When Sigrid Chapman gave birth last month in Women & Children's Hospital, she turned to a

midwife instead of an obstetrician to handle the delivery, a choice being made by more women.

Although nurse-midwives attend to a small portion of births in the United States, demand

for their services has increased almost every year since the late 1980s and hit an all-time

high in 2006.

Now, midwives in New York State see the potential for additional growth. They won a major

battle last week to work more independently after the Legislature repealed a requirement for

written agreements with doctors to deliver babies.

The change, which Gov. David A. Paterson still must sign, could increase the availability

of midwives to women like Chapman, who opted for midwifery because of its focus on natural

childbirth.

"My obstetrician wanted to do a repeat Caesarean section, and the midwife was less

skeptical and more encouraging about doing what I wanted," said Chapman.

Midwives work with obstetricians, who may do the delivery or provide backup in case

problems arise. But generally speaking, the professions practice with different philosophies.

Midwives specialize in assisting through low-risk pregnancies and helping women who want

natural births with minimal technological intervention. Obstetricians tend more toward active

management of deliveries to anticipate and prevent potential problems.

The written agreements spelled out the working arrangement between doctors and the 1,300

licensed midwives in the state.

Midwives contended the agreements were unnecessary because midwives have a professional and

ethical obligation to consult with obstetricians with or without a written practice agreement,

particularly when a pregnant women encounters problems and needs the expertise of a physician.

Midwives argued that physicians, especially in smaller and rural communities, refused to

sign agreements, preventing them from delivering babies. They noted that elimination of the

agreements doesn't change the scope of their practice — what it is they are allowed to

do professionally as midwives.

"The bill makes it easier to practice, and for patients, it removes a barrier to access

us," said Laura Sheparis, president of the New York State Association of Licensed Midwives.

A similar bill for nurse practitioners to eliminate written agreements with doctors is

pending in the New York State Legislature.

Physician groups oppose the measures.

The American College of Obstetricians and Gynecologists made the legislation a patient

safety issue, arguing that the agreements ensure an OB-GYN will be contacted immediately if a

midwife is faced with a high-risk birth. After passage of the bill in the Legislature, the

organization stated that patient safety will continue to exist in midwife-attended births in

hospitals but not for home births.

"The agreements are a safety net in case something goes wrong at the end of labor," said

Donna Montalto, executive director of the college's New York State section. "If there's no

doctor supervision, midwives shouldn't be doing obstetrics."

Dr. Mark Weissman, a Buffalo OB-GYN, said he supports midwifery and believes most midwives

will continue to collaborate with physicians, but he worries that the relationship will be

unregulated with the elimination of the agreements.

"The delivery of a baby should be a shared responsibility. Without the agreement, midwives

will be able to perform home births and create their own birth centers," said Weissman,

chairman of the college's Buffalo-area section.

Nurse-midwives delivered 317,169 babies in the U.S. in 2007. This represents 7.4 percent of

all births and 10.8 percent of vaginal births, according to data published last year in the

Journal of Midwifery & Women's Health.

For midwives, the written agreements come across as an unneeded obstacle to providing

services that they see as increasingly relevant to pregnant women, especially in efforts to

help avoid Caesarean sections.

"We have a pretty good track record of achieving natural births," said Elaine Clutterbuck,

a midwife with Nurse Midwifery Associates of Western New York.

A Caesarean, also known as a C-section, involves the planned or unplanned delivery of a

baby through a cut in the mother's belly and uterus.

It is usually done because of problems that arise, such as slow or hard labor, signs of

distress to the baby or concerns over the size of the baby.

The Caesarean section rate in the U.S. has been increasing steadily for more than four

decades, rising from 21 percent in 1996 to its highest level ever in 2007 of 32 percent,

according to the federal Centers for Disease Control and Prevention.

But many experts worry that C-sections pose risks to mother and child, and cite evidence

that many of the procedures may be unnecessary. A recent report by Public Citizen, an advocacy

group, suggested that nearly one-third of Caesarean sections performed in the state are

unneeded.

The group analyzed Caesarean rates in New York and found rates among hospitals in 2007

ranged from 16.6 percent to 53.3 percent. Rates in Buffalo-area hospital's that deliver babies

all fell near the state average of about 32 percent.

Clutterbuck said the report lends support to midwifery. She cited its conclusion that

choosing a midwife will likely decrease the chance of an unnecessary Caesarean since the

likelihood that one will be needed is generally less with midwives than with obstetricians.

With obstetricians more inclined to perform a Caesarean, some women worry about losing

control of their delivery.

Chapman, a neonatal nurse in Buffalo, received a Caesarean for her first birth in 2008, but

she found it difficult to recover from what turned out to be a physically and emotionally

wrenching process for her.

"It was very hard on my body," she said. "When I got pregnant again, I wanted the delivery

on my terms. I wanted to do it on my own and feel like a real woman."

Her second baby was larger than average, like her first, and the obstetrician worried that

a normal birth could cause a uterine rupture, particularly with the previous Caesarean.

"When I asked her about doing a vaginal birth, she looked at me as though I was crazy,"

said Chapman.

She sought out a midwife anyway — Clutterbuck's group — and liked that her

desire for a vaginal birth was treated with encouragement rather than skepticism.

The baby was born naturally June 13, a bit overdue but in good health. Mom was thrilled

with the way it went.

"The doctor was doing what she thought was best," Chapman said. "But the midwives made me

believe I could do it instead of leaving me with the feeling that I would have to fight for

it."