Aszani Kunkler: "Holding the space" for mothers and babies

By Amanda N. Wegner

Each year, more than four million births take place in the United States. The Centers for Disease Control and Prevention note that 99 percent of those are in hospitals.

But there’s an alternative that just one percent of mothers have or will have experienced: natural birth, attended by a midwife, outside the hospital. And certified nurse-midwife Aszani Kunkler, CNM, MSN, CLC, owner of the Madison Birth Center (MBC), hopes that in the future, that small percentage will rise.

“For me, it’s the desire to be with women as they have their babies and protect the childbearing environment so we can continue to have and offer unmedicalized births,” says Kunkler.

Staggering stats
If those first statistics weren’t staggering, try these: The number of mothers having Cesarean sections has risen over 50 percent in the United States since 1996; about one in every three babies is delivered via C-section.

Another one in three labors is medically induced and nearly 90 percent of birthing women are given drugs for pain relief.

These interventions and medications are often necessary for high-risk pregnancies. But as 90 percent of American women have completely healthy pregnancies and births, using these interventions routinely in healthy women leads to more harm than good.

What’s more is that the United States spends more money on obstetrical care than any other country in the world, yet we are 29th in the world when it comes to infant mortality (the number of infant deaths per 1,000 births each year) and the maternal mortality rate ranks us 25th in the world. For all the money and technology we have, those outcomes could be better.

Moving to a midwife, mother-friendly model of care could, in part, do that. “Countries with lower costs and better outcomes for mothers and babies rely on midwives to attend most births, and many support out-of-hospital births,” says Kunkler.

In fact, in many other developed countries, obstetrical care is provided almost exclusively by midwives. “In Europe, you can’t even see a physician unless a midwife refers you,” notes Kunkler. “There, midwives are the ‘guardians of normal.’”

Evidence supports midwifery, proving that it’s safe, cost-effective, supportive and produces excellent outcomes for mother and baby. Since opening MBC, Kunkler’s practice has had “great success for mothers and babies.”

Can we do it? Yes we can!
For hundreds of thousands of years, women gave birth, without intervention, in their own homes. While a hospital birth experience will continue to be necessary for some mothers, for many others, the interventions available today are superfluous and excessive.

“It’s about ‘holding the space.’ That space of pregnancy and childbirth as something sacred and natural and normal. Women really want natural childbirth, but when one woman after another is offered drugs, inductions, other interventions that are in no way benign, women start to feel - because they are constantly being bombarded with negative images and messages - that childbirth isn’t natural, that it isn’t doable, that they don’t have the strength when, in fact, they really do,” says Kunkler.

Research indicates that all the routinely used technological and pharmaceutical interventions available during childbirth have done little to improve the outcomes of mothers and babies. To that end, midwifery is based on evidence that goes back to the same tenets our foremothers and grandmothers relied on when bearing their own children.

“Midwifery care is safe, cost-effective, individualized and mother- and baby-friendly,” notes Kunkler.

Kunkler has long been committed to helping women “hold the space.” Kunkler’s first child, her daughter Maureen, was born in a hospital. But her son, Daniel, was born at home; that, she notes, “was an amazing experience.”

In the 1980s, Kunkler owned Full Bloom on Madison’s east side, a business focused on providing childbirth classes, doula services and massage to mothers-to-be. She attained her midwifery certificate from the Frontier School of Midwifery and her master’s degree in nursing from Case Western Reserve University in Cleveland, Ohio. She is an advanced practice nurse prescriber (APNP) as well as a certified lactation counselor (CLC).

When she first began working as a CNM, Kunkler commuted to Chicago to practice, as at that time, “there were no jobs for midwives around here.” Taking the future — and the futures of many women and their babies— into her own hands, she opened MBC, located in the Middleton Hill’s neighborhood, in 2003.

At first, neither the city of Middleton nor the state of Wisconsin knew what to think about Kunkler’s idea; there were no regulations regarding free-standing birth centers, of which Kunkler’s facility is Wisconsin’s first. From the start, it has “very much been an interesting learning experience.”

Today, MBC is one of only 54 hospitals and birth centers in the United States to receive national accreditation and is one of 77 designated “Baby-Friendly” birth facilities. Plus, it’s the only birth center to achieve both of those honors.

“It’s been an interesting journey,” says Kunkler, “and I don’t feel like my work is done. We still have a lot of education to do in the medical community and the community at large about midwifery. It is really the best option for many mothers.”

Your questions answered

What’s a CNM? CNMs are trained in both nursing and midwifery and are certified by the American College of Nurse-Midwives. To be certified, a CNM must be formally educated in midwifery through an accredited program affiliated with an institution of higher learning, demonstrate clinical competence and pass a rigorous national certifying exam. Madison Birth Center is staffed by board-certified nurse-midwives, each with a master’s degree in nursing.

Who can birth at MBC? MBC only provides care for healthy mothers-to-be experiencing normal pregnancies. Should any serious medical conditions arise or a mother learns she’s carrying multiples, Kunkler and her staff defer care to an OB/GYN. And should any complications arise during delivery (and that rarely happens, as MBC’s intrapartum transfer rate is a mere seven percent), the mother is accompanied by MBC staff to the hospital for advanced support. MBC also offers well-woman care outside of pregnancy, including annual check-ups, preconception visits and primary care.

Is it covered by insurance? Births at MBC cost 50-percent less than a hospital birth, but area HMOs don’t cover services there, except for one Unity product. Insurance barriers are a problem all over the United States for women seeking midwifery care, says Kunkler, even in hospital settings. The center does offer payment plans for any costs not covered by insurance.

The cost of c-sections

The cost savings for reducing the Cesarean rate are staggering. The Milbank Report estimates that $2.5 billion would be saved per year if the Cesarean rate was reduced to 15 percent. Kunkler estimates that Madison Birth Center has saved the local health care system $3.9 million over five years in avoided C-sections and epidurals and increased breastfeeding rates. This estimation uses real numbers from local hospitals about their costs.

Amanda Wegner is a freelance editor and writer in Madison. Visit her site at www.amandawegner.com

REPRINTED FROM:
Wisconsin Woman
May 2009