I spoke at a conference in Omaha, Nebraska recently because I want to stand in solidarity with the persevering Nebraskans who have fought valiantly and vigilantly to protect the rights of birthing families for over 30 years.
Nebraska is one of just two states to deny Certified Nurse Midwives, or CNMs, the right to attend homebirth; the other is Alabama. The national certifying body for CNMs, the American College of Nurse Midwives (ACNM), does not support this restriction. Instead ACNM says that,
“CNMs…are qualified to provide antepartum, intrapartum, postpartum and newborn care in the home.”
Every woman has a right to an informed choice regarding place of birth and access to safe home birth services.
WRITTEN PRACTICE AGREEMENT
Despite the fact that the International Confederation of Midwives recognizes midwifery as an autonomous profession, Nebraska and most other US states require that CNMs have a written practice agreement with a physician. A written practice agreement is a signed document that outlines the physician-midwife relationship as it applies to the care of the midwife’s client. It can either be supervisory or collaborative.
The main issue with written practice agreements is whether or not their specific legal requirements for physician involvement limit the services CNMs can provide and areas where they can practice thereby making it more difficult for consumers to access a full range of birthing choices.
A physician might refuse or hesitate to sign a written practice agreement with a midwife—and thus control or limit her ability to practice—for a variety of reasons unrelated to the quality of care that the midwife provides. In Nebraska, for examples, some physicians charge as much as $20,000 a year to sign a written practice agreement.
In some towns, especially rural communities, there are often simply not enough physicians to sign written practice agreements with midwives. And, ultimately, written practice agreements are untenable because they require a physician, who competes with a midwife for clients, to be her supervisor, thereby providing opportunities for restraint of trade.
While most states do have written practice agreements, the trend is to do away with them for all advanced practice nurses, including CNMs. A 2015 RAND study commissioned by the Ohio Association of Advanced Practice Nurses found that
granting Advanced Practice Nurses full practice authority would likely increase access to healthcare services for Ohioans, with possible increases in quality and no clear increase in costs.”
Currently bills are underway to expand the scope of practice for CNMs in Oregon, Kansas, Illinois, Michigan, and Florida.
DIRECT ENTRY MIDWIVES
In the US, in addition to Certified Nurse Midwives or CNMs, we also have direct entry midwives. CNMs have bachelor’s degrees in nursing and an advanced degree in midwifery, so they enter midwifery by first going to nursing school. Direct entry midwives—who may also have undergraduate or graduate degrees—enter the profession directly either by attending a direct entry midwifery school or by apprenticing with an existing midwife and learning through self-study.
Some states license direct entry midwives and designate them Licensed Midwives (LMs); others register them and designate them as Registered Midwives (RMs). In addition, many are nationally certified by the North American Registry of Midwives (NARM), which designates midwives are Certified Professional Midwife (CPMs). According to the Midwives Alliance of North America (MANA), CPMs are legal in 28 states; 13 states have pending CPM legislation and 9 more are planning legislation or advocacy efforts.
While CPMs practice exclusively at home, CNMs practice mostly in hospital. In 2012, 94.9% of CNM attended births nationwide took place in the hospital; 2.6% occurred in free-standing birth centers and 2.5% at home.
NEBRASKA AND OTHER STATES
In Nebraska, CPMs are not licensed and efforts to regulate homebirth in the state have repeatedly failed. Understandably, midwives and consumers in the state are themselves divided about advocating for direct entry midwives or CPMs when CNMs have been able to win so few rights.
As in Nebraska, birth rights have also been suppressed in Kentucky. In Nebraska there is just one birth center and no legal options for birth outside of the hospital. In Kentucky there are no birth centers and only a handful of midwives who are legally permitted to attend births outside of the hospital.
Under Kentucky law, new health care facilities must prove that there is an unmet need for their services to secure a Certificate of Need (CON) from the state. Just last week, Franklin County Circuit Judge, J. Phillip Sheppard, reversed an earlier denial of a Certificate of Need for the Visitation Birth and Family Wellness Birth Center. The original denial was based on opposition from three local hospitals that currently hold the monopoly on birth related services.
In his ruling, Judge Sheppard’s said:
“Here, the question is whether health care providers who do not operate an ‘alternative birthing center’ have standing to protest an applicant for approval to operate such a facility. While the [hospitals] provide prenatal and birthing care, this Court holds that traditional health care providers, by definition, are separate and distinct from ‘alternative birthing centers.’ The long line of cases that holds that state licensees have no right to be free from competition applies here. The CON statute… allows competitors to protest only when they are ‘affected parties.” “…These protestors do [not] operate, nor even propose to operate, another ‘alternative birthing center.’ Rather, they simply argue that all women would be better served by limiting themselves to the options currently provided.”
In stark contrast to Nebraska and Kentucky, stands New Mexico, a model midwifery state where CNMs attend one third of all births. In addition, direct entry midwives became licensed to practice in New Mexico in 1975 and currently attend 1.3% of live births in the state. This rate has remained steady for roughly 10 years. New Mexico currently licenses 74 direct entry midwives, approximately half of whom are in active practice. In Santa Fe and Taos, the homebirth rate is 10%.
THE NATIONAL CLIMATE
Most people would say that modern midwifery in the US began in 1925 when Mary Breckenridge founded the Frontier Nursing Service in eastern Kentucky. From 1925 to 1951, the Frontier Nursing Service achieved a maternal mortality that was nearly four times less than the national rate.
In 1932 the Metropolitan Life Insurance Company of New York issued a report in which it estimated that if services like the Frontier Nursing Service were adopted nationwide, the perinatal mortalities of the time would be reduced by 60,000 a year. Since 1971, the maternal mortality rate of the Frontier Nursing Service has averaged better than the rest of the country and better than Sweden.
The Maternity Center Association, founded in 1918, opened the Lobenstine Midwifery Clinic in 1931 to care for immigrant families in upper Manhattan tenements. From 1932 to 1958 its graduates attended over 7,000 births, most of them in the mother’s home. The maternal death rate for NYC during this period was 0.9, more than 10 times better than the national average of 10.4. If you’ve seen the BBC show, Call the Midwife, you will have a picture of this clinic and these midwives.
In 1962 a pilot project in Madera, California using nurse midwives reduced prematurity by almost half and neonatal mortality by more than half.
In 1971 in Holmes County, Mississippi, infant mortality dropped from 38 deaths per 1,000 to 20 per 1,000 two years after CNMs starting offering primary care.
In 1979, 88% of women from NY’s most distressed areas, working with CNMs at the North Central Bronx Hospital, experienced normal, spontaneous deliveries and the neonatal death rate at North Central was less than it is today.
Despite the overwhelmingly good results of midwifery care, the licensure of midwives was opposed and midwifery care relegated to the immigrant communities and low-income populations. However, something changed in the US in the1970s when midwifery care—which have long been available to women of all classes in other countries—actively began to be sought out by economically affluent women. By 2009, the profile of CNM births mirrored the national distribution in race and ethnicity.
However there were then and continue to be many barriers to greater utilization of midwives. As early as 1980, the Government Accounting Office issued a report entitled, “Better Management and More Resources needed to Strengthen Federal Efforts to Improve Pregnancy Outcome.” In the report they identified six barriers to greater utilization of midwives:
- A limited supply.
- Few training programs
- Physician resistance
- Lack of availability of obstetricians with which to work
- Reluctance of some nurse-midwives to work in rural or other undesirable areas.
- Restrictive state licensing or third party reimbursement practices.
At that time, 2,200 midwives were certified by ACNM. Most worked for hospitals or physicians, but about 200 worked in birth centers nationwide. 1989 was the first year that CNM statistics were made available and since then, the percentage of CNM-attended births has risen nearly every year.
As of 2012, CNMs attended 313,846 US births, according to the National Center for Health Statistics. This represents 11.8% of vaginal births, or 7.9% of total US births. In 2012, CNMs attended 91.7% of midwife-attended births and 30.4% of out-of-hospital births, up from 28.6% in 2005.
INCREASE IN HOMEBIRTH
In 1900, almost all US births occurred outside a hospital; however the proportion of out-of-hospital births fell to 44% by 1940 and to 1% by 1969, where it remained through the 1980s. After a gradual decline between 1990 and 2004, the percentage of out-of-hospital births began a steady increase from 0.87% of U.S. births in 2004 to 1.36% of U.S. births in 2012, its highest level since 1975.
In 2012, over 4 million babies were born. Of these births, 53,635 took place out of a hospital. Of these out of hospital births, 35,184 occurred at home and 15,577 occurred at a birthing center. Most out-of-hospital births—two-thirds—occurred at home. Twenty-nine percent occurred in a freestanding birthing center. And, the remaining 5% occurred in a clinic, doctor’s office or other location.
About 89% of the total increase in out-of-hospital births from 2004–2012 was due to the increase among non-Hispanic white women. The increase was much smaller for women of color.
In six states, more than 3% of births occurred outside a hospital in 2012:
- Alaska (6.0%)
- Montana (3.9%)
- Oregon (3.8%)
- Washington (3.4%)
- Idaho (3.4%)
- Pennsylvania (3.1%).
In five states, 2% to 3% of births occurred outside a hospital:
In contrast, the percentage of out-of-hospital births was less than 1% for southeastern states from Louisiana to Georgia, as well as for Nebraska, South Dakota, North Dakota, Oklahoma and others.
WHY I TALK ABOUT HOMEBIRTH
Before I proceed, I want to make it clear why I talk about homebirth. I talk about homebirth for two reasons. First, the recent visibility and growth of homebirth have highlighted the work of midwives in all settings. And, secondly, I don’t think we can believe that birth is normal if we don’t believe that homebirth is safe. Overwhelming evidence supports the fact that birth is safe In any setting so it is important and just that we talk about all birth settings equally: home, hospital, and birthing center.
But why has there been all the brouhaha about homebirth recently? One reason has been the visibility of the many celebrities choosing homebirth, often for privacy reasons. Ricki Lake’s 2008 film, The Business of Being Born, had a huge impact on birthing women because it showed homebirth as normal, and diverse and really beautiful. And, it showed midwives as hip and modern and competent. Plus the fact that the film ended with a transport to the hospital made it real.
Alongside the celebrity glow that homebirth and midwives have enjoyed in recent years, are women’s legitimate fears of surgical birth. They know that their odds for normal birth are poor if they give birth in the hospital where cesarean rates average 32.7%. But, this is just the average. In some hospitals, like The Jennie M Melham Memorial Medical Center in Broken Bow, Nebraska, the cesarean rate is 42.9% while at other hospitals, like Box Butte General Hospital in Alliance, Nebraska, the cesarean rate is 10.3%. You can find the cesarean rate in your local hospital at cesareanrates.com
It’s a crapshoot out there for women and their births. We write birth plans and know what we want, but the odds can be stacked against us in ways we don’t even know and few appreciate how unequal maternity care can be depending on where you live and how much money you have.
RISE IN CESAREANS
The national cesarean rate has risen steadily since 1996 when the American College of Obstetricians and Gynecologists changed the Vaginal Birth After Cesarean (or VBAC) guidelines. (see chart below from the US National Center for Health Statistics). Cesarean section is the most common operation performed today in US hospitals. Overuse of this procedure is associated with excess death among women and babies. For both commercial and Medicaid payers, total maternal-newborn costs are at least 50% higher for cesareans than for vaginal births.
The increase in cesareans has been driven primarily by the declining rate of VBACs, which is now less than 10%. The World Health Organization says it should be 75%
A cesarean rate of 5% to 10% is optimal; in 1965 it was 4.5%. In a recent study of birth centers, it was found that the cesarean rate in birth centers is 6%. The cesarean rate for CNMs is 6.1%. And, a landmark study in 2014 showed a cesarean rate of 5.2% among women who plan a homebirth.
No wonder women are choosing birth outside of the hospital. They have good sense. They know that, when the cesarean rate is three times what evidence suggests it should be, that they are literally being experimented on.
ATTACK ON HOMEBIRTH
The growth in homebirth in recent years has not happened without resistance. In their 2011 position statement on homebirth, The American College of Obstetricians and Gynecologists (ACOG) says:
Planned Home Birth
Number 476, February 2011
ABSTRACT: Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”
So basically, ACOG says, “You silly little mothers. We know that homebirth is not safe and that your baby will die, but go ahead. You get to choose.” How terribly patronizing. I have no doubt that if two to three times as many babies died at home than at the hospital, that we mothers would have known this and told each other long ago. We are not stupid.
ACOG’s outrageous claim of two to three more deaths at homebirths is based on a controversial study published in the American Journal of Obstetrics and Gynecology in September 2010. The study reported significantly more neonatal mortality in out of hospital births than in hospital births. For this epidemiological study, the researchers looked at the birth and death data from the CDC between 2006 and 2009. They compared neonatal mortality for singleton babies
delivered by midwives and physicians in hospital with births delivered by midwives and ‘others’ out of hospital.
This study links raw CDC birth and death data. It has been widely criticized for failing to differentiate between high-risk and low-risk women or between planned and unplanned homebirths. [Historically, attempts to discredit homebirth have been made by using studies that combine unplanned with planned homebirths.] Midwives in the study have the same neonatal mortality rate as taxi cab drivers.
Many, more rigorous studies contradict the findings of this one study. Nonetheless, the British medical journal, the Lancet, supported the ACOG study in an editorial entitled “Home birth —proceed with caution.”
In response, the American College of Nurse Midwives issued a statement,
“It’s surprising that this study is getting traction, when virtually every other organization that has looked at it has pointed to flaws in the methodology of the study.
There are several concerns.
They included studies that did not distinguish between planned and unplanned home births. For example, if you had planned a hospital birth, but your labor progressed so quickly that you gave birth before you even made it to the hospital, then you wouldn’t have had a skilled attendant or necessary resources present.
In contrast, a planned home birth means that the woman and her health care provider have determined she is healthy, at low risk for complications, and has the necessary resources in place for a safe birth. By combining the two types of home births, the findings are limited.
Second, a meta-analysis is a way of combining the results of many studies. But in this case, there seems to be no clear reason as to which studies they included versus those they excluded. In fact, they actually did not include the best and by far the largest study that’s been done.
The “best and by far the largest” study ACNM refers to is “Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births,” published in April of 2009 in BJOG, an International Journal of Obstetrics and Gynaecology. This is a nationwide cohort study of birthing women in the Netherlands. It’s conclusion:
This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
In 2008, a meta-analysis of six controlled observational studies showed that for low-risk women there is no significant difference in perinatal mortality between planned homebirth and planned hospital birth.
And, a January 2014 study in The Journal of Midwifery and Women’s Health of 16,924 women who planned homebirths with midwives shows low Apgar scores in just 1.5% of the births and early neonatal mortality of 0.41 per 1000. [US average 6.7 per 1000]. The study concludes:
Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.
Finally, a summary of research on midwifery practice in the United States, available on the ACNM website, lists several advantages of midwifery care that are supported by research and scientific evidence:
- Lower rates of cesarean birth
- Lower infant mortality
- Lower rates of labor induction and augmentation
- Lower than national rate for episiotomy (3.6% compared to 25%)
- Significant reduction in the incidence of third and fourth degree perinatal tears.
- Lower use of regional anesthesia
- Higher rates of breastfeeding
- Clients have better prenatal knowledge
- Clients have high readiness for labor and birth
- Higher rates of satisfaction with care
- Increased access to care
Despite the overwhelming evidence of both the safety, efficacy, and economy of midwifery care, its growth in the US is still impeded by prejudice and professional jealousy. But, internationally it’s a different story all together.
On a global scale, a lack of midwives is a healthcare emergency. According to the World Health Organization (WHO), UNICEF and other groups, maternal mortality is the “highest health inequity in the world.”
The United Nations 2014 report, The State of the World’s Midwifery, focuses on the urgent need to improve the availability, accessibility, acceptability and quality of midwifery services. Despite a steady drop in maternal and newborn deaths since 1990, hundreds of thousands of women and newborns continue to die each year during pregnancy and childbirth: An estimated 289,000 women and about 3 million newborn babies died in 2013 alone. The vast majority lost their lives due to complications and illnesses that could have been prevented with proper antenatal care and the presence of a skilled midwife during delivery.
In November 2013, a Cochrane Summary from the well respected Cochrane Collaboration, stated that, “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.”
In mid-2014, the British Medical Journal, Lancet, issued an historic Series on Midwifery. The Series is comprised of four separate papers that have been developed collaboratively by a multidisciplinary group, including academics, researchers, advocates for women and children, clinicians, and policy-makers. Together, the papers address key issues on the contribution of midwifery, and challenge much of the current thinking and attitudes among health professionals, decision-makers, and the public. Key findings include:
- These findings support a system-level shift, from maternal and newborn care focused on identification and treatment of pathology, to a system of skilled care for all, with multidisciplinary teamwork and integration across hospital and community settings. Midwifery is pivotal to this approach.
- Since 1990, the 21 countries most successful in reducing maternal mortality rates—by at least 2·5% a year—have had substantial increases in facility-birthing, and many have done this by deploying midwives.
- Investment in midwives, their work environment, education, regulation, and management can improve the quality of care in all countries.
In December of 2014, the UK’s National Institute for Health and Care Excellence (NICE) issued new guidelines for the care of healthy women and their babies during childbirth. After reviewing the evidence, NICE recommended that low risk pregnant women—the vast majority of the over 700,000 women who give birth in the UK—give birth at home or with a midwife-led unit, rather than a hospital. Here are some of the specific recommendations for British birth practitioners:
- Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth.
- Advise low‑risk multiparous women that planning to give birth at home or in a midwifery‑led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.
- Planning birth at home or in a freestanding midwifery unit is associated with a higher rate of spontaneous vaginal birth than planning birth in an alongside midwifery unit, and these 3 settings are associated with higher rates of spontaneous vaginal birth than planning birth in an obstetric unit.
- Planning birth in an obstetric unit is associated with a higher rate of interventions, such as instrumental vaginal birth, caesarean section and episiotomy, compared with planning birth in other settings.
- There are no differences in outcomes for the baby associated with planning birth in any setting.
It’s particularly significant that these recommendations were made in the UK as the UK ranks number one in the world in quality and efficiency of health care. Health expenditures per capita in the UK in 2011 were $3405. By contrast, the US, which ranks 11th in the world spends more than twice as much per capita, $8508.
Homebirth and midwifery care are increasingly viewed through the lens of reproductive justice. According to Leandra Carasco in “Seeking Reproductive Justice: Written Practice Agreements and [the Lack of] Home Birth Choice.”
Born in the 1990s, Reproductive Justice is a framework for looking at the intersection of all factors affecting a person’s ability to determine her or his own reproductive identity and future. It focuses equally on the right to have a child, the right to not have a child, and the right to parent in the way one chooses (including how to birth). The framework also looks at the factors that facilitate these rights, like a living wage, accessible education, and public services.
According to Sister Song,
Reproductive Justice addresses the social reality of inequality, specifically, the inequality of opportunities that we have to control our reproductive destiny.
Amnesty International sheds a light on this inequality with “Deadly Delivery,” their 2010 report on the US maternity system:
The total amount spent on health care in the USA is greater than in any other country in the world. Hospitalization related to pregnancy and childbirth costs some US$86 billion a year; the highest hospitalization costs of any area of medicine. Despite this, women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries.
For example, the likelihood of a woman dying in childbirth in the USA is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain. More than two women die every day in the USA from pregnancy-related causes. More than a third of all women who give birth in the USA – 1.7 million women each year – experience some type of complication that has an adverse effect on their health.
African-American women are at especially high risk; they are nearly four times more likely to die of pregnancy-related complications than white women. Even for white women in the USA, however, the maternal mortality ratios are higher than for women in 24 other industrialized countries. These rates and disparities have not improved in more than 20 years.
When US women lack access to midwifery care, to care that they prefer, to care that has lower rates of interventions, their reproductive rights are violated. When women are subject to care that is not based on evidence, their human rights are violated.
HOW SOCIAL CHANGE HAPPENS
But, how does social change happen anyway? How long will it take until midwives are freely practicing in Nebraska? In the US?
When we are new to a burning issue, we believe that people just have to be informed in order for change to happen. As a new breastfeeding advocate in the 70s I thought that it was just a matter of getting the word out. Now I know that health policy has as much to do with prejudice and politics as it does with evidence and justice. Even when the evidence is overwhelming, people can refuse to believe.
In addition, social change just takes time. In his book, Soul of a Citizen, Paul Loeb says that the movement from lynching to jails, the movement for public education, and the movement for civil rights each took 100 years. At first something is ignored; then it’s ridiculed; and finally, it’s attacked. Attack is a good sign.
My generation thought we had taken care of things when we brought down the cesarean rate down in the 80s and 90s by coining the term VBAC and advocating for it to increase. But, we were wrong. We saw the cesarean rate go up again, way up, as the VBAC rate went down. The truth is that we have to be ever vigilant about our rights and each generation has to re-win those rights. It’s never done. Freedom is a constant struggle.
RESTRAINT OF TRADE
One of the most relentless obstacles to universal midwifery licensure and availability is a Catch 22: it is doctors, specifically obstetricians, who decide the fate of midwives. According to the American Law Review,
If an obstetrician denies hospital privileges to a nurse-midwife, the obstetrician has, in effect, eliminated a potential competitor. An obstetrician’s exclusion of potential competitors would be anticompetitive and, therefore, might be actionable under antitrust law. Health care providers increasingly are initiating antitrust actions in order to obtain hospital privileges. Nurse-midwives, as allied health professionals, also are following this trend in an effort to compete more effectively in the health care system.
In 1980 the House of Representatives Subcommittee on Oversight and Investigations of the Committee on Interstate and Foreign Commerce held a hearing on “Nurse-Midwifery: Consumer’s Freedom of Choice” in which CNM, Sally Tom testified that:
..fear of economic competition underlies much of the resistance to nurse-midwifery practice.
She went on to say:
…licensure, direct third-party reimbursement, homebirth services, and out of hospital birth centers all raise the question of whether nurse midwives are or should be ‘Independent practitioners.’ But, what does this mean? Midwives practice in collaboration with physicians and other midwives. ACNM and state laws require this. Midwives always practice in a formal collaborative relationship with a physician. What has changed is that they no longer work for the doctors, but may have economically independent practices.
After the congressional hearing, ACNM established an AD Hoc Committee to study the relationships between nurse midwives and physicians as something urgent and requiring immediate attention. Looking back on years of advocacy, Barbara Goddard said,
We either believe in ourselves and our viability or we are lost. We are still trying to get medicine to like and understand us. We should work harder at just being ourselves, autonomous and accessible to the public.” In her opinion, nurse-midwives had wasted time and energy bending over backward to accommodate and explain their philosophy to physicians. “Now is the time to end our conciliatory behavior. Being friendly and agreeable has not substantially changed our professional ability to practice over the past twenty years.
Goddard’s comment echoes the 1984 words of psychiatrist RD Laing,
We do not see childbirth in obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse. And, birth as a home and family event, has virtually been cultured out. Women are allowed or not to have their babies at home. In hospital, they are allowed or not to move, scream, sing, stand, walk, sit or squat. Women are allowed or not to have their babies after birth…To allow is to exercise as much, if not more power, than to forbid. Why should any one way have to be imposed on all? Why cannot two or more ways coexist in the same society? Why should there be any monopoly on what is available?
Peggy O’Mara is the editor and publisher of peggyomara.com. She was the editor and publisher of Mothering magazine from 1980 to 2011 and the editor-in-chief of Mothering.com from 1995 to 2012.. The author of Having a Baby Naturally; Natural Family Living; The Way Back Home; and A Quiet Place, Peggy has conducted workshops at Omega Institute, Esalen, La Leche League, and Bioneers. She is the mother of four and grandmother of three.