In a society where freedom of choice is considered of utmost importance, it stands to reason that people would desire options in even the most important of circumstances – like having a baby.
While most people choose to bring children into the world in the systematic environment of a hospital facility, some prefer to do so in the familiar confines of their homes. The most integral aspect of making that possible is a person called a midwife.
In Missouri, two types of midwives can legally conduct business: Certified Nurse Midwife (CNM) and Certified Professional Midwife (CPM).
CNMs must follow regulations set forth by the state board of nursing, and are required to have formal degrees, be licensed by the state as a registered nurse, and have a collaborative practice agreement with a qualified physician. CPMs must also meet certain requirements, but are not regulated by the state nursing board, and don’t need a degree or a collaborating physician.
Expecting mothers in Houston and the surrounding area have one CNM at their disposal: Bucyrus resident Terina Knarr.
“Everybody wants choices,” Knarr said. “We want choices on how to school our children, in health care and in everything else. We don’t necessarily want every aspect of our lives dictated to us.”
In her four years as a midwife. Knarr figures she has “caught” about 250 babies.
“We don’t deliver babies,” she said. “Moms deliver babies and midwives catch babies. The moms do all the work, and we’re ensuring that they’re safe. At any point that it’s no longer safe, we need to make sure we’re getting the mom to the safest place to do a delivery.
“We’re not out there acting like cowboys. I think sometimes there’s a misconception that we’re doing something dangerous, but we’re not. We make sure we’re providing the safest care possible for a mom.”
Prior to venturing into the midwife field, Knarr accumulated many years of nursing experience in conventional situations, including stints with the Army at Fort Leonard Wood and at Texas County Memorial Hospital. She is still a general practice nurse in the army reserve and calls her business Safe Journey’s Midwifery.
CNM regulations include having to practice within a certain radius of a collaborating physician’s office. Knarr’s collaborating doctor is Nancy Hayes of Mountain Grove.
Having a relationship with Hayes gives Knarr consistent access to assistance or advice.
“If I have an issue, I can pick up the phone and she can give me further guidance, or suggest that a patient be transferred to a hospital,” Knarr said. “I’m required by law to have that, but it’s a good thing. CPMs don’t have to, but they don’t have as broad a scope of practice as I have. I can write prescriptions, order and do ultrasounds and order lab work.”
“I’ve known Terina for years, from back when she was employed at TCMH labor and delivery,” Hayes said. “I respect her the most for continuing her education –– not being satisfied with the status quo. When she asked if I was willing to be her collaborating physician, I had no qualms at all.
“As a midwife, she has excellent skills but also doesn’t let her ego get in the way of a patient’s safety. Honestly, most of the time when she calls with a question, my answer is that she’s on the right track and just needs to hold the course. She has helped a great deal with my own pet project of trying to improve healthcare to the disenfranchised and uninsured: mostly Amish from the Seymour area.”
Knarr said there are a few CPMs working in and around Texas County, and she’s happy to help them out whenever the need arises.
“Sometimes a CPM might come to point where they’re wondering about something, and they’ll call me and ask me what I think,” she said. “I might then ask them to come see me, or I might go see them and we go from there. Then if it gets out of my scope of practice, I might send them to see a physician. It’s a nice chain that results in better care for the patients.
“And I must say I’ve met some wonderful CPMs and even learned a lot from some of them.”
Knarr even gained an interest in becoming a midwife while being assisted by a CNM.
“I was working in labor and delivery with my own midwife, and I told her, ‘I want to do what you’re doing,’” she said. “She said, ‘OK, let’s get you started.’”
Knarr went to midwife school and several years later made the career move. Despite all the positive aspects she sees in midwifery, she said it’s not for everyone.
“We see well, healthy women,” Knarr said. “We don’t take care of women with diabetes or high blood pressure and those complicated pregnancies. Someone who isn’t healthy shouldn’t be at home –– that’s what hospitals are for.”
Many of the deliveries Knarr tends to take place in small swimming pools set up in clients’ homes.
“Water is wonderful, because it relaxes them,” she said. “I call them ‘aquadurals’ instead of epidurals. Moms get in there and they just kind of relax and melt into the water. That facilitates the birth a lot better.”
A lifelong Texas County resident, Knarr has worked on several occasions with the Amish community near Seymour.
“I’ve caught several babies by lamp light,” she said. “I’ve done a lot of bartering, too. Sometimes I’ve even been paid in chickens.
“I think sometimes in medicine we get too caught up in the money. To me, it’s not about the money, and if it was, I wouldn’t be in home birth. It’s truly about what I can do to help people and give them the best care I can.”
When she goes to work, so to speak, Knarr brings along a paid assistant.
“I want an extra set of calm hands to rely on in case something happens,” she said. “I don’t want to depend on a dad or a grandma. We know things can be unpredictable and things can happen, no matter how good you are. Things sometimes happen in a hospital, too.”
Knarr, who offers free initial consultation, said people choose home birth for a variety of reasons.
“Some don’t have insurance or don’t qualify for Medicaid,” she said, “but I have people who are insured and say they really don’t want to go to a hospital. When I ask them why, a lot of them say they just don’t want to be part of the system I call ‘cookie cutter medicine.’ They say they want to feel like they’re someone and not just get pushed through the system.
“But it’s important for them to trust me and me to trust them. Then if a time comes when I say they need to go to a hospital, they say, ‘OK,’ with no hesitation. It’s more than me coming in and catching a baby –– I get to know my patients and I make friends. I know the kids, the husband, the dog and the cat, and I know where the bathroom is.”
One local woman who had a home birth using Knarr as a midwife is Licking resident Brandy McCloy, who delivered her son Knox McCloy during a snowstorm on Feb. 10, 2011. Knox was McCloy’s third child, but her first born at home.
“I personally don’t ever like to be in a hospital,” she said. “I have a beauty salon and someone came in with a baby she had delivered at home. I thought it was the coolest thing; I was very intrigued and asked her tons of questions, and decided I wanted to do it.”
McCloy’s decision suited her well.
“It was wonderful,” she said. “We didn’t have all the rules, policies and procedures. I was at home and I could do whatever I wanted to do. I could take a bath, shower, lie down, stand up, throw in some laundry –– anything.”
McCloy considered the experience more enjoyable than the birth of her other children.
“It was more relaxing, and I think that being relaxed and not stressed helps everyone involved,” she said. “And my husband, Ben, thought I recovered much faster and that I had lot more energy. He thought life went back to normal quicker than it did with the first two.”
A major factor in McCloy’s decision to birth the now two-year-old Knox at home was that doctors had informed her after her second delivery that her next baby would have to be induced.
“They said there was a good chance I wouldn’t make it to the hospital because I barely made it there with the second one,” she said. “I definitely didn’t want to induce labor because I like to do things as naturally as possible.
“I’m not against medicine or anything like that –– we take medicine and do vaccines and everything. I just like things, if possible, to progress naturally.”
McCloy said the perception is inaccurate that midwifery is a primitive medical procedure haphazardly performed by ill-equipped people.
“I think a lot of people think you just invited some friends over and popped out a baby,” she said. “But we had a nurse practitioner midwife, a registered nurse and an LPN. It’s not like we were without skilled professionals.
“And Terina is great. She does lots of prenatal care, she’s very personable and really cares about her clients.”
While Knarr does no direct billing to insurance companies, she said clients can be compensated for midwife services through post-birth reimbursement. She said she hopes government agencies someday take greater advantage of midwifery’s significant financial benefits.
“The cost of what we do is so low, we could save taxpayers lots and lots of money,” Knarr said. “For low-risk women, the outcome for babies is just as good in home birth as in a hospital setting. I just can’t fathom how people have not jumped on this bandwagon.
“Even the World Health Organization says we should be using more midwives. We have more doctors than midwives in this country, but in other countries they have more midwives than doctors. I think we need to fix that and shift the focus of care.”
Knarr said she wanted to make it clear that midwives understand the value of doctors.
“Midwives have never said they don’t need doctors –– there’s always an appropriate time and place for physicians and hospitals,” she said. “It’s important for people to recognize that, but to also recognize that midwives offer a great service. We’re clean, we’re thorough and we’re good for women, babies and families.”
Sometimes duty calls on Knarr when she would otherwise be spending time with her own family (she “caught” four babies in a six-day period during the holiday season last year). But the rewarding nature of what she does makes it all worthwhile.
“It can be very stressful, but it’s exhilarating,” Knarr said. “It’s absolutely amazing, and it’s like the first time every time. But how can you not be amazed when there’s this little person every time?”
Knarr said she doesn’t take lightly the fact that people ask her to be present during one of the most memorable moments of their lives.
“In a hospital, it’s an on-call system, and you might happen to be on call,” Knarr said. “In midwifery, I get invited to a birth, and that’s amazing. They ask me attend their labor and the birth of their child, and that’s a very intimate, special thing.”
Terina Knarr, Safe Journey’s Midwifery: phone, 417-967-5424; web address, www.safejourneysmidwifery.com.
Missouri Midwives Association web address:
http://www.missourimidwivesassociation.org/cpm.html
Citizens for Midwifery web address:
http://cfmidwifery.org/states/states.aspx?ST=MO
We’re not out there acting like cowboys. I think sometimes there’s a misconception that we’re doing something dangerous, but we’re not. We make sure we’re providing the safest care possible for a mom.”