place to learn. I believed that in opening Casa de Nacimiento I could meet these goals by providing a clean, safe, caring environment to birth and to learn about birth.
El Paso, Texas is situated on the Mexican border, separated from its sister city of Juarez only by a relatively small river, the Rio Grande. Seen from the air, there is little to differentiate the two cities. El Paso has a predominantly Hispanic population, most people being considered as ‘working poor’, as well as people from Mexico who want to use United States services in almost every commercial sphere, including its health care. Its per capita birth ratio is one of the highest in the country, making it an ‘excellent’ site for the birth centre I envisioned. Midwifery has always been legal in the state of Texas and governed by the Texas Department of Health Midwifery Board. The city of El Paso regulated its midwives and their practice standards by a City Ordinance. The governing body was the El Paso Lay-Midwifery Commission. This commission set the standards of practice and the risk criteria used by midwives in the city. The community had already been supporting birth centres operated and staffed by direct-entry, ‘lay’ midwives. However, there had been contention between the doctors and the midwives. I knew that my knowledge, skills and background were excellent, and that I would be able to pass this on to the clients we would serve, and to the aspiring midwives that the birth centre could train. This knowledge made me confident that I would be able to gain credibility in the community and win over the physicians so that client-centred births could become the norm. By my definition, ‘client-centred births’ are those in which the clients’ needs supersede the political and financial agendas of the medical community, and my aim was that of working towards better outcomes for the women and their babies.
In 1975 I began working for Dr Hai Abdul who was my preceptor and mentor. The hospital he practised at was unwilling to do labour bed births and very critical of any accidental bed births. He encouraged me to begin to look for another hospital which would allow labour bed births and which would consider establishing home-like birth rooms where labour bed deliveries could be done. Several hospitals refused but finally a small community hospital with a need for increased revenue recognised that it would be a sound decision for them economically. We then noticed that although some women did not feel safe at home, they did not want to go to the hospital to deliver either. The need for a freestanding birth centre became apparent. I found a building that would suit our needs and we set up a fully functioning obstetric unit with a classroom and two birth rooms. I worked with Dr Abdul in his practice of 70 to 90 births a month for over 3 years, gaining not only skills as a midwife but also the skills which are necessary to start a birth centre. I then moved and began a private practice in a rural setting. After 8 years of home births I then made the decision to move again, this time to a site where I could open a birth centre, work out of one place and be able to train aspiring midwives. I felt that I had the experience and confidence to make my vision come true. In the spring of 1985 I arrived in El Paso to begin my quest. I happened upon a real-estate agent who taught me about the history, demographics and politics of this city but also listened carefully to what I thought my needs were. So, as we drove a grid, beginning in the central city at the border and working slowly, street by street, up towards the mountain, we talked and noted all the properties that were available or appeared to be abandoned. The agent sifted through the list that we had made and we began to actually look at the properties. Several things then became apparent-I realized that the location would have to depend on accessibility, visibility, city zoning regulations, bus routes and parking availability, and not just on the actual building architecture. After 2 weeks of diligent searching we found an old cinder block building, 4000 square foot, which had formerly been used by an advertising agency, facing Interstate 10. It had been sitting empty for 2 years with windows broken and a leaky roof and had no showers or baths. It was like a maze, with no lights and dangling wires hanging from the ceiling. It would take a good imagination and a lot of work to make it into a functioning birth centre. My agent negotiated a lease with an option to buy, 4 months rent-free for cleaning and repairing, no first- or last-month prepayments and a reduced rate during the start-up time. In 2 months Casa was ready for its grand opening, a large portion of its space had been refurbished with examination rooms, birth rooms, a laboratory, and a waiting room. Casa was not like the other birth centres in El Paso-it was large, clean, well decorated and well equipped.
MIDWIFERY IN AN EL PAS0 BIRTH CENTRE
To practice legally in the city I had to get an El Paso lay midwifery permit. The El Paso Lay Midwifery Commission mandated that the clinical experience for this permit had to be gained in the city, regardless of any previous experience. To my surprise, one of the physicians and the certified nurse midwife on the Midwifery Commission invited me to spend a month doing clinical rotations with them at the county hospital, which had about 600 births per month. They had opened a door for me in a way which was unprecedented. This same hospital was the one which received most of the transfers from birth centres, the one whose security officers escorted midwives out when they came in with their clients to the hospital! The clinical rotation they set up for me allowed me to meet all the necessary requirements and to take and pass the next scheduled exam, a much faster process than going to births with the two friendly midwives in town. I thought at the time that they had set this up for me because they knew that I was highly qualified and would be an asset to the community.
In a matter of 5 months, Casa’s client load had increased from zero to 30 births per month. I hired two Hispanic women to help in the office, translate and work with the clients, but I needed qualified staff midwives. Hiring a midwife was difficult-they would need a high level of experience, commitment and stamina, as well as an El Paso lay midwifery permit. Out-of-state midwives began to consider relocating to El Paso and obtaining a legal permit to practice there. Occasionally, friendly local midwives helped out at Casa to ease the load when things were busy. I had envisioned Casa taking midwifery students from the very beginning. Two of the apprentices that I had in my private practice followed me from Idaho to Texas. Gradually, more aspiring midwives came to Casa to train and gain experience. These students have been an essential part of the workforce necessary to care for Casa’s clients.
Casa was busy all the time, with appointments, deliveries and students. The media and the government were fascinated by us. Reporters came from as far away as Japan and Brazil to interview and photograph Casa. I appeared on business programmes and morning talk shows. The US State Department brought tours of physicians in to see this birth centre, a phenomenon that had been created and run with few financial resources but with great results, using it as an example for possible duplication in other countries. Here was a free-standing birth centre on the border with Mexico which provided full maternity services for women in the community for $450 to $600, staffed by direct-entry midwives who could provide care for low- to moderate-risk clients without the need for medication or surgical procedures. This birth centre was using no government funds, such as welfare, loans or grants, and yet it was prospering.
Before 2 years had passed, Casa had approximately 60 to 70 births per month, with a client load of about 225 women. At about that time, however, it appeared that the medical community of El Paso turned and became hostile toward Casa. The other birth centres had closed down and there was another new centre opening in El Paso, but Casa was now the largest birth center in the state of Texas. Even by conservative estimates, Casa’s 60 births per month were taking about three and a half million dollars annually from El Paso medical providers. I never imagined that prejudice against midwives and the economics of a free-standing birth centre could so inflame a medical community. Everything that we did was scrutinised by the city’s Midwifery Commission. This commission was made up predominantly of physicians controlled the midwives and their practice using the El Paso City Ordinance regulations and their power to suspend and revoke midwifery permits.
Meanwhile, with all this attention on the birth centres in El Paso, and more centres opening across the state, Texas decided to begin mandatory licensing of birth centres by the Texas Department of Health, Certification and Licensure Division. Regulations were drawn up by Department staff physicians and nurses. They had never done out-of-hospital deliveries, run a birth centre or had an active practice. Some of the rules and standards of practice represented positive efforts to improve the quality of care and provide protection for the clients and practitioners, but others amounted merely to harassment. Department representatives would go through birth centres’ premises and records, searching for anything that might be construed as a violation of safe practice or of some regulation. One small mistake on a chart could easily be blown up into multiple violations and become an indefensible mistake. During those first years many birth centres closed as a result of the constant intimidation and their inability to afford the legal battles required to keep this state licensing agency at bay. Additionally, the pressure and stress of such defensive practice was more than most could endure. The state had endless financial resources and at least 50 to 60 lawyers to counter any defence mounted by a small birth centre and its lawyer.
By 1989 Casa had become embroiled in the Department’s feeding frenzy that had already closed many birth centres across the state. There was close collaboration between the medical community, the Commission and the Department in their efforts to close Casa. That year a staff midwife at Casa transferred a woman by ambulance to a nearby hospital, with the baby in a breech presentation and a cord prolapse that she was handling appropriately. Upon their arrival at the hospital the attending physician ordered the midwife to remove her hand and get out and threatened to have her removed by security if she did not. She did as she was told and left in tears. All we found out was that the baby was put on life support, then was pronounced dead. This started a chain reaction that resulted in a legal battle that lasted for years. The attending neonatologist hired a lawyer to sue Casa on behalf of the clients for $25 million. Neither Casa nor I have ever carried malpractice insurance so this legal battle had to be taken on by my private lawyer. In the United States, once you are sued you can legally obtain all medical records. These records showed that no one continued to keep the baby off the cord. Instead, the attending emergency room physician called (from the hospital emergency room) the City County Health Director (who was the chairman of the Commission) to tell him that they finally ‘had’ the midwives at the birth centre for attending a high-risk presentation. Thirty-five minutes later the woman was taken upstairs from the emergency room and a caesarean section was performed. The baby was born in severe distress and was resuscitated. They later pronounced the baby brain-dead and kept him on life support until they sold and removed his organs for use at two teaching hospitals in other parts of the country. This act of malpractice by the hospital emergency room physician and staff allowed Casa to bring the hospital and physician into the lawsuit.
There were three other lawsuits filed against Casa at this time that came to a total of over $45 million. The conspiracy continued with attempts to discredit the birth centre and its midwives by calling in the media to witness them filing their lawsuits in court or by making defamatory statements which claimed that we were burying babies in the alley. Interestingly, none of these lawsuits were ever tried against Casa-they were all dismissed. The breech, $25 million lawsuit against Casa concluded with the hospital and the emergency room doctor settling out of court with the family for their malpractice. Casa, the obstetrician and the neonatologist were dismissed from the case.
These same medical ‘professionals’ who initiated the lawsuits against Casa also made complaints to the Department, which then began to investigate them in full earnest. They made unannounced visits to the birth centre, with two or three people flying to El Paso every 3 to 4 weeks from Austin. They would go through our files, interview staff and inspect the premises. They compiled a list of 61 allegations against the birth centre in less than a year. The Department then served Casa with notice that it intended to close the birth centre. Casa requested an administrative hearing before the Department to defend itself from the allegations, most of which were trivial in nature.
I learned that the administrative hearing was to be conducted by a lawyer employed by the Department, who would act as the ‘hearing examiner1,-in other words, the judge. The hearing was therefore to take place with the lawyers for the Department presenting their case to another lawyer for the Department, who acted as the judge! Meanwhile, Casa was continuing as normal, but I was concerned about whether Casa could possibly get a fair ‘trial’ at this hearing. We were not guilty of these charges, but it was us against the Department. Once the hearing began it took 13 days of testimony, spread out over 3 months, with the state officials flying back and forth between Austin and El Paso. The Department spent tens of thousands of dollars in its case against Casa; Casa’s legal fees exceeded seventy thousand dollars. The results of the hearing were astounding-the hearing examiner found only six minor violations out of the 61 original allegations. He recommended to the Department, in a lengthy and detailed report, that Casa should not be closed because the violations he found were so minor.
Under normal circumstances the Department would follow the recommendation of its own hearing examiner, who had conducted the proceedings and heard the evidence. However, in this case the Department overruled the hearing examiner and ordered Casa to be closed. The lawyers for the Department immediately faxed a restraining order to Casa, ordering its immediate ‘closure’ without giving us the advance notice allowed in law. The birth centre licensing regulations, as they were written, stated that a licence was required for ‘births’, so antenatal and postpartum care did not need a licence. We needed to act quickly and creatively so that the clients would not become alarmed. I made the decision that any clients in labour would be informed and offered a home birth and that all other care would go on as normal. This ‘sneak attack’ by the Department’s lawyers meant that Casa was ‘closed’ for a total of 3 days, until our lawyer could file and obtain a ‘stay’ with the State Court in Austin. Fortunately, only one woman went into labour and delivered at home. The ‘stay’ would temporarily stop the Department’s closure of Casa until the Court could rule on the evidence and proceedings. Finally we got the break that we needed-once the case was in the State Court, the Department’s lawyers could no longer represent the Department against us. Instead, the Department was represented by lawyers from the State Attorney General’s Office. Once the State’s lawyers reviewed the proceedings, they were surprised by the Department’s actions. The lawyers from the Attorney General’s Office contacted our lawyer and expressed deep concern that they would be embarrassed to go before the Court to try to close Casa for such trivial reasons. They asked us to agree to dismiss our stay and they would then agree to dismiss the closure order. We accepted gratefully. It had been a life-changing ordeal, but we had survived.
The Commission had to save face somehow as the Department had essentially lost its case. After another highly visible hearing it was decided that they would withdraw my personal midwifery permit for 1 month because I had not made sure that my staff midwife had transferred a client with a breech presentation in a timely manner. The Commission continued to try and discredit midwives in this community. This was easy for them because the doctors on the Commission were the receiving physicians for transfers and they had access to our most difficult cases and their records. The physicians on the Commission became careless in their pursuit, however. They began to abuse their privileges quite flagrantly, placing themselves above the law in their efforts to bring further charges against midwives. I learned of the new charges to be brought against me in an open meeting of the full Commission at which the findings of a secret subcommittee were adopted and there was open discussion about my criminal prosecution and licence revocation. This time, however, I decided to defend myself, as I had done against the State, and take up an offensive position. I appeared at the public meeting with my lawyer, two well-known criminal defence lawyers from El Paso and a professional videographer with his camera running. My lawyers advised the Commission and the City Attorneys, who were present to assist the Commission, that the subcommittee’s findings were in violation of the law. The commission and its members then recognised their precarious position, with everything they said and did being recorded on videotape, and decided to adjourn immediately without taking action. The El Paso City Council decided soon afterwards to dissolve the El Paso Lay Midwifery Commission and leave the regulating of midwives to the Texas Midwifery Board.
I have reflected deeply over the years about why members of the Commission initially helped me to obtain my midwifery permit, so that I could open Casa, and why these same people later became Casa’s most vociferous critics. The only conclusion I have been able to reach is that they initially believed that Casa would do well and push the other birth centres out. Once Casa was the sole surviving birth centre, they thought that I wouldn’t have the strength and determination to fight off all the lawsuits, the medical community and the state and city authorities. They had drastically underestimated this midwife’s determination to survive.
BRIDGING THE GAP
When I came to El Paso, I left a community that was not totally supportive of home births. However, over time I had acquired the respect of a significant portion of the medical community there. That respect created good working relationships between medical providers and myself which greatly benefited the clients: I was able to choose the provider with the particular gifts or specialties that could best serve an individual client. There was no jealousy between us-we worked together hand in hand to serve the needs of the client. I was perhaps naive in my belief that accomplished, qualified providers could work together here in El Paso with a similar respect for one another’s skills and services. Since my arrival here I have become disillusioned and probably a little cynical as a result of the struggles that Casa and I have had to endure. I no longer believe that, as a whole, the medical community here in El Paso focuses on the client as an individual, with specific physical, emotional and social needs. There may be some who do, but they are few.
Recently, I received a phone call from a young paediatric resident. She explained that her sister (in another city) wanted to deliver at home with a midwife. She had decided that she wanted to come to Casa and observe how we assisted childbirth. This was the first time in all our years that a member of our medical community cared enough to learn about us and what we did at first hand. I assigned her to follow one of my best staff midwives and explained that she was to be allowed to observe and participate, where appropriate, in all the services we provided. She was courteous and considerate to all; she asked appropriate questions and helped with even the most menial of tasks. She was able to see and understand that not all deliveries and babies needed all the interventions that she had been taught. She came to understand better why her sister wanted less intervention, by delivering with a midwife, and that it could be safe. With this new understanding and respect for our place in the birth process, she wanted to share her side of birth and babies with our midwife. She arranged with her supervisors at the hospital to bring in a ‘visiting medical student’, our staff midwife. A few short weeks passed and our midwife was at the hospital doing rounds with our new ‘secret friend’, the paediatrician. Our midwife was able to move throughout the shift without question as the visiting ‘medical student’. She was able to observe and learn about the ‘other side’, including caesarean deliveries, neonatal intensive care and the interventions that can save lives. What a tragedy that we cannot support each other openly and bridge the gap in maternity services in this community. Nearly 17 years have passed since I began the mission. Countless people have contributed to Casa over the years. There are so many without whose help Casa might not have survived. My family and friends helped to support me as Casa was born. As Casa grew and developed, other midwives, staff, students and financial and legal professionals helped it to stand on its own feet. The birth centre survived great trials and grew stronger and better for those trials. Casa is still running today, having delivered up to 90 births per month, over 8400 babies, including our babies’ babies and our own children and grandchildren. Casa has been a place of clinical training for over 300 midwifery students from around the world. These students have gained some of the finest clinical experience available. Some of the very best of our students have been coming to Casa for many years and they have become a vital part of Casa’s family, history and workforce. Casa is a fine example of a high volume birth centre which serves its community with quality maternity care at affordable prices.