Midwifery Care: a Good Choice in Childbirth

It's a weekday night and I am headed to bed soon because I might be woken in the night to go to a birth. The birth, when it happens, will be with a young woman who—although she and her partner moved last month to another part of Washington State that has no local midwife—chose to come back to Seattle to stay with an aunt in order to have access to midwifery care. She wants the kind of birth where her chosen care providers and support people will be with her; where she will have privacy and intimacy; where she will be allowed to eat and drink to sustain her energy during the labor; she will be encouraged to be in whatever position feels comfortable to her, including finding comfort in a warm pool of water; and where she and her baby will be carefully monitored to make sure they are well and the labor is progressing normally.

She will be "allowed" to labor at her own pace without intervention, unless she asks for it—whether that takes just a few hours or many. She will be given information at each decision-making point; allowing her the ability to make her own educated choices about her care and her baby's. She and her partner will be supported to make this journey of labor together and she will come out the other side empowered and amazed at what her body can do. She'll know after that intense experience "if I can do that … I can do anything!"

The state of Washington is picking up the tab for her care since she qualifies for Medicaid coverage. DSHS (Department of Health and Human Services) recognized early on, in a study about the "safety of home birth" in Washington, the benefits of Licensed Midwifery care. They halted the pilot program and started providing access to the services of Licensed Midwives as part of the Medicaid plan. What are some of the benefits? Quality care at low cost. Childbirth at home or at a birth center. Lowered rates of intervention, medication, and cesarean section. A higher rate of vaginal deliveries with no increase in adverse events for mothers and infants. There are no differences in birth outcomes, except, as some studies have noted, an increase in maternal satisfaction with the birth, and the care.

Unfortunately many women who are covered by Medicaid don't know it's an option to have a Licensed Midwife attend their birth at home or at a birth center. Even women for whom it may be more culturally appropriate to have a midwife may not know about their rights and options for childbirth; Washington is home to many low income, minority, immigrant and refugee women who might benefit from midwifery care. Fortunately for my client, a very young but educated white woman, she does have the skills and privilege to explore her options and make informed choices.

As much as I love my work—I am honored to be a part of one of the most intimate, challenging, moving moments in a woman's life—it's amazing to me that my midwifery partner and I are still in practice. Indeed, at only seven years in practice together, we are the second longest running midwifery partnership in Seattle. Although we are contracted with insurance companies and receive payment for our services, the costs of having a practice are high and the (financial) payoffs are low. I am still awaiting the decision of legislators in Washington to see if our annual licensing fee, currently the highest of any licensed professional in the entire state, will be stabilized at $500, or rise to the projected $3,000 or more next year. Every year we pay increasingly more for malpractice coverage. And insurance companies reimburse us at a similar rate as MDs. However, although an MD might attend the end stages of a labor or be on call so the labor nurse can consult with them about the management of the birth, a midwife will be at a woman's side for hours on end (without nursing staff or shift changes) in order to give continuous one-on-one labor support.

A San Francisco hospital executive recently described midwifery care as "boutique" care: too expensive and labor intensive to be provided in a hospital setting that serves mostly low-income patients. Is it a luxury to have a provider you trust who will be with you, encourage you in your most difficult moments, help keep your birth safe, give you information and choices about your care, regard you as the expert of your own body, and strive to honor and protect your experience? Rather than having this type of care as a right, women are often forced to sacrifice the right to safety, information and the fulfillment of their goals for birth in order to help the hospital run more smoothly and make the medical doctors less prone to liability. Perhaps normal birth is just not a money-making operation.

As hospital administrators urge their staff to step up production and minimize the risks of lawsuits, caesarean section rates are rising. A hospital in my community is approaching 40 percent. The hospital's Chief of Obstetrics told me "…now that we know c-sections are safer and cheaper, if you discount the personal satisfaction of a vaginal delivery, why have a vaginal birth?" Perhaps he meant it as a tongue-in-cheek statement about how medicine views a normal physiologic process as an accident (or a lawsuit) waiting to happen.

But it's more than just a normal physiologic process; it's a vulnerable, hard, beautiful transition in a woman's life. Doesn't she deserve to be supported, encouraged, and kept safe? Doesn't she deserve information about her body and this experience that will allow her to be an active participant in her care? No matter her culture, race, or income level? So why are midwifery practices closing around the United States at a time when many states are experiencing a shortage of obstetrical services? Why don't public policy makers, MD's, hospital administrators, midwives, and public health educators all agree to provide a team approach to meeting individual women's needs? I worry about the sustainability of my practice if I can't survive financially, or politically. I worry about the lack of access to safe, respectful maternity care for all women, especially if midwives and OB's are not supported to continue to provide quality, individualized care.

These issues are too much for one tired midwife to grapple with alone. I'd like this to be part of every woman's conversation with her friends, partners, health care providers, and above all, her legislators. It's part of a larger conversation about reproductive rights, health care rights, and basic human rights. All women should have their choice of care provider—in the setting of their choice, as appropriate to that individual person.

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  • invalid-0

    The sad thing about your conversation with the hospital’s OB chief is that he spouted that fiction about a C-section being “safer and cheaper”. There’s plenty of evidence out there to prove it is neither.

    As a matter of fact, C-sections make a hospital significantly more money, and result in a much higher rate of complications. The only reason this is seen as a “better” option is that it allows the facility to say they did every intervention possible in case of a lawsuit.

    This complete denial of evidence-based care is part of the crisis our entire health care system is facing, although it is nowhere more painfully evident than in obstetrics. I’ve watched an amazing midwifery practice in my town close because of a similar struggle with insurance costs, hostile (and poorly informed) legislation, and a dogged ignorance of fact by the majority of the local medical community.

    I was fortunate enough to have this practice in place for the births of both my daughters. I greatly fear they will have no such option.

  • invalid-0

    You’re right that giving birth has been turned into a business transaction, and in the process women’s expectations have been lowered, and lowered, and lowered.

    I strongly believe that the act of birth is very much like the act of conception. It’s a wonderful, loving, intimate, life-transforming event – if you feel safe, cared for, are in the presence of people of your own choosing, and are allowed to choose a comfortable physical position. But loss of any say in the process, from what position to assume, to having strangers wonder in can turn it into a traumatic event & cause your body not to perform so well.

    I had two lovely home births with a midwife, the two most empowering events of my life. It is with tremendous frustration that I listen to my niece describe her prenatal care and birth experience with an OB, who spent 9 months underming her confidence by telling her that her pelvis was probably too small and then put her on a rigid time-table for labor, which of course she didn’t meet. Can you say “fast track to c-section?” And yet my niece thinks her doctor was wonderful. She believes it was her own body that was the problem.

    How do we educate mothers-to-be about their rights and their capabilities?

  • http://belliesbreastsandbabies.blogspot.com invalid-0

    I am currently planning my third home birth with a wonderful Washington LM. However, I came very close to not even knowing about the option. With a professional career flowing from an advance degree, I had NO idea that out of hospital birth was such a safe and viable option. I literally stumbled into an interview with a midwife and agreed to do it more on a whim than out of any serious intent to birth at home. It was probably the luckiest stumble of my life.

    I wonder why there isn’t more of an effort in Washington State, which is a leader in midwifery care and out of hospital birth, to reach women of all walks of life to help support the struggling midwifery practices. I realize there are business obstacles to running a successful midwifery practice, but there are so many untapped opportunities to reach women and explain midwifery care to them.

    Instead, we have a culture that supports invasive procedures and rough treatment of newborns, without question. If women know that they could safely have the gentle and respectful care that they can receive in an out of hospital setting – either at a birth center or at home – and that in such care may even avoid some of the hospital pitfalls that could end up being dangerous to their health – they would demand it. Such demands from consumers create a whole new world in maternity care.

    Knowing the birth community well, it seems that no organization feels that it “owns” the job of this type of outreach. Why not? Where should this job lie? What is stopping it from happening?

  • invalid-0

    Hi Tera,
    I agree with you, there is not one organization that makes it’s sole mission to provide outreach and education about midwifery options in Washington. I would love to see something like a local Citizens for Midwifery consumer group that supports midwives as well as the consumer’s right to access to midwifery care. As a consumer of midwifery care and an active advocate in the birth community in Seattle you are aware of Seattle Midwifery School’s outreach efforts, and the Midwives’ Association of Washington does it’s advocating for midwives in the form of professional issues, continuing education, and lobbying efforts. There are many other organizations that each have their particular focus: Great Starts, Healthy Mothers, Healthy Babies. Pacific Association for Labor Support. In my own practice, Michelle and I sit on panels at Schools, colleges and universities, build relationships with other health care providers, community clinics, and ob care coordinators who make referrals for their pregnant clients, offer birth options workshops at Whole Foods, get articles printed in local publications about midwifery care, advertise in our own school newsletters, display at health care fairs, etc. We also attempted to enter into the community health clinics to provide midwifery care in that setting, but were not successful at the time. One our biggest sources of referrals comes from our former clients who simply tell their birth stories to their friends, family and coworkers.
    But I really want there to be not only consumer advocacy and education to other consumers, but public health policy from the top down that promotes these options. For example, why aren’t all women who are signed up for First Steps given information and counseling about what their birth options are…hospital, birth center and home with their choice of licensed care provider? The state should be providing this to every woman.
    Are we each doing our little bit? Are we duplicating efforts when we could be combining efforts and become a more powerful voice? It would be great to see even more collaboration between all these different organizations from midwifery education to consumer groups to midwifery professional associations to governmental bodies.

  • invalid-0

    How do we educate mothers-to-be about their rights and their capabilities?

    I have this hope that because my daughter was born at home and that she sees the work that I do that she will have a foundation in the fact that birth is a normal process and that her body is strong and capable, and that she has the right to make choices and decisions about her body and her health care. But I’m not assuming this is true, and we do spend time talking about it.
    Sometimes I wish every person could attend one birth and be a witness to the kind of empowerment you experienced in your births…I think it would be radical. Many of us in US culture have not been at a birth (or have seen mothers breastfeed, etc).