“Nebraska: The Good Life” (Unless You Want a Home Birth):

Restoring Normal Birth in the Face of Legal Restrictions

“Close your legs, and don’t cough. The baby’s coming any minute, and the OB GYN is still on her way,”

The maternity ward nurse instructs my cousin Karen, who is in labor with her third child, Payson. Karen forces a half-hearted smile and gnaws on an ice chip, the only “food” the hospital has allowed her to consume in 15 hours of Pitocin-induced labor. She’s lying on her back in a dim hospital room, wearing a gown and hooked up to a couple of IV drips. A monitor beeps rhythmically. The next day, Karen — a healthy young woman — admitted that, as family and doctors urged her to “Push!!,” she felt so weak that she feared death. This is the experience of many birthing people in Nebraska, which refuses to license CPMs and is one of only two U.S. states that has declared midwife-delivered home births illegal.

History: Native American and Volga German Midwives

Although Nebraska legislation reflects modern-day skepticism of midwifery, midwife-delivered home births were once the norm in the Cornhusker State. Through the 19th century, Native American women in the Great Plains delivered one another’s babies, and midwifery was likewise practiced among 19th-century American settlers, including Magdalena Forrer, the first Nebraskan to advertise midwifery services. For a brief time, relations between physicians and midwives proved polite and even collaborative; in 1881, a group of physicians, midwives and dentists formed the Southeastern Nebraska Medical Society, complete with a constitution and board of ethics.

Ultimately, however, Nebraska midwifery began to dissolve, a transformation reflected by the experience of the Volga German midwives in the early 20th century. This group of ethnic Germans moved to Russia in the 18th century and, in the 19th century, some of them migrated to Lincoln, the capital of Nebraska. Midwifery featured prominently in the culture of Volga Germans, for whom birth was a social event, and in 1914, Volga German midwives delivered one-sixth of the babies born in Lincoln. These midwives had no formal training — they derived their knowledge from hands-on experience and an oral heritage of folk medicine and superstitions — and they did not advertise their services, instead relying on word-of-mouth and family connections.

At this time, U.S. mainstream medicine was beginning to appropriate maternity care as male doctors publicly criticized female midwives, writing them off as unsafe and asserting that women should not work outside of their homes. As a result, childbirth rapidly moved into the hospital, where physicians treated it not as a natural process, but instead as a pathology. According to Professor Laura E. Ettinger, “Physicians were seen as status symbols, while midwives, commonly associated with the poor, were seen as déclassé.” Similarly, in early 20th century Nebraska,

“The midwife became a symbol of all that the immigrant represented — supposedly dirty, ignorant, and responsible for the unchecked reproduction threatening to destroy America’s ‘racial balance.’”

Most Volga Germans, however, prized the work of midwives over that of physicians, who spoke an unfamiliar language and whose services were more expensive. The Volga German community observed gender segregation, and therefore women felt more comfortable with a female midwife than a male physician. Furthermore, Volga German midwives remained with families for several days after delivery, helping the family adjust to its newest member.

Gradually, mainstream medicine encroached on Volga German midwifery. According to an 1891 medical licensing law, any individual without a medical certificate could not legally practice medicine. The law included obstetrics, which the Board of Health refused to separate from midwifery. Although the state had initially been relaxed in its enforcement of the law, by 1895 Nebraska Board of Health Secretary F.D. Halderman not only promoted its more rigid enforcement, but also recommended that the state compel midwives to pass an additional exam that it did not mandate for physicians. Halderman asserted,

“Few of those now practicing could pass the required examination, and those who were qualified would be given a standing, and they would assist in suppressing the rest.”

Despite Halderman’s attempts to undermine the work of midwives, they remained in high demand among the Volga German population. Lincoln Department of Health Secretary Dr. Chauncey Chapman hoped to oversee midwives under the Board of Health; after all, “If Lincoln residents were going to insist on midwife attendance, as a public health official, he felt an obligation to make sure they had access to trained attendants.” Dr. Chapman, who wished to decrease the total number of midwives and bolster the knowledge of those remaining, was chiefly concerned about an apparent high infant mortality rate among the Volga German population. In fact, the Volga German population did not actually suffer from an inflated infant mortality rate; instead, the Volga Germans did not report a substantial number of births, and the mortality rate was no higher than in other regions of Nebraska.

Volga German Midwives

Dr. Chapman ultimately allowed the midwives to decide whether they wished to organize with the health department. They agreed, as the opportunity presented a number of benefits, including legal protection, access to education, and a heightened sense of community. However, health department supervision also came with a number of drawbacks, including a loss of autonomy and forced adherence to the medical model of birth. Combined with other factors, such as a decline in Volga German immigration, Volga Germans’ general assimilation into the American community, and the efforts of pro-medical model social workers, Volga German midwifery — and with it, Nebraska midwifery writ large — gradually declined.

Modern-Day Debate: Midwives vs. Physicians

Today, virtually all Nebraskans deliver their babies in a hospital. Secretary-treasurer of the Nebraska Medical Association Dr. Todd Pankratz announced, “I don’t believe home births are a safe option.” Nebraska doctors warn expecting parents that, particularly in remote areas of rural Nebraska, home-birth midwifery is unsafe, as a birthing person cannot efficiently seek emergency medical attention.

On the other side of the debate are Nebraska birthing people and midwives who assert that the law should respect expecting parents’ autonomy, allowing them to “give birth where [they are] comfortable and in control of the moment.” Furthermore, they argue that hospitals are not necessarily safe for childbirth, given the risk of unnecessary medical intervention, including labor induction and cesarean section. Nebraska Friends of Midwives, a non-profit organization that supports and promotes Nebraska midwifery, has engaged in a protracted battle with the Nebraska legislature over the legalization of home-birth midwifery. Given the government’s resistance, however, the organization has lost steam. Chairwoman Shanna Wright admitted, “People are tired.”

Nebraska residents who desire home births must hire a midwife surreptitiously or trust a partner and/or other loved ones to deliver their baby. In the former case, both the birthing person and midwife risk a felony charge. According to Kate Sorenson, a Plattsmouth, Nebraska mother who delivered at home with a midwife from Europe, “It require[d] a lot of planning, a lot of extra cost. And a lot of keeping my mouth shut before it happened.” In the latter case, the birthing person and infant risk their health and even lives, as no one with formal training can facilitate the delivery and assist in case of emergency. The result of Nebraska’s proscription of midwife-delivered home births is akin to that of the outlawing of abortion; some people continue to deliver at home, just like some people continue to procure abortions, but with increased risk. Each year, about 85 Nebraskans give birth at home.

Midwifery in Nebraska’s Birth Centers: Just Two (Pricey) Options

Even in the face of these restrictions, Nebraskans can opt for a birthing experience that is different from the medical model. These include a midwife-delivered birth in a birth center or hospital. If a Nebraskan wishes to deliver in a birthing center, then that individual has just two options: Good Life Birth Place, Nebraska’s only freestanding birth center, or the birth center at CHI Health Immanuel Hospital, Nebraska’s only birth center inside a full-service hospital. Both options subscribe to a natural, birthing person-centered model of maternity care. Good Life Birth Place provides for expecting parents who “think childbirth should be more comfortable than clinical,” and the CHI Health Birth Center boasts that it “respects [birthing people’s] choices and encourages participation” and prides itself on “enhancing the power to give birth that lies in every [birthing person].”

Birth Center at CHI Immanuel Hospital in Omaha, Nebraska

Notably, however, a birthing person’s access to midwife delivery might be severely limited by both geography and class. In terms of geography, Good Life Birth Place and CHI Health Immanuel Hospital are located in Lincoln and Omaha, respectively, which are the two largest cities in Nebraska and about an hour’s drive from one another in eastern Nebraska. From points west, however, these cities are as far as seven hours away by car, meaning that individuals from western Nebraska might not have the opportunity to travel to either birth center.

Map of Nebraska

In terms of class, a birth center delivery might not be an option for individuals with limited financial resources who can only afford the hospital births covered by insurance, as many insurances do not cover midwifery. Notably, neither birth center website mentions cost, but the ornately decorated birthing suites suggest a hefty price tag.

Prior to the establishment of Good Life Birth Place, a birth center called The Midwife’s Place was located in Bellevue, Nebraska. The birth center nearly closed in the summer of 2016, due to “‘political struggles in the natural birth community and the medical community.’” After drawing up a formal transfer agreement with theNebraska Medicine-Bellevue hospital, wherein midwives could transfer patients to the Bellevue hospital in case of emergency, the center remained open for a while longer. However, The Midwife’s Place no longer exists today.

Good Life Birth Place Birthing Suite in Lincoln, Nebraska

Midwifery in a Nebraska Hospital: The Success of UNMC

Perhaps the premier example of Nebraska in-hospital midwifery is the Olson Center Midwives at the University of Nebraska Medical Center (UNMC) hospital, the largest public medical center in Nebraska. According to UNMC CNM Kate Scott, UNMC midwives provide a “high-touch, low-tech birth experience,” wherein midwives understand the importance of educating birthing persons on their bodies, respect birthing persons’ autonomy, and show confidence in birthing persons’ bodies as conduits for human life. UNMC CNM April Nelson affirmed, “Women should trust their bodies […]. We believe that [birth is] a normal process and not a medical condition that needs to be treated.”

Nelson’s views reveal her understanding of the crux of American midwifery, as articulated by Yale University Professor of Midwifery Holly Powell Kennedy:

“The practice of U.S. midwifery is deeply rooted in a belief in the normalcy of pregnancy and birth as a physiologic event that is more likely to be healthy than pathologic.”

Furthermore, UNMC midwives enjoy a collaborative relationship with doctors, whom they consult only for emergencies. In the case of emergency, the midwife remains with parent, baby and OB GYN through delivery.

UNMC midwives pride themselves on developing intimate relationships with families and birthing people, whom they educate on their bodies. According to Scott, “It’s about helping you […]. […] understand your body. If you don’t understand how your body works, how will you know when there’s a disconnect?” UNMC midwives spend significant time with expecting families in the months leading up to delivery, during which period they strive to become close to the family and understand the birthing person’s pregnancy and childbirth goals. UNMC midwife Calida Gardner reflected,

“It’s important [for birthing people] to have a provider that they can trust in, that understands them […]. It’s not about the time crunch. […]. Being able to take the time to really listen to women is a big part of midwifery care.”

The experience provided by UNMC midwives corresponds with the results of a 2015 study published in Maternal and Child Health Journal that examined the relationship between midwifery care and patient-provider communication in an American context. Researchers found that midwifery care promotes open, clear and extensive patient-provider communication. The study states, “In an era of increased attention to patient engagement in health care decisions, this finding is both important and actionable,” suggesting that UNMC midwifery is on the cutting edge of patient-provider communication.

Jessica Schultze gives birth to her daughter, Evalyn Louisa. Schultze delivered with midwife April Nelson at UNMC.

Despite the birthing person-centered, natural aspects of a UNMC midwife-delivered birth, the experience retains some characteristics of the medical model, as suggested by the pictures of Jessica Schultze, who delivered her baby with a UNMC midwife. Indeed, Jessica was free to move while laboring and helped deliver her baby. However, as pictured, she wore a gown and delivered in a sterile hospital room complete with medical equipment, suggesting the current inability of UNMC midwives to completely detach the experience of their clients from the surrounding medical setting.

Nelson with Schultze during labor

Conclusion: Toward a Model that Trusts Birthing People’s Bodies and Choices

While it does not appear that the Nebraska legislature will legalize home-birth midwifery in the near future, the (limited) midwifery services that Nebraska does offer suggest that a demand, however small, for natural birth still exists in the Cornhusker state. Nebraska midwives possess a keen understanding of the foundational principles of midwifery, reflected in their respect for birthing people’s autonomy; eagerness to develop intimate relationships with and educate the families for whom they care; and trust in birth as a natural process that ought not to be medicalized.

The day after she gave birth, Karen was overjoyed to hold a sleeping Payson in her arms, but also exhausted by the troubling events of her delivery. She reflected, “Payson just wasn’t ready to come out. I wish the whole experience could have been more natural and on Payson’s terms.” With the clear vision, relative success, and dedication of Nebraska midwives, perhaps the medical community will begin to loosen its grip on maternity care, and providers will educate expecting parents on all of their maternity care options. This would allow more births to take place not only on the terms of babies like Payson, but also on the terms of their parents, who deserve autonomy, knowledge about the birthing process, and confidence in their bodies.