As she labored to deliver her eighth child, Tamar Van Wingerden squatted on an exercise ball in her living room, stood in her shower until the hot water ran out and then - for the final push - climbed into her own bed.
A week overdue, Eva Brielle Van Wingerden was born Oct. 28 in the master bedroom of her family's 100-year-old farmhouse west of Billings.
Pat Schwaiger, a midwife licensed by the state of Montana, coached Van Wingerden and her husband, Abe, through the delivery. Schwaiger also delivered the couple's 16-month-old daughter, Ashlynn, at home.
"A doctor really just comes in to catch the baby," said Van Wingerden, whose own mother delivered her at home in the Netherlands. "Midwives do all the special little tricks, like hot washcloths and olive oil."
About 8 percent of babies born in Montana, or just more than 1,000 births in 2004, are delivered by licensed midwives, according to the American College of Nurse Midwives.
It isn't known how many of the deliveries are home births. In Montana, midwives can deliver babies in a hospital or at home.
Nationwide, fewer than 2 percent of births attended by certified midwives occur at home, according to ACNM.
But in Montana and across the nation, the number of babies delivered by midwives is on the rise.
From 1990 to 2004, midwife-attended births in Montana increased by almost 7 percent, ACNM statistics show.
Nationally, fewer than 1 percent of births took place with a midwife in 1975. Three decades later, in 2005, slightly more than 7 percent of all births were attended by a midwife.
"This generation having children seems to be reclaiming it," said Schwaiger, whose business is Mountain Midwives. "Around the world, home birth and midwives are the standards. When you consider it in a global way, having babies in the hospital in the United States is the stranger course of things."
Schwaiger sees the trend toward home births and midwifery as a sign that Americans are taking charge of one of the most important milestones in their lives.
"There are certain passages in a person's life that you're supposed to go through to be a better person, and birth is one of those passages," she said. "I believe death is one of those passages."
"In our culture, we've given those two important passages away. We've given them to the medical profession," Schwaiger said. "We use machines. We use chemicals. We don't want to deal with it. In doing that, we're robbing ourselves of a cultural experience and an opportunity to experience life."
Still, midwifery is not without controversy, and home births often take the brunt of the criticism.
Citing flaws in studies that compare the safety of hospital births and home births, the American College of Obstetricians and Gynecologists last year issued an official statement against home birth.
"Until such studies are convincing, ACOG strongly opposes home births," the statement reads in part. "Although ACOG acknowledges a woman's right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide home births."
Meanwhile, the American Public Health Association has endorsed home birth as having "as safe an outcome for low-risk mothers and babies as does hospital birth."
APHA bases its position on a study of more than 5,000 women with low-risk pregnancies who set out to deliver at home.
Almost 90 percent of women in the study actually gave birth at home, and the mortality rate among those births matched mortality rates of infants born in hospitals after low-risk pregnancies.
Women in the study who didn't end up having home births went to hospitals because of complications that arose before or during labor. Most midwives, including Schwaiger, make it clear to clients that they will be taken to a hospital if something goes wrong during delivery.
Regulation of home birth and midwifery varies across states, with some outlawing home deliveries altogether and others taking no stance on the practice. Licensing rules also differ around the country.
In Montana, 68 people hold midwifery licenses. Most - 47 - are nurse midwives who have a minimum of a master's degree in nursing with a focus on midwifery.
The rest are direct-entry midwives, who must take pregnancy and childbirth classes that have been sanctioned by the state and then must pass a licensing exam.
Midwives differ from medical doctors in that they view pregnancy and childbirth as a journey to be traveled rather than a problem to be fixed, said Pam Rox, a nurse midwife who delivers babies at St. Vincent Healthcare.
"Sometimes in our mechanized society, (the attitude is) just get the baby out, and we neglect the process," Rox said.
Midwives tend to spend more time with pregnant women during prenatal visits, and they stay at a woman's side throughout labor and delivery, Rox said.
"The basic philosophy of midwifery is to help women feel confident with wherever they're coming from," she said. "It enhances their life if they have a baby and feel like they did a good job."
For Jenny and James Robinson, using a midwife meant having more say in how their daughter was born. Rox delivered Elaina Jeanne Robinson, the Billings couple's fourth child, at St. Vincent on Sept. 18.
"You have a lot more choices," Jenny Robinson said. "They're really open about how you experience the birth of your child."
Robinson said she had more control over who was in the room during the delivery and over some such decisions as when she took medication or got up and walked around.
The Robinsons went to an obstetrician for their second baby because they didn't realize people with health insurance could go to the Elizabeth Seton Prenatal Clinic, where Rox practices. Most Elizabeth Seton clients do not have insurance.
"With a regular doctor, it was a lot more like, 'Let's get this person through here,' " James Robinson said. "It's understandable. It's what they go to school for, the way they're trained. It's not wrong. It's just different."
Many health insurance plans cover the cost of having a baby in the hospital with a midwife, and some also cover home births.
At St. Vincent Healthcare, patients are billed between $4,500 and $7,000 for a normal delivery. Mountain Midwives charges $3,000 for its prenatal and delivery services.
All eight Van Wingerden children were born with midwives, although only the youngest two were born at home. The couple's 4-year-old twins were born in a hospital, and the older children were delivered in birth centers in another state.
Tamar Van Wingerden was nervous before her first home birth, but she said the comfort and freedom it allowed her far surpassed the experience she had in the hospital, where doctors overruled her on some medical decisions.
"Sometimes we go into birth blindly, trusting a doctor explicitly," Van Wingerden said. "Sometimes they make blanket rules for everyone."
"I believe God created us to give birth," she said. "A woman's body is made to give birth."
Contact Diane Cochran at firstname.lastname@example.org or 657-1287.