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Midwifery in the U.S.
May 03, 2011
by Geradine Simkins
President, and Interim Executive Director, Midwives Alliance of North America (MANA)
This article is excerpted with permission of editor, Geradine Simkins, from "Into These Hands: Wisdom from Midwives." Published by Spirituality & Health Books, April 2011.
Every new member of the human family arrives on Earth through the body of a woman. Each day on our planet, the majority of babies emerge from the waters of their mother’s womb into the hands of a midwife. Since the dawn of time, midwives have been receiving the generations into their hands. Almost without exception, midwives exist in every culture, in every country.
Midwifery may well be the oldest healing profession known to humans. The word “midwife,” derived from old English, means “with woman.” In French the word for midwife, sage femme, means “wise woman.” The Danish word for midwife, jordmoder, means “earth mother” and the Icelandic word, ljosmodir, means “mother of light.” In most cultures midwives have enjoyed a place of honor, respected for their remarkable skills, wisdom and prowess as healers. (1) Yet in the United States midwives are as endangered as the spotted owl or the gray wolf. And like these animals, midwives face significant threats to their way of life.
The United States is one of the few countries in the modern world to have ever outlawed midwives. In 1923 there were about 60,000 midwives practicing in the United States. (2) By the 1960s traditional midwives were all but extinct. (3) Slowly midwives have been making a comeback, but it has not been easy. Today there are roughly 8000-10,000 practicing midwives.
Historically birth has been a social event in which, for the most part, only women participated. (5-6) In the early 1900s nearly all births in the United States (over 95%) were attended by midwives in women’s homes. (7) While birth at home remained the norm even when doctors first began attending births, hospital birth soon became a fashionable status symbol for the middle and upper classes. By 1939 half of all American babies were born in hospitals and by 1970 that rate rose to ninety-nine percent. (21-22)
Unlike the development of maternity care in Europe in the 1900s where male obstetrics and female midwifery developed side by side as compliments to one another, (23) in the U.S. childbirth was marked by the rise of obstetrics and the fall of midwifery and turf wars that persist to this day.
A Captive Audience
With over three-quarters of all American women becoming mothers and over 4.3 million births in the United States each year, (28) it is fair to say that maternity care affects large numbers of women and families. More babies were born in the United States in 2007 than ever before—about 15,000 more than the peak year of the Baby Boom. (29)
At least eighty-five percent of all women in the U.S. enter labor at low-risk for problems. Nonetheless, in a recent national survey women reported that they received at least seven to ten obstetrical interventions, (31) whether or not they needed them, or were given full disclosure about them, and regardless of the scientific efficacy of the interventions. Forty-one percent indicated that their caregiver tried to induce their labor, and fifty-five percent were given a synthetic hormone to strengthen or speed up labor contractions. (32) Close to ninety percent of all women received spinal or epidural analgesia and/or narcotics in labor for pain management. (33).
Use of narcotics can adversely affect mothers and their babies while non-drug therapies that are not dangerous are underused or ignored. Ninety-four percent of women were subjected to continuous fetal monitoring (34) in spite of conclusive evidence that indicates it does not improve outcomes in either low-risk or high-risk women and definitely limits a woman’s freedom of movement in labor and birth. And at the same time almost sixty-percent of women who wanted a VBAC (vaginal birth after cesarean) were denied that option. (53)
While the United States has the highest per capita spending on health care in the world, this has not led to optimal outcomes. (37) The U.S. has one of the highest infant mortality rates in the modern world, ranking about thirtieth among developed nations, and the rate is higher for infants of color. (38-39) Although the U.S. maternal mortality rate has improved over the past century, it has not improved at all since 1982 and appears to be increasing. Our maternal mortality rate is as dismal as some developing nations and the rate is higher for women of color. (40-42) The safety, reliability, price and performance of our current maternity care system are issues of grave concern.
The Delivery Business
The common mainstream belief is that the safest place for birthing mothers and infants is in a hospital under the management of an obstetrician. While this perception has persisted since the early 1900s and has become the dominant American viewpoint, it is neither factual nor supported by research. Low-risk women and infants who are under the care of midwives, regardless of the site of birth, have similar outcomes to low-risk women and infants who are under the care of obstetricians in hospitals. (43).
If you were to ask a group of people to identify the most common reason for hospitalization and the most common surgical procedure in the U.S., they would probably think in terms of acute illnesses, serious accidents or chronic diseases. But they would be wrong. The most common reason for hospitalization in the United States is childbirth. (46)
Cesarean section is the most frequently performed surgical procedure in the U.S. reaching an all-time high of 32.8% of all births in 2009 (47) with rates rising annually. Of the most common hospital procedures, six out of fifteen involve childbirth. (48) The use of obstetrical procedures has doubled in the past fifteen years. Annually, one-quarter of all hospital discharges are for mother-baby healthcare related to childbirth. (49)
Let me be clear: the problem is not that we have obstetrical practices available that can be useful in certain necessary or life-saving situations. The problem is that they are broadly applied to a population—pregnant women—that is basically healthy without concern for necessity or efficacy. In a national survey women reported that obstetrical interventions had been imposed on them without appropriate and timely discussions about the risks, benefits and alternatives and in some cases without their consent. (52)
In short, our maternity care system is profit-driven rather than driven by consumer choice or the best research evidence about childbirth practices. In light of this, it is clear why midwives—who espouse a low-tech, high-caring model, and have the evidence to prove that the midwifery model is safe, satisfying, cost-effective and produces optimal outcomes, have become a threat to a system that advocates a costly high-tech biomedical model of childbirth. It is also clear why organized medicine is dedicated to discrediting the merits of the midwifery model, even seeking to eradicate midwives from the menu of choices for women seeking maternity care. (54)
The Model Matters
For women who want an alternative to a highly medicalized model of birth, who believe that birth is a natural physiological process and even a celebratory event, choices are often unavailable. Normal birth that begins, proceeds and concludes as nature designed it is so rare that most maternity care providers have never seen it, most resident doctors have not been trained to accommodate it, and most women have to go outside the hospital to find an experienced care provider if they choose it. Therefore, women who want to have a natural birth often choose their own home or a birth center. Fortunately, women have excellent choices in numerous areas of this country, but certainly not everywhere. And if you are a poor woman in America, your choices are even more limited and dependent upon what services and providers Medicaid will reimburse.
According to Davis-Floyd the United States and Canada are the only two industrialized nations where professional midwives do not attend the majority of births and where midwives are not fully integrated into the system of care. (61) Throughout the 20th century while America eliminated midwives, Europe generated them. Today in most of Europe the midwifery model coexists with the medical model, customers seem quite satisfied, healthcare delivery is less costly and perinatal outcomes are better than in the United States. For example, Dutch midwives attend about forty percent of all births, Danish midwives attend nearly all normal births, and Swedish midwives care for about eighty percent of all pregnant women and attend all normal births. (62)
Modern Day Heroines
Midwives in the US have an awareness of their place in history and the unique roles they are playing in shaping it. They exemplify the indomitable spirit of consummate revolutionaries. But these midwives are not simply revolutionaries; they hold a vision for an overhaul of the healthcare system. They have generated new ideas, envisioned new paradigms and invented new systems in order to create change.
Midwives work to return birth to the domain of women, put average citizens in charge of family health decisions, replace unnecessary healthcare spending with cost-effective alternatives, utilize evidence-based protocols and practices, and restore normalcy to childbirth. They work to ensure that transformation occurs within a social justice framework so that all people can experience benefits of the system. Most importantly, these midwives form partnerships with women to assist them in discovering and recovering trust in their bodies and faith in the natural processes of pregnancy, birth, breastfeeding, mother-infant attachment and parenting.
This article is excerpted with permission of editor, Geradine Simkins, from Into These Hands, Wisdom From Midwives. Published by Spirituality & Health Books, April 2011.
Photo credit: Greenhouse Birth Center, Okemos, Michigan
Foundation for the Advancement of Midwifery, Inc. (FAM)
2020 Pennsylvania Ave NW
Washington DC 20006
International Center for Traditional Childbearing (ICTC)
2823 N Portland Blvd
Portland OR 97217
Midwifery Education Accreditation Council (MEAC)
PO Box 984 La Conner, WA 98257
360-466-2080 (phone) 480-907-2936 (fax)
Midwives Alliance of North America (MANA)
611 Pennsylvania Ave SE
Washington, DC 20003-4303
National Association of Certified Professional Midwives (NACPM)
243 Banning Road
Putney VT 05346
North American Registry of Midwives (NARM)
5257 Rosestone Dr. Lilburn, GA 30047
1. McCool, William, and Sandi J. McCool. “Feminism and Nurse-Midwifery: Historical
Overview and Current Issues.” J Nurse Midwifery 34. (1989): 323-334.
2. Block, Jennifer. Pushed: The Painful Truth About Childbirth and Modern Maternity
Care. N.p.: Da Capo Press, 2007, 213.
3. Wertz, Richard W. and Dorothy C. Wertz. Lying-in: A History of Childbirth in America.
New York: Schocken, 1977.
5. Jordan, Brigitte, Birth in Four Cultures, 4.
6. Leavitt, Judith Walzer. Brought to Bed: Childbearing in America, 1750-1950. New York:
Oxford University Press, 1986.
7. Wertz, Richard.W., and Dorothy C. Wertz. Lying-in: A History of Childbirth in America.
New York: Schocken Books, 1977, 6. Print.
21. Wertz and Wertz, Lying-in.
22. Ettinger, Nurse-Midwifery, 10.
23. Wertz and Wertz, Lying-in.
28. Sakala, Carol and Maureen P. Corry. Evidence-Based Maternity Care: What It Is and What It Can Achieve. New York: Milbank Memorial Fund, 2008, 10.
29. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics Report 57.12 (2008). Accessed December 2009. <http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf>.
31. DeClercq et al., Listening to Mothers II.
32. DeClercq et al., Listening to Mothers II, 29, 33.
33. DeClercq et al., Listening to Mothers II, 32.
34. DeClercq et al., Listening to Mothers II, 31, 84.
37. Sakala and Corry, Evidence-Based Maternity Care, 10.
38. World Health Organization. “The World Health Report: Make Every Mother and Child
Count,” 2005. Available at: <http://www.who.int.whr/2005/en>.
39. Centers for Disease Control and Prevention, National Center for Health Statistics,
Accessed Dec 2009. <http://www.cdc.gov/nchs/data/databriefs/db09.htm>.
40. World Health Organization, “The World Health Report”, 2005.
41. Centers for Disease Control and Prevention. “Maternal Mortality—United States, 1982-
1996”, Morbidity and Mortality Weekly Report 47.34, 1998.
42. Centers for Disease Control and Prevention. “Safe Motherhood, Promoting Health for
Women Before, During and After Pregnancy”, 2008. Accessed December 2009. <http://
43. Janssen, Patricia. A. “Outcomes of Five Years of Planned Home Birth Attended by
Regulated Midwives Versus Planned Hospital Birth in British Columbia.” Proceedings
of the Seventh Annual General Meeting of the Canadian Association of Midwives,
November 1-3, 2007. Vancouver: Canada
46. Sakala and Corry, Evidence-Based Maternity Care.
47. Centers for Disease Control and Prevention, Mortality and Morbidity Weekly Report.
2006. Available at: <http://www.cdc.gov/mmwr/>.
48. Agency for Healthcare Research and Quality, 2008.
49. Sakala and Corry, Evidence-Based Maternity Care.
52. Declercq et al., Listening to Mothers II.
53. Declercq et al., Listening to Mothers II.
60. Davis-Floyd, Robbie E. Birth as an American Right of Passage, Berkeley: University of
California Press, 1992.
61. Davis-Floyd, Birth as an American Right of Passage.
62. Ettinger, Nurse-Midwifery, 16-18.
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