Marinah Farrell is a Licensed and Certified Professional Midwife with a degree in politics from Arizona State University. She is the current President of the Midwives Alliance of North America (MANA). She is a founding board member and midwife with the Phoenix Allies for Community Health, a free clinic for those without medical care.
L: Do you feel like there is a political aspect to (your role in MANA)?
M: Mostly politics. Birth in this country is very political in general because for the most part birth is…it’s a corporate thing in the US. So what happens is that every…even though we have such a maternal health provider shortage…you know we have OBs and they practice like crazy…and we have nurse midwives but can’t get into programs; there’s very limited programs for nurse midwives; and then for CPMs and LMs, it’s even worse because we have even fewer programs, and yet there is this huge need for maternal health care providers; so, what’s happening is that it’s kind of like everything is stunted by lobbyists…and a lot times it is the OB lobbyists that really don’t want or don’t like out-of-hospital births, and then also they have sort of other issues when it comes to even, you know, um, sort of like being a primary care physician for…even in a group practice where there are midwives. It is very, very political. And right now we are trying to work with the nurse midwives, actually…and the CMs, who are sort of in this bridge ground too, like how LMs are. The CMs are, they can only practice in two states. And it’s kind of crazy, you know. And so we’re trying to actually do some legislative work together, but you can imagine it is very challenging. We have very different paradigms because a lot of us that didn’t elect to be nurses, we often don’t get the complexity of what being a nurse is; and those who are nurses often don’t get the complexity of what it means to kind of struggle to be an out-of-hosp…to be a non-nurse midwife in this country. It’s a very hard bridge to cross. We’re always having to struggle with it, and so a lot of politics is going on with it at the national level. And then, you know, every state has its struggle, every single one. Even, for instance, in Arizona right now, the state is really going after midwives, and they’re doing this weird interpretation of the rules, like when they actually want us to give less care than more care. So we’re struggling with that. So to be a midwife in general in this country, I think, to be a medical care provider in this country, is political, all the time.
M: We’re trying to do some bridging. We’re working with the nurse midwives to sort of bridge pieces of our education, so that our education is more accepted. It’s definitely always political. It’s kind of a bummer because it ends up being not so much about birth as it does about liability and money.
L: Yeah, it is, and especially because cost containment is such a big piece of health care moving forward. I’ve read statistically that birth…or at least… labor and delivery and newborn care is the biggest hospital expenditure…and probably the most they get reimbursed for too.
M: Right, I think they say that the physicians that are the highest paid are the anesthesiologist and the OB. They’re like one and two on the list. And I’m like ‘Of course they are because they work together,’ you know? And I think it’s like 70% of income for hospitals is OB, I think. So, we’re looking at a system where a lot of money is made.
L: Do you have lobbyist or is it midwife driven?
M: We work with some…there are some organizations out there for midwives. Usually midwives themselves, for instance, in Arizona, the Arizona Midwives Association just simply can’t afford lobbyists, and even if they could, the amount of money that we could pay a lobbyist is nothing compared to what, like, the OBs pay or even the AMA. The AMA is really who calls all the shots. And so, we have a group called the Big Push. Their whole purpose is to try to get midwives credentialed in states, or licensed in states. They sometimes do have lobbyists that work for them, but I think, I mean, again, they’ve done comparisons…like, if you go to BigPush.org, you can see some of their data there. They do comparisons of how much they pay versus how much that big medicine pays, and it’s almost nothing. So, I would say ‘not really.’ You know, it’s kind of incredible when you look at how many gains midwives have made in the last 30 years without money.
M: There are a lot more consumer groups popping up, and they can do it. They can stand up to them, which is really good.
L: There was a consumer group that helped with SB 1157, right?
M: Exactly. If it wasn’t for the consumers, who knows what would have happened. And you’re seeing that in a lot of states. You’re seeing where consumers groups are really the power, which is really interesting. So it’s really moms and families asking for changes.
L: So, was it mostly, uh, people who have had home births and used midwives? Is that who the consumer group was mostly made up of…?
M: I think so. I mean yeah. I think it is. Although, we also now have the birth bar rights association…or the birth bar association, which is just attorneys for birth. It’s definitely expanding. I think that in the last decade, I have seen so many more supporters coming out for midwives than ever before.
L: Yeah, that’s great. So, what happened to SB 1157? It passed out of the health and human services committee, and then it just dropped?.
M: Well, what happened was, um,…what I think happened is I think that the…uh…I’m not going to remember her name…but the main chair of that committee is an MD, and what happened was during the hearing they had…it was very interesting how they did it, because the had an OB and a nurse midwife speak to the work of licensed midwives. They didn’t have any licensed midwives speak, and then we had our time to speak but it was very short. They only would gives 2 minutes or, you know. But, at one point, the doctor who was the chair (and I can’t remember her name) brought up abortion, and she basically said something like, “I believe in women’s rights, but I’m antiabortion, and I also worry about that you all are hurting babies or that babies are dying.” She said something to that effect. And that created a huge ripple…that we actually went to the national organizations and said, “Hey, this is what she said.” And there was a ton of moms in that audience who were very conservative, who also were pro-life, but they’re home birthers, and they were furious. They were like, ‘How dare she assume that we’re not pro-life because we’re home birthers?’ And it got a little bit hairy. And, I swear, I really think that she, that she just dropped it. I think they didn’t want the controversy. I think it was a really big political maneuver that happened.
L: I think her name is Ward. I watched so it afterward online. [Lisa paraphrases what Ward said.]
M: There is a big knowledge gap. But, you know what happened was that we knew that after about the first 10 minutes of it that it had already been decided.
M: She [Ward] kind of shot herself in the foot doing that, because I really believe that she thought home birth were completely unpolitical, were completely crazy radical, not realizing that in this state that people who have advanced our causes more than anybody have been republicans because republicans are home schoolers, and they’re home birthers, and they’re Mormons, and they’re all these things that they love midwives. And so, um, that was fortunate in that…because I think it could have gone a different way and not a good way for us. I think it could have actually gotten very constrained. I think that is what she wanted. So even thought it didn’t go the way we wanted to go, it didn’t go the way we didn’t want it to go.
L: Do you think the passage of the Affordable Care Act has helped midwives or has been neutral for midwifes? Because it’s hard to get on provider panels to begin with – do you have any thoughts on that?
M: I will be really honest and say we don’t really know. We thought it would be, and some of the wording and legislation of the act gives us a little more power as providers, but I don’t really think it’s made a whole lot of difference. I guess time will tell but it doesn’t seem like it. And I hate to say that because it hasn’t all played out, but it sure doesn’t seem like it.
M: And what scares me, or one of the things that scares me, is that midwifes can’t get it together to be one powerful force and what’s scary about that is that who is starting to do births are PAs who have two years of education. I oversee PAs at the free clinic and I am not kidding you, Lisa, they do one semester of women’s health. And that’s it. They do one semester, and the only hands on thing they do, they do a vaginal exam on a woman, not even a pap, that everyone does a vaginal exam on – someone they’ve hired to do the exam on. And they literally graduate…I just had a PA student who just graduated directly into an OB office and a week after she graduated, she caught a baby. She had never even been to a birth and she was catching babies. And moms don’t know this and I often wonder did that mom know. I love NPs. I say, let there be more NPs. In other countries they call them OB nurses. They don’t do that here…but advanced practice nurses make great midwives. But instead not even nurses are being able to catch babies. But nurses are actually the professionals here. They know how to catch babies, not a resident or a PA that happens to be here because the physician is not here or whatever. So less expensive options, but also less skilled options are replacing us.
L: That is very similar to other NP and PAs. Physicians prefer PAs because they’re practicing under their license and are taught under the same medical model, which is obviously different than the nursing model.
M: It’s amazing how many PAs are graduating out of two-year programs and replacing nurse midwives and nurses in a big way. It’s just something to kind of think about, when thinking about the legislative thing and workforce. That picture is a really important picture too.
L: So on my blog the biggest question that always comes up – the people who comment are nurses and they work in hospitals and see bad outcomes – The question that always comes up, is that if the mom really knew all the risks involved maybe she wouldn’t choose a homebirth. How would you reply to that?
M: Hmmm….well, in a way I think it really downplays the importance of women and birth. And I think that’s true for anyone who provides care to women. I think women often don’t receive true information and informed consent. But honestly, when do women truly have informed consent? It’s very rare and so I think there is some truth to that. I think even midwifes can be guilty of not fully informing clients of risk.
Yet, studies have shown even here in the U.S if you are a low-risk mom with a certified professional that has proven her competency, then you are in pretty good hands. Your outcomes are just as good as a hospital birth. It’s a little bit more questionable around the baby and the health of the baby, but I think those studies are really controversial because they’re based on birth certificate data. They include people who never intended to have a homebirth but had their baby at home, or just didn’t make it on time and even people who don’t go to hospital because they can’t afford to, so they just birth, unassisted at home. It can include a wide range of outcomes that have nothing to do with midwifes. It has to do with faults in the system. So if you look at MANA and their division of research studies, they take women who have planned homebirths, the outcomes are great. Even when it comes to things like water births, MANA is coming up with some great research. Overall it’s not totally true to say that.
But there are things that are critically important. Midwives do need to know how to transfer in a manner that is effective and safe. There does need to be more inter-professional care. And there might need to be a little more oversight, especially in states where there is no licensure. So what happens is there are states that don’t licensed midwife’s because they think midwives are unsafe, so what ends up happening is that they truly have midwifes that are unsafe because they don’t license them. Of course, that’s not everyone. I know some amazing midwifes who have been working underground for more than 20 years, but I’ve also known moms who have had terrible outcomes in states where midwifes – God only knows where they got their education, and it reflects badly on all of us. And people say well, “that’s the midwifes! That’s what they’re like!” So for nurses in hospitals that are seeing our transports, it really is a drag, and they think there is no system in place, no education, no oversight. It should be included in their education. But at the same time there is some truth on each side. And I didn’t used to think that, but the more I understand the whole playing field, the more I realize that it’s mostly the system and the system tries to put blame on the midway. I can’t think of a single out-of- hospital midwife who wouldn’t love to have a better system, wouldn’t love to have more time with nurses in the hospital, would love to have more doctors who are willing to do collaborative care. It truly is a desire but what happens is the system doesn’t allow it.
L: So where do you see the issue of midwife practice in the context of policy development? Do you think, in general, it’s more in an early stage?
M: I think it depends on what level you’re talking. It’s definitely in early-stage as far as policy development at the national level as it relates to ACOG and ACNM. I would say in the last five years we are doing a lot more work with ACNM…. and even AGOG. The homebirth summit is kind of a big deal, providers from maternity care all over the U.S. getting together and talking…. so it is newer. Yet, for instance, the CPM and having our own credentials that started in the early 90s. There is a little bit where at the grass roots level it’s been happening. In Arizona for example it’s been going on since the 70s. It’s kind of been at this grass roots level like a snail… Yet big leaps have been made in 30 years.
What’s interesting is that we’ve had a voice in the international world for a long time – since the 80s actually. So it’s kind of interesting in that we haven’t been recognized, yet we have.