Terah Lara can’t conceive of a life where she isn’t helping deliver babies.

But you won’t see the Enumclaw resident running down the busy halls of St. Elizabeth Hospital in pastel-colored scrubs — you’ll actually find her down the street on Washington Avenue, where she practices as a licensed midwife (LM) and certified professional midwife (CPM) at Foothills Midwifery.

“I had my babies with midwives, but my mom also had her kids — me and my brother — with midwives,” she said. “I can’t imagine not wanting to have a baby, or not wanting to be around birth.”

Midwifery has been making headlines the past few years as home births are becoming more popular, albeit marginally.

Historically, nearly all births (at least in America) were aided by midwives, according to Rutgers University history professor Margaret Marsh, who spoke on the history of birthing in America with the NPR program All Things Considered in 2013.

But around 1760, women started wanting doctors to be involved instead, believing they were better trained and equipped than midwives (though it appears there is much argument about whether that was true). In either case, doctors were aiding in 50 percent of births by the 1900s, and as more and more women gravitated toward hospitals to deliver their children, became involved in 99 percent of all births by the 1970s.

That hasn’t changed all that much in the present day, but a 2019 study titled, “Trends and state variations in out-of-hospital births in the United States, 2004-2017,” shows that home births increased 77 percent between that time period, and that an estimated one of every 62 births are now done outside a hospital. Birthing centers more than doubled during that time as well, and — perhaps unsurprisingly — the Pacific Northwest appears to be one of the more popular places to have a home birth.

All this has started a debate within the healthcare community over whether home births or hospital births are safer, although what data has been collected appears to show both delivery settings are, on the whole, safe for the mother and her child.

And while Lara argues that home births have lower rates of both morbidity and mortality (at least in Washington), there are other strong considerations for why women prefer to have their child outside a hospital setting.

“I think it’s because of the setting, why they seek out this kind of care,” she said. “They don’t feel like pregnancy is a reason to be in the hospital, so it’s not treated like an illness. It’s treated like a personal, spiritual, normal thing that happens in their life.”

This doesn’t mean women who seek out a midwife are sacrificing safety for comfort. In fact, midwives can be very selective when it comes to which patients they take on, because while they have all the necessary schooling, training, tools and much of the emergency equipment needed for a successful birth, they do lack the ability to administer an epidural or perform c-sections.

Those reasons are why midwives like Lara only take low-risk patients for births, and encourage everyone else to receive care at a hospital.

Those that do qualify are offered the same technical treatment they’d receive in a hospital — preconception care, prenatal care, delivery and birth, and onto postpartum and newborn care — but with a more human touch than some may get in a larger institution.

“There’s always somebody one-on-one with you. We have less people that we’re seeing, so we’re not being taken away,” Lara said, who herself takes on only four to five due dates a month.

Another perk is that the Washington State Department of Health licenses midwives to be the baby’s pediatrician for the first 21 days, extending the continuity of care.

Having a home birth also allows for family and friends being present for the procedure, which Elizabeth Dillon, a midwife student doing her residency with Lara, sees as a huge benefit.

“When birthing people want family like children, their parents, or siblings there, it makes the experience so rich,” she said. “The ability to have flexibility in that is really valued.”

These differences in care could explain why women who use a midwife tend to experience less anxiety and depression after birth. A 1998 study had 120 women split into two groups; those who received a postnatal “debriefing” by a midwife, and those who did not.

Three weeks after birth, half the women who did not receive a debrief reported a high amount of anxiety, and more than half reported a high amount of depression, whereas only four women that received the debrief reported anxiety, and five that reported depression.

“It doesn’t matter what happens during their birth — it matters more how they are treated,” Lara said.

SAFETY AND MORTALITY

Whether using a midwife or having a home birth is safe is much debated, and safety can depend on what part of the country you live in.

Some studies show that overall, home births — even with a midwife — are less safe than hospital births. One 2016 study, led by Dr. Amos Grunebaum, former director of obstetrics at New York Weill Cornell Medicine, showed home births with an uncertified midwife had an infant mortality rate of nearly 14 deaths per 10,000 deliveries.

With a certified midwife, the death rate dropped to 10 per 10,000 births, and the rate dropped further to just 3.2 out of 10,000 when a midwife is present during a hospital birth.

For comparison, a Reuter’s article about the study claimed the death rate for babies delivered by doctors is around 6 per 10,000 deaths, but it’s unclear where that statistic originated. However, a New York Times article about an earlier study by Grunebaum claimed the reason why doctor-delivered babies have a higher death rate is “almost certainly because the most complicated births are generally handled by physicians.”

A second study pulled data from the Midwives Alliance of North America Statistics Project from 2004 and 2009, and found that infant death rates during home births were rare; out of 1,000 births, 1.3 deaths were intrapartum, 0.41 deaths were early neonatal (died before a full week of life), and 0.35 deaths were late neonatal (after seven days of life).

What state you live in, though, can greatly impact what quality of midwife care someone receives.

One 2018 study published by PLOS One rated each state on how well midwives are integrated into their respective regional health care systems, and drew correlations between successful integration and successful births; higher scores were correlated with higher rates of spontaneous vaginal delivery and vaginal birth after a c-section, but lower rates of c-sections, preterm births, low birth rates, and infant deaths.

Out of a score of 100, Washington was the highest at 62, whereas North Carolina came last with a score of 17.

Another safety concern revolves around how the baby is delivered, and there is much debate over whether or not a water birth (giving birth in a tub of water) — a common delivery method used by midwives — is safer than a non-water birth.

According to a 2016 study published in the Journal of Midwifery and Women’s Health, infants born underwater “fared better than their non-water birth counterparts on all neonatal outcome measures.”

For example, 4.5 percent infants out of the roughly 10,000 not born in water had to be hospitalized within the first 6 weeks of life, whereas the rate dropped to 3.4 percent of the 6,500 water births. Infants born underwater were also less likely to be admitted to the NICU (1.4 percent) than infants born out of water (2.4 percent).

Despite the relative safety of using a midwife, emergencies do happen, but Lara comes prepared.

“Almost all of the time, under any circumstance that I can remember, I’ve dealt with all the emergencies we needed to out of hospital, and then either stabilized people enough that we transferred in at that point, or never transferred, because it was managed then,” she said, adding she has a close professional relationship with St. Elizabeth Hospital. “Even if somebody transfers to the hospital, they’re still getting such a different kind of care that can lead to different feelings about how they were treated, postpartum and beyond.”

Terah Lara’s office on Washington Avenue is just about a year and a half old, but the birthing center (or birthing cottage, she calls it) is brand new and ready to take on patients. Photo by Ray Miller-Still

BIRTHING CENTERS

There is a between option for women who don’t want to give birth at home, but also don’t want to go to a hospital — birthing centers.

Birthing centers resemble something more like a hotel room or a cottage, rather than the impersonalization of a hospital room, but can also be a more controlled and hygienic environment than a home.

And safety-wise, births in birthing centers look to carry the same risk as giving birth at a hospital. A 2011 study published in the British Medical Journal (BMJ) looked at about 65,000 births that were completed at home, in a birthing center, or at a hospital, and found that “adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings.”

Though Lara has been practicing for 15 years (eight years in Enumclaw), she’s only just been able to open up her first birthing center at her office location this month. It sports a large tub for water births, a dresser for clothes, an armchair, a small office desk (complete with a computer) and a large bed.

“I wanted it… to be attractive and feel like a home, so that people felt like they were going from one home to another,” Lara said.

St. Elizabeth Hospital also has a birthing center suite at the hospital, and it’s easy for patients at both locations to be transported to a regular hospital bed should the need arise.

For more information about Terah Lead and Foothills Midwifery, head to https://www.foothillsmidwife.com/.