Midwives: the choice of some couples

EVEN though she was up most of the night delivering a baby, Nannette Landry got to the office this morning in time for a full day of examinations and visits with families. Dusk is gathering now, and she keeps fingering the beeper that dangles from her belt, waiting for the next call.

``Sure, it's hard work, but it's what we love,'' she says.

``It may sound corny and all that, but it's the way we feel - that it's an honor and a privilege to attend a woman in birth.''

When Ms. Landry uses the word ``we'' - and it recurs constantly as she talks about her work - she's referring to the estimated 3,000 certified nurse-midwives who are legally recognized to practice in all 50 states.

They work in health maintenance organizations, private practices, clinics, hospitals, and increasingly in birthing centers. Together they deliver 3 percent of all American babies - triple the share they delivered 10 years ago.

Most of the births, an estimated 85 percent, occur in hospitals. But 11 percent are delivered in birth centers, and another 4 percent are delivered at home.

In many ways, Landry is one of a new breed of young, highly trained nurse-midwives. After graduating from Boston University's School of Nursing, she worked for five years as a labor nurse at a Boston-area hospital, where she also taught childbirth education.

She went on to Columbia University for 18 months of graduate studies, graduating with a master's degree in nurse-midwifery, and then had to pass a written examination administered by the American College of Nurse-Midwives in Washington, D.C., the professional regulatory organization.

Landry now works in private practice with four physicians on Boston's South Shore. After six months of committee meetings with administrators, she was able to have the bylaws of a local hospital amended to grant her privileges there. She now has access to the hospital birthing rooms for her clients. At age 30, she has already delivered 300 babies.

Landry tends to accept as clients ``low risk'' women - those who are in good health and under 40 years of age. She tries to limit her deliveries to between 10 and 12 a month, so that she can devote adequate time to each couple.

``When I say I'm there for delivery, I'm in the room for however long labor takes - breathing and walking and working with the woman.''

Sometimes, Landry says, clients will ask her what her next professional step will be, assuming that she wants to go on to medical school to become an obstetrician.

``But that's not it at all - I don't want to be a physician,'' she explains.

``We view our role and profession as separate from the medical profession. We try to facilitate the process by tending to a woman's emotional and spiritual needs, as well as her physical needs.''

That philosophy has been the guiding light of the practice of midwifery from biblical times to the present.

The first nurse-midwives to practice in the United States were trained in Britain and worked for the Frontier Nursing Service in eastern Kentucky in the 1920s.

Since then, the profession has gained steady ground and acceptance - especially in the public sector, where the federal government has played a major role in endorsing nurse-midwives by funding programs that have employed them.

In the late 1960s and early '70s, consumer demand for new alternatives in maternity care began to coincide with a realization that the numbers of obstetricians available in the future weren't going to be adequate to care for all women of childbearing age across the US.

And in 1971, nurse-midwives received encouraging professional recognition in a joint statement issued by the American College of Obstetricians and Gynecologists and the Nurses Association of the American College of Obstetricians and Gynecologists, as well as the American College of Nurse-Midwives.

There now are 25 graduate programs in nurse-midwifery nationwide - at such prominent institutions as Columbia, Yale, Johns Hopkins, Emory, and Stanford.

``Many people, when they hear the word `midwife,' think of lay midwives doing home births, and they don't associate her with somebody who's well educated and part of the mainstream of maternity health care,'' says Joyce Roberts, director of the nurse-midwifery program at the University of Colorado Health Science Center in Denver.

That characterization probably wouldn't sit well with the community of so-called ``lay'' midwives who have been delivering babies at home for years. These women usually learn their art through apprenticeship rather than formal education. They often serve in low-income or rural areas where doctors are scarce.

Forty years ago, there were an estimated 20,000 lay midwives practicing in the US, but their ranks have declined sharply in recent years. The latest figures available indicate that there were about 1,800 lay midwives practicing in 1976 - almost half of whom were in Texas.

``There are only 17 states where we're legally recognized, and another 12 to 15 where we practice in a gray area,'' says Julie Buckles, a self-described ``direct entry'' midwife (one who has no nursing training) who's coordinator of the Midwives Alliance of North America, based in Cheyenne, Wyo.

``In all the rest, we may be operating illegally, but we're accepted because we're a reality of life in many small rural communities.''

Although their training and philosophies differ somewhat, both lay and certified nurse-midwives feel they're meeting a growing need in this country.

``Lay midwives are basically out there for self-selected groups of people who are motivated to have a home birth, which can be a wonderful experience,'' says Landry.