When Janet Podell became pregnant in 1989, she determined to have "the real thing"—the fully natural, satisfying birth experience that had eluded her when her first two children were born. Although midwives had assisted her in the two unmedicated births, the impersonality, tension, conflict, and pointless restrictions she experienced in the hospital had left her feeling frustrated and violated. Both times, for example, she was separated from the baby and from her husband after the birth. After moving to western Massachusetts, Podell found a pair of midwives to attend her birth at home. What resulted was a qualitatively different experience: She felt as if she had really given birth under her own power, in an atmosphere of loving support.
As Podell later recalled in The Midwife Advocate, the newsletter of Massachusetts Friends of Midwives: "I came away from my hospital births with a sense of helplessness. I came away from my home birth feeling that I had learned deep and amazing lessons about my own strength and resilience, about trusting my body and my instincts.…What would happen in this fearful society of ours if all the mothers who gave birth had such an experience?"
Podell is one of many American women who have chosen to give birth outside of a hospital during the last 10 to 15 years. Disillusioned with the routine intrusiveness of conventional hospital obstetrics, they have voted with their feet by giving birth at home with the help of family, friends, and supportive attendants. Some of these women, inspired by the rediscovery of birth as a natural and social event, have become midwives themselves, learning their trade by working with more experienced midwives or with sympathetic physicians.
This social movement, until recently marginalized by organized medicine as a softheaded countercultural rebellion, is now finding common ground with mainstream economic and public-health concerns: the rapid escalation of health-care costs; the loss of obstetricians resulting from the epidemic of malpractice suits; and the high rate of infant mortality among the inner-city poor. Midwifery works, people want it, and it provides an answer to some urgent policy questions. But although midwifery has made progress in recent years, a variety of laws and regulations still prevent midwives from offering their services to everyone who could benefit from them.
The advantages of midwifery depend on a more thoroughgoing change than just plugging in one type of practitioner in place of another. If the law confines midwives to the role of obstetrical handmaidens working exclusively in hospitals under the direction of physicians, it will prevent them from making their full contribution. For the word midwifery really stands for a fundamentally different model of maternity care: different people doing different things, often in a different place.
Midwives reject the view that giving birth is a medical procedure like having a gall bladder removed. Instead, they understand it as a natural process that ordinarily does not require drugs, surgery, or high-tech equipment. Obstetricians, whose skills and techniques are best reserved for complicated births, are in most cases not well prepared to attend normal births. They know how to intervene but not how to support without intervening.
The high-tech, interventionist approach of obstetricians is illustrated by the widespread use of electronic fetal monitoring. EFM—which records fetal heart tones and the pressure of uterine contractions, either through electrodes passed through the birth canal and attached to the baby's scalp or through a transducer placed on the mother's abdomen—may have a legitimate rationale in high-risk births. But from the beginning it was marketed indiscriminately to physicians hungry for precise diagnostic information.
As a result, by the mid-1970s most U.S. hospitals had adopted EFM for routine use, without any controlled studies showing it to be more effective than traditional, noninvasive methods of listening to the baby's heart. Now studies published in the last two years in such prestigious publications as the British journal The Lancet and The New England Journal of Medicine have shown that, in the absence of specific indications for its use, EFM not only has no demonstrated benefit in reducing childhood disabilities but may even be dangerous.
EFM plays a major role in the futile cycle of defensive obstetrics brought on by malpractice hysteria. For legal protection the physician uses the monitor so he can show, if anything goes wrong, that he "did all he could." But with the monitor readings a matter of record, his actions will be further scrutinized to see if he once again "did all he could" in response to an abnormal reading.
Alarmist reactions to insignificant variations in monitor readings contribute to the current 24-percent cesarean-section rate in the United States (a rate twice as high as the World Health Organization recommends). Indeed, any medical intervention in childbirth tends to necessitate further intervention by disrupting the normal physiology of labor and by immobilizing, enervating, disabling, and dispiriting the mother.
A midwife strives to avoid such intervention. Rather than "deliver" the baby, she brings out the birthing woman's own physical and emotional strength—resources left untapped or suppressed by standard obstetrical practices. This is more than touchy-feely rhetoric. It translates into concrete clinical expertise: an appreciation of the variations of normal labor, of the way some problems can correct themselves with time, of the influence of emotional support and a sense of well-being during labor, and of many nonchemical, noninvasive means of encouraging progress.
An obstetrician's highly specialized knowledge represents only a narrow segment of the whole range of knowledge relevant to childbirth. A midwife draws upon a traditional body of knowledge that guides her both in forming a supportive bond with a pregnant woman and in shaping a positive experience of—and attitude toward—birth. In addition to emphasizing prenatal education and preparation, she comes to know the woman, her environment, and the way she lives, and thus can better understand her reactions and assist her during labor.
Podell writes: "The midwives gave me all the room I needed, but they were never distant; they were always right there, offering energy, a sip of juice, a word of encouragement. Their presence comforted me and gave me confidence. One thing I didn't understand.…Without internal exams, how could they tell how the labor was progressing?…They said my body would know what to do and when. And to my very great surprise, they were right."
Instead of pain medication, midwives use noninvasive methods, physical as well as psychological, to help women cope with pain. The midwifery model in its pure form does not allow the use of anesthetic or analgesic drugs in normal births, since these medications interfere with the natural process of labor. Home-birth attendants avoid the use of such drugs entirely, since the safety of a home birth depends on supporting the natural process and not creating added risks. In hospitals, on the other hand, nurse-midwives sometimes make pragmatic compromises, giving pain medication to women who want it in order to make other benefits of midwifery available to them.
It should always be a woman's right to choose between midwifery and obstetrics for whatever reasons matter to her, including her preferences regarding pain medication. At the same time, as the midwifery model comes to be more widely known and better understood, more women may approach the pain of childbearing in a positive way, as Podell did: "The labor was short, intense, and sweet. It wasn't any less painful than the others, but I tried to put all my concentration on welcoming the pain, on assenting to open up. Away from the interference of the hospital, comfortable in my own familiar house, I felt a lovely sense of freedom. I wasn't anybody's patient. I was myself, doing a task I had really been preparing for since childhood."
The beneficial effects of the laboring woman's sense of well-being, comfort, and control are enhanced in the home or (to a lesser degree) in the home-like setting of a midwife-run birth center. In the words of the prominent Dutch obstetrician G.J. Kloosterman: "The advantages of home confinements are that in her own home the expectant mother is not considered a patient, but a woman, fulfilling a natural and highly personal task. She is the real center around which everything (and everybody) revolves. The midwife or doctor and the maternity aide nurse are all her guests, there to assist her. This setting reinforces her self-respect and self-confidence."
This endorsement of home birth runs counter to the prejudices of most Americans, who have been led to believe that the best outcomes occur when childbirth is managed by obstetricians in hospitals where medical technology is readily available and where there is little hesitation about using it. This view equates safety with active technological intervention carried out by highly specialized personnel in an institutional setting.
Proponents of this position offer three main arguments. First, they cite the decline in maternal and infant mortality that coincided with the shift to medicalized, institutionalized childbirth in this century. But such a sweeping historical comparison is meaningless because it disregards many other changes that occurred at the same time: better nutrition, sanitation, and personal hygiene; fewer large families and closely spaced children; the development of antibiotics; and improvements in diagnosis, risk assessment, and instrumentation. Contemporaneous comparisons, such as one conducted by the New York Academy of Medicine from 1930 to 1932, have almost invariably shown that midwife-attended or home births have outcomes as good as or better than physician-attended or hospital births.
British statistician Marjorie Tew, in her 1990 book Safer Childbirth? A Critical History of Maternity Care, uses data from the special British birth surveys of 1958 and 1970 to make detailed comparisons—regional, historical, and individual—of the outcomes of home vs. hospital birth and of high-intervention vs. low-intervention birth in populations closely matched for risk factors. Tew concludes that increased hospitalization and obstetrical intervention cannot be credited with improving the safety of childbirth. To her, in fact, the weight of the evidence suggests that these changes have done more harm than good.
Second, opponents of midwifery argue that mortality statistics show babies are at greater risk if they are born outside a hospital. This fallacious comparison, first made in a 1978 press release by the American College of Obstetricians and Gynecologists, rests on raw statewide figures showing that the risk to a baby's life was two to five times greater in an out-of-hospital birth. But the "out-of-hospital" category included not only intentional home births, but also late miscarriages, premature and precipitous births, and unplanned home births. Such undifferentiated data say nothing about the safety of planned, properly attended home births.
Finally, when forced to confront the lack of statistical evidence in their favor, proponents of orthodox obstetrics say, "OK, so the differences in safety are too small to show up in the data. But even one unnecessary infant death is too many—especially if it's yours." This argument, while highly effective in inducing fear and guilt in parents, fails to take into account the countervailing risks of medicalized birth, such as infections resulting from hospital sepsis or from unnecessary surgical procedures and the many complications that can result from interfering with the progress of labor.
Opponents of midwifery also ignore a large body of evidence that low-intervention maternity care by midwives results in outcomes as good as or better than those of hospital births. Since 1925, for example, the Frontier Nursing Service in Kentucky has provided outstanding maternity care to a poor, geographically remote population. The service, whose midwives attended nearly all births at home (sometimes on horseback) until the late 1960s, has compiled an outcome record that compares favorably with that of mainstream America.
In a remarkable real-life experiment in Madera County, California, neonatal mortality dropped from 24 to 10 per 1,000 when nurse-midwives were introduced into a poor agricultural area in 1960. Pressure from the state medical association ended the program in 1963. Midwives were replaced by obstetricians, whereupon neonatal mortality rose to 32 per 1,000. The number of women receiving no prenatal care doubled.
Midwifery programs are having an important impact among the urban poor as well. With one-third of its largely black and Hispanic clients classified as high-risk, the North Central Bronx Hospital midwifery service has the lowest cesarean-section rate in New York City and lower-than-average rates of low birth weight and perinatal and neonatal mortality. In a well-controlled study involving low-income women in a Houston hospital, published in 1991 in The Journal of the American Medical Association, the continuous companionship of a doula—a woman trained to provide labor support—shortened the duration of labor, cut the cesarean-section rate in half, and reduced the need for other interventions along with the incidence of maternal fever and prolonged infant hospitalization. And the doula provides only part of a midwife's comprehensive skills and services.
Two years ago the National Birth Center Study reported on birth outcomes for nearly 12,000 women admitted to freestanding birth centers in the United States, three-fourths of them operated by midwives. In this largely low-risk population, the low overall perinatal-neonatal mortality rate of 1.3 per 1,000 was comparable to that of low-risk hospital births. Moreover, it was achieved with minimal intervention (most notably, a 4.4-percent cesarean-section rate), low morbidity, and high levels of satisfaction. Similar findings were obtained in a review of more than 3,000 out-of-hospital (mainly home) births attended by licensed direct-entry midwives in Arizona between 1978 and 1985.
Further evidence comes from Holland, where the national health-care system deliberately reversed a trend toward American-style hospital births a decade ago. In a study published recently in the British journal Midwifery, researchers who analyzed all Dutch births in 1986 found that, at all risk levels after 32 weeks' gestation, perinatal mortality was "much lower under the noninterventionist care of midwives than under the interventionist management of obstetricians." And this is in a country with an ethnically diverse population (including guest workers).
Studies also find that midwifery is much less expensive than conventional obstetrics. The cost-effectiveness of the midwifery model follows from its reliance on natural processes and settings rather than on expensive technology. In one of the first demonstrations of the cost-saving potential of midwifery, Blue Cross/Blue Shield estimated that its costs for a birth in the Maternity Center Association's Childbearing Center in Manhattan in 1976–77 averaged only 37.6 percent of the cost of an uncomplicated birth in a nearby hospital (including both hospital and physician charges). As documented in a report prepared for the Federal Trade Commission, Blue Cross/Blue Shield's decision (against formidable opposition) to authorize reimbursement for the center was a major breakthrough in making the freestanding birth center a viable concept in the United States.
Since then, this initial indication of the savings to be achieved through broader application of the midwifery model has been borne out by other research, most notably a Health Insurance Association of America (HIAA) study published in 1989. These savings can be realized in a number of ways:
Lower fees. According to the HIAA study, the average physician's fee for a normal pregnancy and birth is $1,492, while a midwife's fee averages $994. A midwife's fee typically covers more time spent before, during, and after the birth and includes comprehensive services that otherwise would require a team of providers.
Lower site-related costs. According to the HIAA study, a normal birth involving a one-day stay in a birth center costs $2,111, compared with $3,233 for a one-day hospital stay. (These figures include practitioners' fees.) Since the average length of stay in a hospital is longer than in a birth center, the difference in practice is even greater. Thus, the average hospital cost for a normal vaginal delivery is $2,842 in addition to the physician's fee of $1,492, for a total of $4,334.
In a home birth there are no site-related expenses. In Australia, for example, an estimate published in the journal Family Physician indicated that insurers and families might save A$83 million a year if 30 percent of births took place at home. Of course, the cost of maintaining hospital backup for cases requiring transfer must be factored into the overall costs of out-of-hospital birth services. But such on-call auxiliary services require only a fraction of the institutional resources routinely used and paid for under the present system.
Reduced use of technology. Midwives rely much less on technical procedures that entail material costs, increased practitioners' fees, and (often) longer hospital stays. A birth by cesarean section costs an average of $7,186, compared to $4,334 for a vaginal birth in a hospital. Since midwife-attended births have a cesarean-section rate 50 percent to 70 percent lower than physician-attended births in comparable populations with equivalent outcomes, the savings to be realized from this aspect of the midwifery model are enormous. If all of New York state's hospitals operated in the manner of the North Central Bronx midwifery service, the reduction in cesareans alone might save nearly $150 million annually. Ending the indiscriminate use of other specialized procedures, such as electronic fetal monitoring, ultrasound, IVs, and episiotomy, would also save money.
Lower training costs. The Congressional Office of Technology Assessment calculated that the cost of training a certified nurse-midwife in 1985 averaged $16,800, compared with $86,100 to train a general physician, let alone an obstetrician. Since midwifery training is more appropriate for a large majority of births, there is great potential for savings here.
Lower liability costs. As of 1987, 71 percent of obstetrician-gynecologists had been named in one or more liability claims, compared with 10 percent of nurse-midwives. Direct-entry midwives (those not trained and regulated by the nursing profession) are even more rarely sued. Why these disparities? First, obstetricians deal with more complicated cases with a greater likelihood of a tragic outcome. Second, obstetricians have deeper pockets. (Like physicians, certified nurse-midwives—registered nurses with additional training in midwifery—have malpractice insurance; direct-entry midwives generally do not, except in states where they are licensed.)
Third, and perhaps most important, people who choose a midwife (especially a direct-entry midwife) commit themselves to sharing the risks and responsibilities of birth. Rather than expect a guaranteed perfect outcome, they participate with an understanding of nature's uncertainties. The midwife actively encourages this informed participation. And because she establishes a relationship of trust, full and open communication, and emotional support, the midwife does not leave her clients feeling abandoned and resentful in the event of a tragic outcome.
Lower health-care costs after birth. The costs of childbirth pale beside those of taking care of premature and sick infants and children. According to the HIAA survey, it costs nearly $1,000 a day to keep a baby in a neonatal intensive care unit; a 30-day stay can cost $30,000. Hospitals that bear these often uncompensated costs should heed the documented success of midwifery programs, over a range of settings and income levels, in reducing the incidence of low birth weight, which is directly associated with prematurity. To the extent that midwives' emphasis on a healthy environment during pregnancy can reduce the short- and long-term effects of malnutrition, smoking, heavy drinking, and drug use on maternal and child health—in some cases preventing lifelong disability—the contribution of midwives to reducing health-care costs may be incalculable.
In the case of midwifery, the evidence is overwhelming that better care can cost less. Indeed, the American system of obstetrics is so inappropriate and inefficient that only as a protected monopoly could it have gained and held its dominant position. It could not have survived, and cannot now survive, in a free market. But the monopoly is well entrenched by law.
Direct-entry midwives are legal in some states, illegal in others. In a plurality of states their legal status is uncertain. But if a state's medical-practice act includes childbirth among the conditions exclusively reserved for medicine, then direct-entry midwifery is presumed to be illegal. And in the Catch-22 of midwifery regulation, some states (such as Rhode Island) won't let midwives practice without a license but won't license them either.
This patchwork of laws resulted in part from deliberate efforts by organized medicine to create a protected monopoly and in part from an unconscious societal assumption that midwifery had disappeared. During the past few decades, midwifery has been allowed back in a limited role in the form of certified nurse-midwives. CNMs practice legally in every state, but their scope of practice—indeed, their ability to practice at all—is often severely restricted when physicians withhold the requisite institutional or logistical support.
Direct-entry midwives are often prosecuted for practicing either medicine or midwifery without a license. Sometimes these prosecutions help clarify the legal status of midwives. In 1990, after charges were brought against a Pennsylvania midwife who attended Amish clients, a judge ruled that state law did not prohibit the unlicensed practice of "lay" midwifery. But in Illinois in 1991 a court decision calling for clarification of the state's medical-practice act led to legislation that included childbirth within the scope of the act. Midwives have also suffered setbacks in Southern states such as Alabama, where public-health departments have forcibly retired the experienced "granny" midwives who often were the only providers of maternity care for the rural or urban poor. In Arkansas, public outcry over such action persuaded the legislature to legalize direct-entry midwifery. In Georgia, however, recently issued regulations have made the practice of direct-entry midwifery a felony.
A decade ago in REASON, Sarah Foster documented the various tactics that the medical establishment uses to intimidate and exclude midwives ("Up Against the Birth Monopoly," September 1982). In one of the more prominent cases to have occurred since then, a local obstetrician pilloried nurse-midwife Debby Sweeney in front of her students at the Medical College of Georgia School of Nursing in 1986, falsely charging that she was practicing medicine illegally and endangering her patients. The obstetrician's group practice prevented Sweeney from continuing to teach in one of the hospitals affiliated with the college, complaining that they "could not allow their patients to be exposed to students who are being instructed by one who advocates the home delivery concept." Sweeney had run afoul of the medical establishment by advertising her home-birth practice.
Such anticompetitive tactics thus far have limited the availability of qualified attendants for out-of-hospital births and deprived women and families of information about birth options. Unless a woman happens to know someone who knows the local midwife, she may see and hear only horror stories about home birth.
Reform is coming, however. Many prestigious institutions are calling for more widespread adoption of midwifery or a low-intervention approach to childbirth. These include the World Health Organization, the European Economic Community, the Institute of Medicine, the Office of Technology Assessment, the General Accounting Office, the American Public Health Association, and the National Commission to Prevent Infant Mortality. The strongest advocacy has come from the women's health movement. A detailed position paper issued jointly in 1990 by the Women's Institute for Childbearing Policy, the National Women's Health Network, the National Black Women's Health Project, and the Boston Women's Health Book Collective argues for a midwifery-based maternity care system that favors out-of-hospital birth settings.
The great stone face of the birth monopoly is visibly cracking. Hospitals hit hard by the loss of obstetricians are advertising for midwives. HMOs, after considerable resistance, are incorporating midwifery services. Boston will be joining New York, San Diego, and other localities in setting up a public out-of-hospital birth center for low-income women. At the federal level, direct reimbursement for midwives has been mandated for the armed services, Civilian Health and Medical Programs of Uniformed Services (CHAMPUS), and Medicaid. One by one, state governments are authorizing limited prescription privileges for certified nurse-midwives and licensed direct-entry midwives. They are also beginning to remove the statutory and regulatory barriers to direct third-party reimbursement for midwives.
In a major breakthrough, Ontario recently recognized midwifery as an independent, self-regulating profession authorized to practice in the home, birth center, or hospital. Ontario's action set a precedent for Canada, which had made no provision for midwifery in its national health-care system. In the United States, legislative efforts continue in New York, California, and other states to legalize midwifery as an independent profession.
Licensing clearly is preferable to illegality; however, in states where midwives currently are unregulated, midwives and their supporters are divided over whether it is better to be licensed or to continue on a laissez-faire basis. Midwives who oppose licensing consider midwifery a "spiritual art," in the words of Ohio midwife Kimberly French, that cannot be regulated by uniform standards as medicine is. "Would we be willing to give up certain aspects of our craft in exchange for certification, such as handling breech births, vaginal births after cesareans, and twins?" asks French in the periodical Friends of Homebirth. "What about the woman who is left with no other option but a cesarean if we, as midwives, were restricted…by law?"
Furthermore, opponents of licensing are reluctant to exclude midwives who might not meet the formal criteria established by the law. "I feel strongly," writes Maine midwife Jill Breen in The Midwife Advocate, "that there always will and should be a place for the apprentice-trained midwife, the community-called midwife, the non-medically-oriented midwife."
With few exceptions, midwives who support licensing do so not to protect their hard-won turf or to save the public from unqualified practitioners, but because they are weary of their denigrated status as "lay practitioners." They are interested not so much in excluding others as in including themselves in the professional health-care system. Longtime Oregon midwifery advocate Alan Solares, whose arguments against licensing were influential a decade ago, has now changed his position. He addresses the concerns of many midwives today who feel that "they cannot fairly compete in a health-care system based increasingly on third-party payment."
Implicit in Solares's argument is the assumption that, in today's highly professionalized society, the benefits of third-party reimbursement, public visibility and trust, and secure hospital backup cannot be obtained without some concession to "professional standards" and "consumer protection." For this reason, most people on both sides of the debate would welcome a system of voluntary certification such as New Hampshire's, which sets standards for certification but does not bar uncertified midwives from practicing as long as they do not claim to be certified. But this is not a likely prospect in many states.
For now, midwives and others who seek to open up the health-care market will continue to face rear-guard obstacles such as unequal access to reimbursement, regulatory mechanisms that place competing practitioners under the control of physicians, an information monopoly that can frustrate informed choice even when more overt restraints are halted, and a long accumulation of prejudice against non-technological alternatives to conventional health care. The hardest obstacle, however, may well be a certain faintheartedness in the American public, an ingrained reliance on "consumer protection" even at the expense of consumer choice.
Archie Brodsky, a senior research associate at the Harvard Medical School's Program in Psychiatry and the Law, is a former president of Massachusetts Friends of Midwives and coauthor of Medical Choices, Medical Chances and Home Birth: A Practitioner's Guide to Birth Outside the Hospital. The author is indebted to Carol Sakala of the Women's Institute for Childbearing Policy for some of the information in this article.