Midwife offerings include intimacy with mom-to-be

FAYETTEVILLE — A soccer player at the University of Arkansas, Jennifer Creel was fit and healthy when her first child was conceived in 1994. She returned home to Nashville to deliver her baby naturally in a hospital.

But the experience wasn't what she expected.

The doctor didn't believe her when Creel said she was ready to push. His back hurting from a golf injury, he was replaced by another doctor. She was given Pitocin during labor, to make contractions closer, longer and stronger.

Creel crouched by the bed, then, at the attendants' urging, got on the bed, intending to use the squat bar. However, the nurses then pushed her onto her back. When her daughter's head appeared, she saw the look on her sister's face as the doctor took scissors and silently performed an episiotomy.

She didn't know her choices then and abdicated responsibility - and control - to the medical staff.

"I didn't feel like I had a say. I felt like nothing was explained to me," said Creel, now 34. "The more you know and the more of an open dialogue that you have, the more choice you have ... the more control you have."

Creel later had trouble nursing because her daughter, Greenley Littlejohn, was taken to the nursery so Creel could sleep. Her mother had given birth naturally and had been part of La Leche League, an international breastfeeding support group. At her mom's suggestion, Creel went to a meeting.

That's where she learned from other mothers about more childbirth options, including natural birth with a midwife.

"They got something out of their experience that I didn't get," Creel said.

She researched midwifery and discovered that countries that use it predominantly have lower infant-mortality rates. She returned to UA to finish her zoology degree but already was planning to become a midwife.

A friend's mother, Kate Conway, was starting the Arkansas Midwives School and Services in Fayetteville. Creel began apprenticing with Conway and two other midwives, Teresa Elder and Bonny Bowen, and started classes in 1998.

There, she learned the three C's of midwifery: continuity, choice and control.

"You have a relationship with the same person, so you have a rapport with them," she said.

That is well known to Maria Chowdhury, a partner with Creel at Birthroot Midwifery before starting her own practice.

She was raised in California, in the foothills of the Sierra Nevada mountains. The nearest hospital was an hour away, so many children were born at home.

Chowdhury, 34, wanted to be in a healing profession, so she became a massage therapist 12 years ago and lived in Hot Springs. She knew and admired the midwife down the street.

Years earlier, Chowdhury participated in a sweatlodge, an American Indian ceremony, with several midwives.

After a month-long, 266-mile hike in Oklahoma and Arkansas in 1997 to sort her thoughts, she was sure midwifery was her calling.

Midwifery isn't healing, but it's guiding a woman through an innate, physiological function. Chowdhury had no children of her own and wasn't yet married. But she wanted to carry on the tradition she'd known since childhood.

TRADITION AND TREND

Carrying a heavy pack on her long hike, Chowdhury coped by counting to four, over and over. She used that same technique when giving birth to her son, Sequoyah, in July 2004, with Creel as her midwife and her husband, Pritam, at her side.

"I personally feel like midwifery is a spiritual practice for me," Chowdhury said. "I feel connected to life force and the woman and that baby, and so that [1997] trip, that hike, really laid that groundwork."

Midwifery has been legal in Arkansas since the mid-1980s. Most of the 30 licensed midwives are in the northwest and central parts of the state.

Hospital births became the norm in the mid-1900s, making them the "trend," she said. "The [midwifery] tradition long surpasses that. So midwifery is the tradition, not the trend."

Chowdhury moved to Fayetteville in 2000 and began classes at Arkansas Midwives School and Services on Sept. 11, 2001. (The school is now closed, and there are no other midwifery schools in the state.)

Her training included two years of classes and apprenticing under five midwives. Now, midwives have to attend 40 births - 20 as an observer and 20 as a participant - and 75 prenatal and 75 postpartum visits.

During her apprenticeship, Chowdhury saw several easy births, and some complicated ones that required hospital care. She said she's glad she experienced both extremes. She found mothers to be "resilient" and "resourceful."

"Once they set their mind to something, they can do it," she said. "[A woman's body] will just keep going until that baby is here, no matter what. It's pretty awesome."

As midwives who help moms deliver babies naturally in their homes, Creel and Chowdhury are a rare pair.

In 2005, less than 8 percent of the 4.1 million births in the United States were attended by midwives, according to the Centers for Disease Control and Prevention. About 93 percent of those midwife-guided births happened in hospitals, with only 4.5 percent at home.

Creel is a licensed lay midwife through the Arkansas State Board of Health and a certified breastfeeding instructor. Chowdhury is a licensed lay midwife and a certified professional midwife, issued by the North American Registry of Midwives. They have physician backups at local hospitals.

Between them, the women have attended about 425 births - Creel some 75 more than Chowdhury.

During their time working together, the women each became the primary midwife for half of their clients. At any one time, they'd each be working with 10 clients; combined they'd attend about 40 births in a year.

THE CLIENTS

The midwives met with Brannan Sirratt and family for her first prenatal appointment last Valentine's Day. It was a Thursday, one of their clinic days, when they schedule prenatal visits in the office and go on home visits.

Other days, Creel and Chowdhury lead childbirth classes and make home postpartum visits. They're on call all the time.

During the hour-long office visit at Birthroot Midwifery, clients sit on a brown couch, blue chair or wooden rocking chair. They set their tea or cup of chlorophyll health drink on the coffee table and chat. The midwives talk with them about exercise, nutrition and stress.

"Women need so much processing," Chowdhury said.

They continue to a medical exam that includes checking fetal movement, fetal heartbeat and fundal length, along with mom's heartbeat, blood pressure, weight and urine sample. If there are unanswered questions, they recommend an ultrasound.

During labor, the midwives intermittently monitor the woman. They watch before, during and after a contraction, to get a base. They encourage her to walk or squat or move around to help the process, watching the mother for cues instead of letting the clock control the labor.

In most countries, midwifery is the primary method used to deliver babies. In the United States, midwives guide women through births at hospitals, birthing centers and private homes.

Most clients pay out-of-pocket rather than use insurance. Many times, the client's insurance deductible is nearly as much as the midwives' fee.

Insurance coverage for midwives' fees is rare in Arkansas, Creel said. Wal-Mart Stores Inc. covers 100 percent with a special plan through Blue Cross Blue Shield. The University of Arkansas, which uses QualChoice, covers a portion of the fee. In general, however, Blue Cross Blue Shield doesn't cover it. Neither does Medicaid.

Their clients fit in varied categories: conservative, liberal, Christian, wealthy, poor, black, white, Hispanic, rural, hippie, well-educated, executive, stay-athome mom.

"They all have different reasons and different backgrounds," Creel said, adding that she enjoys working with the fathers, who show the midwives a "window of their intimacy," a genuine sweetness that most women only see with their husband and father.

No matter their background, parents-to-be want similar things: a gentle experience, a sense of control, someone to come to them, to not have their baby separated from them, an hour of prenatal time to ask questions about birth and how it fits into the rest of their life. Chowdhury said she's often a sounding board for the moms, and she helps them stay focused.

"They want that smiling face. They want that hug goodbye. They want that personal, friendly person to pay attention to them," Chowdhury said.

LIFE AND DEATH

Birth happens just a few times in a family's life. Creel believes the experience greatly influences how the mother interacts with her child in the future.

"Birth is the hardest thing that you ever do. Even though it's rewarding and empowering, it's by far the biggest challenge in a concentrated time," she said.

When Creel gave birth to her second daughter, Elleya, in November 1999, she had a supportive, loving husband and the help of Kate Conway, her midwife mentor.

Creel walked for hours with her husband, Curt Richardson, on the land around their house, with Conway occasionally checking her progress. After the birth, she laid down on a futon mattress to nurse her newborn, and Conway took family photos.

A rain came, and the family slept.

Elleya's birth was a bonding experience for her parents, who've been married 10 years, and "when we felt the closest," Creel said.

"It was a completely different experience" from the birth of her first child, she said. "I was able to nurse her right away and be there right away, and I felt like I had control."

During the labor for Huxley, her son, her daughters made forts throughout their house, while friends watched the girls. From a backpack carried by Richardson, Elleya touched Huxley's head right after it emerged.

Elleya died at age 5 from a sudden infection. Creel continues to grieve, a pain that lingers much longer than birth.

"I'm so glad now, looking back on that, that I chose to participate fully in that experience," she said tearfully about having a midwife. "So that I didn't miss out on any chance to be with her and be fully present in the joy of her birth. And neither did Curt."

Creel went back to work 14 months after her daughter's death, which she said wasn't long enough. She felt she needed to support the midwifery community.

"I feel a responsibility to maintain midwifery as a positive, competent choice, and also to be a solution to the problem," she said. "And I feel I have to dig deeper than I used to, to give and to do that and to be fully present in that way."

THE MIDWIFERY APPROACH

A vocal proponent of natural childbirth, Creel has dampened her criticism of obstetricians in recent years. She thinks many women don't take responsibility to keep themselves healthy, then expect the doctor to "give them a healthy baby."

"Consumers need to understand that they're the primary health-care provider for their baby - what they eat, what they drink, if they exercise," Creel said.

Doctors being trained today may not see many natural births, and they may view Caesarian sections as normal and augmenting with medicines, like Pitocin, as standard.

"Obstetrics can be life-saving, but one in every three women does not need major abdominal surgery to have a baby. That's a complete misuse of technology," she said.

"Midwives view birth as a natural, physiological process that works best when women are in a comfortable situation - feel uninhibited, safe and cared for - rather than a medical event where the situation could turn to disaster at any moment," she adds.

In working with several firsttime moms in recent months, Chowdhury has realized that American women are used to a fast-food, fast-lane lifestyle, where they take pills for pain and to elevate their moods.

"We don't really struggle for much. And birth is that. Birth is a struggle," she said.

Many women fear natural childbirth will be too painful and last too long, "without realizing that every good thing in your life is worth working for, every good relationship, everything."

Sometimes, a "C-section" birth is necessary.

"The baby's not coming any other way," Chowdhury said. "A skilled surgeon, they are specific and precise and fast and clean. And that's really impressive."

There are many pressures with having their own practices. Creel and Chowdhury handle all the scheduling, billing, paperwork - and they attend births in the middle of the night.

"People are counting on you, and you have to be with it and be together and get there and get it done," Creel said. "You just can't get caught unprepared."

Her midwifery gear stays packed. She always has a plan for child care and often leaves her family's dinner in a Crock-Pot.

Chowdhury finds midwifery fulfilling and soulful.

"I feel like it's a real gift. So, I foresee myself being a midwife forever," she said.

Creel took off the month of July and spent it with her family. After six years without a vacation, Chowdhury took off all of August and went with her family to visit relatives in California. Her only worry was that she might not make it back before Sirratt went into labor.