“There are renegades delivering babies in the woods,” Aria says, in a tone both ironic and mischievous. She is a doula living in Hayfork, California, a community of about 2,500 located in the rugged mountains of Trinity County. Towns here often don’t consist of much more than a gas station, general store, post office, and a requisite bar, and are linked by narrow, windy roads. Drives through the dense wilderness between them can take up to a few hours. In these remote outposts there exists an underground current of women who have their babies at home, hours from the nearest hospital.
Some of these expectant mothers employ a midwife or doula if they can, and some deliver their children without any assistance at all. But others use uncertified midwives, a practice that is illegal for mothers in some states (though not California), and always illegal for the uncertified midwife.
“I’ve caught a few babies illegally,” Aria says. Doulas are licensed to provide emotional support and advocacy for mothers during the birthing process, but they are not healthcare providers. Aria is training to be a Certified Professional Midwife, though. So far she’s completed the required classes and passed the exams. Now she’s accumulating field experience, having officially logged attendance at fifteen home births as a midwife assistant out of the necessary fifty.
Aria – who, along with others in this story, has had her name changed for privacy and protection – can easily think of six other mothers who have birthed their babies with uncertified midwives. She also knows of two other unlicensed midwives that have – or are willing to – deliver babies illegally in Trinity County. The story of these covert births is one that introduces a world of exquisite tenderness comingled with the gritty self-determination of people who don’t believe in the system they’re bucking, a world that celebrates women with romanticism, and vilifies western medicine with tones of trauma.
Aria, a vibrant woman in her forties, is married with five children. She and her husband own a sprawling house with chickens, cows, and a garden. She began questioning standard birth practices after impersonal, high-pressure treatment at hospitals during her first two pregnancies left her feeling traumatized. When Aria found out she was pregnant with her third child, she opted for an alternative, hiring a midwife and preparing for a home birth. She had her last two deliveries at home, experiences that redefined her understanding of the culture surrounding childbirth.
“We’ve taken away that instinctual birth,” she says. “Some people still have it, but a majority of people just don’t know. We’re taught that it’s terrifying and that it’s the most horrible thing you’re ever going to experience. You go in for your first birth and it traumatizes you.”
By her fifth pregnancy, Aria and her husband were well acquainted with the art of homebirths, performing all the necessary prenatal care themselves. They had planned for a midwife to assist with the delivery and hired Eva, who was the closest certified midwife they could find, and still lived two hours away. When Aria’s contractions started, she called Eva, but her labor progressed quickly, and by the time Eva made it to their home, the baby had already arrived, healthy and delivered by Aria’s husband Drew in their living room.
“I had printed out a home-delivery emergency manual for Drew from the internet,” she says. “Me and Drew just did it.”
This experience drove home what Aria considers the natural role of a woman as the director of their own delivery, and was a catalyst for Aria’s path to becoming a midwife.
“We both felt super-human,” she says. “It’s the most empowering thing you can do.”
Midwifery is controversial in the United States, often perceived as a risky departure from the codified realm of hospitals and western medicine. In 2014, 98.5% of all births in the U.S. took place in hospitals. Of these, doctors attended 84.8%, and certified nurse midwives took part in only 8%. Just 1.5% of births were out-of-hospital deliveries, and of these 63.8% – about 59,000 – were home births.
But these statistics actually paint the U.S. as an aberration in the world, even among industrialized nations. Midwifery persists in many parts of the globe as standard prenatal care that is respected and honored. Midwifery is also a formal medical field backed by training and science. In Britain, pregnant women are recommended to a midwife as a standard part of medicine. Midwives there are integrated into the prenatal healthcare system, building a medical process that safely supports homebirths, smoothly transitions expectant mothers into hospitals when needed, and helps to ensure better-monitored midwifery practices.
In the U.S. midwifery system, certified midwives act as primary healthcare providers to women throughout pregnancy, birth, and during the postpartum period. There are three different types of certified midwives that receive medical training and are able to practice in hospitals, birthing centers, or in homes. But midwifery isn’t commonplace, and there isn’t a system for integrating homebirths into hospitals, or consistent laws and regulations that define the midwifery medical field. Access to midwives, and knowledge about them and alternative births, is limited. The Midwives Alliance of North America (MANA) estimates that there are just 15,000 practicing midwives in the United States.
McKenzie is a mother of four who also lives in Hayfork. After two conventional births – one in a hospital and one at a birthing center – McKenzie was confident that she wanted to have her babies at home.
“I had already had one really scary birth, and it was very conventional,” she says. “I just went along and followed the steps: see a general practitioner in Redding, eighty miles away. I met them once; [they were] very cold. I had a very bad experience in the hospital. And I never felt like that experience was because of my body failing. I felt like it was a lack of support from my team and I didn’t have the knowledge to voice my opinion.”
McKenzie wasn’t sure what was happening to her. She says she had a 106-degree fever and was in horrible pain. The doctors insisted nothing was out of the ordinary. But her condition persisted for hours until, eventually, a nurse brought her a will to sign, and asked if she minded if a hospice nurse came and prayed over her. Still, her doctors didn’t explain what was happening.
“I felt like I was probably going to die,” McKenzie says. Ultimately, her newborn arrived healthy and she recovered, but the experience left a mark on her.
“It felt counter-intuitive,” McKenzie says of her hospital experience. “Me having to ask where the doctor was, not knowing the nurses and them having to look at my name on a chart … It just didn’t feel right. They put you on your back and strap your legs up, and they give you medicine that numbs your body. I felt like I needed to be strong, and they were trying to make me feel weak and do it for me.”
Statistics comparing safety and infant mortality rates for homebirths versus hospital births are conflicting and convoluted. One emerging trend seems to indicate that typical hospital procedures carry a high rate of cesareans and other invasive procedures, which can create undue stress, complication and risk, while homebirths are alleged to carry a higher rate of infant mortality, although this point is often disputed. The American Congress of Obstetricians and Gynecologists characterize the issue as one that is under debate.
As a medical practice, midwifery lacks legal and institutional support, and even the legality of midwifery in the U.S. is in transition. Midwifery laws and regulations vary from state to state – only midwife nurse practitioners are legally allowed to practice in all fifty states – adding complexities as well as barriers to this form of prenatal care. Recent studies show that nearly half of all U.S. counties don’t have an obstetrician/gynecologist operating within them, and 56% don’t have a certified nurse midwife. Most insurance companies won’t cover costs for midwives and home births, and most state-funded medicine won’t provide for this service either, making midwifery cost-prohibitive for the low-income household.
When McKenzie was pregnant for the third time three years ago, she decided to have the baby at home. After some investigating and consideration, she asked Aria to assist with the delivery instead of the closest licensed midwife, who lived two hours away in the next county and didn’t have the finest reputation. In case something went wrong, she procured ambulance and even helicopter insurance – to avoid a possible two-hour drive to a hospital in a potential high-risk situation. But in the end, Aria helped McKenzie deliver baby number three without incident, and was hired for birth number four as well.
“By far my two home births were more comfortable, easy, and amazing than my other births,” McKenzie says.
While the evidence advocating for the safety of homebirths versus hospital remains inconclusive, the more positive experience of midwife medical care during pregnancy and labor doesn’t seem to be debated. Midwifery is distinct from many forms of medicine in that patient-focused care is a definitive part of the treatment model, crafted to address women’s mental, emotional, spiritual and cultural needs, and recognizes these elements as essential components to effective medicine.
Midwifery has been growing in popularity, in large part linked to advocacy and growing medical and legal legitimacy. It emerged as a movement in the 1970s, brought to the national stage by advocates such as Ina May Gaskin, who is considered the founding mother of the natural birth movement, and continued in documentaries such as “Pregnant in America” and “The Business of Being Born,” which characterize hospital births as unnatural, invasive, and dehumanizing.
Much of the original midwifery movement came as a backlash to practices that are now viewed as barbaric, such as the “twilight” births of the ’50s in which mothers were sedated and babies were forcibly removed with forceps. This movement coincided the counterculture of the ’70s, carrying with it tenets of female empowerment, and taking root in the back-to-the-land movement, an era of time when young Americans rejected urban life and moved to the country to grow their own food, connect with the earth, and become self-sufficient.
Tessa has been illegally delivering babies in Trinity County for roughly thirty years. She arrived in 1984 on the tail end of the back-to-the-land movement to establish an intentional community and shortly afterward began delivering babies there.
After birthing five of her six children at home, shadowing Eva – the same midwife Aria had – and doing her own reading on home births, Tessa began overseeing births for women who cycled through the intentional community where she lived, and eventually to others living in Trinity County.
Tessa typically charges around $2,500 for her services, which include care throughout the pregnancy, delivery, and post partum care. She estimates she has overseen between 75 and one hundred births, and has chosen to not get certified on principle – she just doesn’t like the medical system.
Tessa says she’s never lost a baby or a mother, though there have been a few complications that have required hospital care – lucky for her because the death of mother or infant can incur manslaughter charges for the uncertified midwife.
You have to be fearless,” Tessa says. “Women have been having babies for thousands and thousands of years. We are designed to birth.”
In the midwife community, the dialogue around homebirths revolves around the central themes of female empowerment and patient-focused medicine.
“Historically, birth was a community thing,” Aria says. “You got to see it, you learned about it, you had an innate trust in your body. Western medicine has stripped us of this. We’re alone in a hospital room.”
In a larger context, the position of midwives continues to evolve. In light of a shrinking number of obstetricians and gynecologists, new studies are recommending offsetting this gap by integrating midwives into the medical system. Midwife advocacy groups have also successfully lobbied for limited access to midwifes under Medi-Cal, California’s state supported insurance. New attention has also been paid to the U.S.’s notoriously high mortality rates. According to a 2010 U.N. study, the U.S. maternal mortality rank dropped from an already dismal 41st to 50th in the world. Midwifery proponents cite common medical procedures and practices as key causes of this high rate of mortality, and while this isn’t agreed upon, midwifery advocates are highlighting weaknesses in current medical practices and offering solutions to them.
Aria has no plans to continue offering her services illegally, but there is a demand for them.
“It’s word-of-mouth that helps you find unlicensed midwives,” she says. “I have people calling me to do births now, because they heard from somebody who heard from somebody that I did a birth.”
Aria’s work as a midwife has been, and will continue to be, defined by the tensions between the existing medical system, and the emerging midwifery system. Once certified, she will still be working in a field that offers little legal protection or institutional support. But Aria is a passionate believer in her practices. She is working to offer what she sees as a vital service that honors women and birth, while providing a human-centered form of medicine that offers patients more autonomy.
“A lot of times mothers choose to have home births just to keep some amount of control,” Aria says, “because it’s F-ing terrifying.” In her opinion, hospitals only add to a new mother’s anxiety. “When you go to a hospital they take away a lot of your rights. If you disagree with the program you’re treated like a criminal. It’s limiting. You need to be free.”