Laboring to save home births

Midwife Diane Goslin’s farmhouse office bustles with activity this summer morning. Horse drawn buggies line the driveway, while pregnant women line the waiting room inside – their hair tucked into bonnets, their dark dresses covered by black aprons.

A mother expecting her 11th child arrives with her daughter, who is expecting her first. Women do mending as toddlers scoot around their ankles. Childhood friends reunite, chattering in Pennsylvania Dutch. Sisters shriek with laughter at the unexpected sight of their expectant aunt.

Outside, on the porch – in a waiting room of his own – a lone, straw-hatted man rocks, amused, pretending not to overhear the women.

The Amish here in Lancaster County may go to the hospital if they break an arm or need surgery, but when it’s time to give birth they stay home. Usually, they deliver their babies with the aid of a midwife, and the women in this waiting room half-joke that if Ms. Goslin goes out of business, they are through with childbearing.

It appeared to be coming to just that last fall when the Pennsylvania Board of Medicine ordered Goslin to cease and desist assisting her mothers, deeming it “practicing medicine and nurse midwifery without the appropriate licensure.”

Though the case arose because an infant delivered by Goslin died a day after birth, it was never considered her fault, nor has there ever been any suggestion that her rates of death or complication are unusual. If she were practicing in any of the 24 states that recognize her status as Certified Professional Midwife (CPM) by the North American Registry of Midwives, she’d have proceeded with her usual 200 to 300 deliveries a year.

But Goslin’s case illustrates the debate about whether childbirth is a natural bodily function or a medical event necessitating hospitalization. As in all ethics-meet-medicine turf battles, one party’s science is often another’s smokescreen.

Indeed, this isn’t new for the Pennsylvania midwife. Last fall’s case was the third time similar charges were brought against her in 18 years, and the third time they were dropped. In May, a 5 to 2 decision by the Pennsylvania Commonwealth Court overturned an $11,000 fine and lifted the cease-and-desist order. All three cases were brought after the state received complaints that Goslin was violating its licensing regulations. Simply doing what she does is against the law, maintains the state. And her business card, on which Goslin “is advertising her services,” is “clearly evidence of unlicensed practice,” says Leslie Amoros, of the Pennsylvania Department of State, which oversees the board of medicine.

Though cleared, Goslin’s work continues under a legal question mark because Pennsylvania recognizes only nurse midwives. Most of those are hospital affiliated and unavailable for home birth.

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In the Amish farmhouses of this rolling hill country, Goslin is considered family. For some women, she’s delivered a dozen babies. And, in Goslin’s own time of need, this community rallied to help – a departure for the reticent Amish who generally refuse to be photographed or be quoted by name. But on behalf of their midwife, they protested at the state capitol, staged benefits and teas, and filed an amicus brief.

Non-Amish – who make up 35 percent of Goslin‘s practice – also turned out, as did advocates of women’s right to give birth in whatever setting and with the attendant of their choice.

The home birth debate has been joined recently by such participants as talk show host Ricki Lake, with her pro-home-birth documentary film, as well as by traditional players such as the American College of Obstetricians and Gynecologists, which recently reiterated its opposition to home birth.

“The [issue of] the medicalization of childbirth has been around for a long time, now,” says Arthur Caplan director of the Center for Bioethics at the University of Pennsylvania. “There will always be [people like] the Amish, who want no technology” on one end of a continuum, and those who will refuse to have a baby “if they can’t deliver at University of Pennsylvania” on the other. He argues that the home-vs.-hospital argument should be removed from the ideological push and pull, and instead be driven by safety data specific to the woman‘s age and risk factors as well as the availability of emergency backup care.

But it’s not always that simple. Such data are everchanging, and, debatable. Research, reports the Midwives Alliance of North America, suggests that safety rates of home births are equal to or better than those of hospital births for low-risk women (with no other health problems). Even so, that’s a difficult comparison, because the total – 40,000 to 45,000 babies born at home each year, according to alliance statistics – remains only about 1 percent of all US births.

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But demand is still high enough that in her 28 years of midwifery, Goslin has never advertised, nor had to hang a shingle.
The world of medicine, for Goslin, is no enemy. Raised in an extended family of doctors, and the mother of a physician as well, she became interested in home birth, she explains, when a hospital-acquired infection she sustained at the birth of her oldest child left her infertile.

Seven years later and about to begin medical school herself, Goslin learned that – in spite of her diagnosis – she was pregnant and decided against medical school.“I wanted to raise my miracle baby myself,” she says. She delivered with a midwife and, believing that such care shouldn’t be solely a counter cultural option, began to apprentice with a midwife.

With 5,000 babies under her belt, Goslin seems to have encountered every twist and turn that childbirth can take. She points out that CPM certification requires attendance at more than double the number of births required for nurse-midwife licensing. Many of these births are required to take place outside the hospital, thus affording rare experience in successfully delivering breech babies, twins, and handling many other conditions that in a malpractice-minded age often trigger automatic cesarean sections in hospitalized patients. But, she adds, “I never had a baby that I could say ‘if that baby had been born in a hospital it would have been OK.’ ”

Now a mother of five, Goslin has been married 34 years to her junior-high school sweetheart, a teacher who is so familiar with her work that she calls him her “armchair midwife.”

She is a member of a conservative evangelical church. “I’m a Christian. I pray for each of my patients. I ask God for wisdom.”

During labor, Goslin’s mothers find that Scripture reading often calms them, and in the packet of instructions on diet and exercise she gives new patients are suggested Scripture passages. She says she feels called by God to her work, and assisted by God in her work.

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On Wednesdays, once again, the gentle, dark-haired Goslin presides over her office as staff prepare the women – taking belly measurements, recording vital signs, and screening for conditions requiring special instructions or referral to an obstetrician. They lend books on pregnancy, answer questions, and make appointments – “You say you all want to come back in on the same day?” Though she has been paid in quilts or livestock, the customary charge is $1,000 per delivery.
When labor begins, parents will lay out linen, basins and other supplies, and contact Goslin, who, with an assistant, heads out into the hills, her 2003 Subaru already loaded with delivery bag, emergency equipment, and – the mothers’ favorite – Goslin’s personally designed birthing chair.

After checking on the patient, she may tidy up a kitchen, cook for a husband, or read. “Most of the time, if truth be told, we’re not needed,” she says. But at other times she is perhaps actively directing a mother through an arduous delivery, or removing a wrapped umbilical cord, or suctioning a baby that has breathed in meconium.

Annie (who, agrees to be identified by first name) is expecting her seventh child, and she knows the drill. “I pace my kitchen floor, lean over my chair, say my prayers.... When Diane comes, she’s my boss.” Even Annie’s most difficult delivery was met with a sunrise, a moment so tranquil, she recalls, she gave the child the middle name of “Joy.”

An Amish mother expecting her sixth child recalls how Goslin strapped her birthing supplies on a toboggan and walked uphill to her farm when the road was impassible one winter. “I didn’t even think to be worried. I figured she’d get here. She always does.”