Update: The Case of Indiana Midwife Ireena Keesler--and Why She Won't Be Practicing
In the past few months, two certified professional midwives have been arrested in Indiana for attending homebirths. As I wrote on BlogHer last week, Ireena Keeslar, 49, a diabetic mother of five, is one. Now this dedicated, experienced midwife who mostly works with low-income Amish women has said she will no longer practice.
In Indiana it is a felony for certified professional midwives, like Keeslar, to attend homebirths. “We have defined the delivery of babies as the practice of medicine,” said Representative Tim Brown, M.D., an emergency room doctor who is chair of the Public Health Committee in the Indiana House of Representatives, and who currently opposes the bill to license certified professional midwives. “That’s the law,” Brown said.
Like many doctors in Indiana, Brown believes CPMs are not qualified.“I don’t think they have the training and expertise that at this time renders them qualified that we should license them in the state of Indiana,” Brown said.
“The delivery of a child in a hospital or at home is the practice of medicine, and lay midwives do not have the educational training required in the event of an emergency,” agreed Mike Rinebold, director of government relations for the Indiana State Medical Association.“Even in the most routine births, things can go wrong in a heartbeat. You have to have the education and equipment necessary to be prepared for an emergency.”
But a spokesperson from the North American Registry of Midwives, the non-profit organization that provides national certification, disagrees. “Evaluating risk is part of the training,” said Debbie Pulley, director of public education and advocacy and a CPM in Lilburn, Georgia. “CPMs are certified in neo-natal resuscitation. They are trained in how to deal with hemorrhages, and they have knowledge when to transfer care to the hospital.”
CPMs must have 1,350 clinical contact hours with pregnant women, mothers, and babies, as well as the knowledge and the skills to pass a 4-hour skills exam and an 8-hour written exam. “Our certification insures that midwives meet core competencies for knowledge and experience,” Pulley said. “NARM requires both didactic training and clinical internship and passage of the national exam for certification.”
The average length of training to become a certified professional midwife is three to five years, according to Pulley. “The required number of births, prenatals, and postpartum visits that family practice doctors, certified nurse midwives, and certified professional midwives need is virtually the same,” said Mary Ann Griffin, president of the Indiana Midwives Association.
Keeslar, who lives in Howe, was arrested on Saturday morning, March 31. She spent the day in a jail cell with no access to her medications. There was someone else’s phlegm in the sink and she was served food inappropriate for a diabetic. She was released Saturday night on bond.
Keeslar’s daughter, Anastasia Griffith, was at her job at Hardy’s, a travel store on the south side of the toll road in Howe, when her older brother Nathan called to tell her their mom had been arrested. “My brother picked me up and went over to my parents so I could sit with my father,” Griffith said. “He was sitting at the house not knowing what to do. He was just as confused as I was.”
Griffith has been married for five years and is looking forward to starting a family. She believes women in Indiana should be able to choose where and with whom they give birth. “I’m definitely having a homebirth,” she said. “This cause means a lot for me personally to have my mother be the one who delivers my child in my home in Indiana.”
Griffith believes criminalizing certified professional midwives is unfair. “What hurts me the most about this is that now I don’t have that choice for myself anymore.”
Women in Indiana who want CPM-attended homebirths are crossing the border to Michigan. In Michigan certified professional midwifery is not expressly forbidden by law, though midwives say they are still vulnerable to harassment or prosecution.
America has one of the highest maternal mortality rates of any industrialized nation. According to Save the Children, the likelihood of a mom dying due to pregnancy related causes in the U.S. is seven times greater than in Italy or Ireland; the likelihood of her dying as a result of childbirth is five times greater than in Germany and Spain, and 15 times greater than in Greece. One recent study of maternal mortality in New York City found that 79 percent of women who died in childbirth had Cesarean births.
While other countries report an increase in positive outcomes and a decline in childbirth-related complications, “near misses” (pregnancy-related complications so acute a woman almost dies) are climbing in the United States, according to a 2010 report by Amnesty International.
Yet the vast majority of births take place in the hospital. Fewer than 2 percent of American women choose to have their babies at home. Birth activists point out that it is unnecessary intervention, harmful hospital protocols, and doctor error in the hospital that accounts for the poor birth outcomes in America.
Dozens of scientific studies have found that for low-risk mothers, homebirth is as safe as hospital birth. One recent study from the Netherlands, where 30 percent of the births take place at home, confirmed the safety of out-of-hospital birth for low-risk women. The Netherlands has much lower maternal and infant mortality rates than the United States. “There are places in the world where homebirth is offered as a reasonable option in a well-established system of obstetrical care: Holland, Britain,” said Dr. Mary Elizabeth Soper, M.D., an Indianapolis-based obstetrician who has been practicing for 35 years.
Soper supports licensing certified professional midwives. “There are places where homebirth is considered to be a normal, possible choice,” Soper said. “The thing that makes it possible is well-trained midwives, well-established criteria for who can have homebirth, and well-established emergency procedures.”
While many hospitals have protocols that make it difficult or impossible for a laboring woman to move freely--and most obstetricians expect women to give birth lying flat on their backs--women at home attended by midwives can labor as they wish. Moving freely during labor, being allowed to eat and drink, not being monitored constantly, and having one-on-one attention have all been scientifically shown to increase the chance of a good outcome. “I do not believe it’s about safety. There’s no evidence to back that up,” says Anastasia Griffith, Keeslar’s daughter.
On Monday, April 9, more than 100 supporters gathered outside the LaGrange County Courthouse to protest Keeslar’s arrest. One man held a sign to oncoming traffic: HONK IF U SUPPORT MIDWIVES. Mary Ann Griffin, president of the Indiana Midwives Association, was at the rally. She said the mood was peaceful, even joyful. Many of Keeslar’s former clients, including more than two dozen Amish women, were at the courthouse, as well as other supporters from northern Michigan and southern Indiana. “They are very worried about what is going to happen,” Griffin, who lives in Rockville, said.
About 45 minutes after the crowd started gathering, a police officer announced that Keeslar’s hearing had been postponed.
Like Keeslar, Griffin is a certified professional midwife. Like Keeslar, under Indiana state law, every time Griffin attends a homebirth she is committing a crime. But Griffin has attended about 2,000 homebirths in Indiana over the 29 years she has been a practicing midwife. She said she’ll continue to do so.
“It’s a calling. We can go to cities or other states and have a life. There are 26 states that license you,” Griffin said. “But there’s a need in Indiana and I live here. I’ve always felt like it was an issue of justice for women. Women need to have the right to choose where they give birth.”
Griffin is a mother of nine, including 17–year-old twins. She has ten grandchildren. She delivered eight of them herself at home. ““I am the most vocal visible person in this state,” she said. “I’m just glad they haven’t arrested me.”
Mike Rinebold, director of government relations for the Indiana State Medical Association, is hoping that will change. “We are thankful there is a prosecutor in LaGrange County who is willing to enforce the laws,” Rinebold said.
Keeslar, a trained nurse, worked in obstetrics for almost ten years at two different hospitals and two freestanding birth centers. Newspapers have reported that Keeslar let her nursing license lapse. But she says that in 2004, she chose to put it in inactive status. “Since that license did not allow me to practice midwifery, I chose to not keep it current in the state of Indiana,” Keeslar said.
Keeslar has a nursing license in Michigan and is also licensed as a midwife in Virginia. Griffin said she and other Indiana midwives and doctors have been working to change the law. In Indiana only certified nurse midwives may legally attend homebirths. These midwives are advanced practice nurses who specialize in obstetrics.
The bill to legalize certified professional midwives has been filed in the Indiana legislature for the past 17 years, but has never been heard by both chambers. “The bill has failed over technicalities or for lack of being granted a hearing,” Griffin said.“We are being stopped by the Indiana State Medical Association, which has a powerful lobby. I’ve met with them many times. They have told us that we have been their number one priority. This little tiny group of midwives. There are about only about 15 CPMs in Indiana. It’s a tiny group. We serve 1,000 families a year who want to have a homebirth.”
Griffin says the question of who can attend homebirths is not about safety. She points to studies that have shown that birth at home with a competent attendant is as safe as hospital birth for low-risk women. What makes homebirth dangerous, Griffin says, is when midwives are considered felons for helping pregnant moms.“When there is no regulation and midwives are criminalized then the state drives competent safe midwives out of state,” Griffin said. “We want collaboration, that’s what makes homebirth safe.”
In the past Rep. Tim Brown, M.D., has attended homebirths as a doctor. “At that time it seemed like the appropriate thing to do,” he admitted. “Part of all healthcare is we need to give more options...I think women should have some options.”
But Keeslar will stop delivering babies in Indiana. “Since they are coming after me, I’m thinking I don’t want to risk it. It’s not worth it to me to set in jail. I can’t practice or even assist at a birth in Indiana anymore.”
Instead, Keeslar is planning to practice out of state in a brand new not-for-profit birth center, funded by Amish cattleman Jonathon Lambright. The birth center is open to any woman who wants a home birth. The cost to women to stay at the facility will be between $400-$800 for up to 36 hours, a small fraction of what a hospital stay costs. The fee for the midwife will be extra.
Keeslar has not received a new court date. I asked her if she was concerned she might go to jail.“I don’t feel worried,” Keeslar admitted, “but I don’t know if that is peace from God or if I’m just ignorant about how this works.”
Readers who want to help Keeslar cover legal fees can send checks to:
Ireena Keeslar Legal Fund
7570 East 750
North Howe, Indiana 46746