Mother-Friendly Childbirth Is A Consumer Issue


Maternity care clearly is part of "reproductive healthcare" and a key component of "maternal health", but is rarely addressed in that context. There is an unspoken assumption that U.S. maternity care is great just the way it is, with 99 percent of births in the hospital and skyrocketing rates of interventions (PDF) from induction of labor to cesarean section. However, U.S. maternity care does not compare favorably with the rest of the industrialized world. Maternal mortality is under-reported and increasing, and we have a higher infant mortality rate than many other countries. In many of the countries with better outcomes, midwives are the primary care providers for pregnant women, according to Marsden Wagner.

A recent San Francisco Chronicle article stated that the percentage of births attended by midwives in the United States has decreased in recent years (to just below 8 percent), and implied this was due to fewer women wanting the natural childbirth associated with midwives. However, less access to certified nurse midwives in hospitals and birth centers may be the reason. Many birth centers and hospital-based midwifery services across the country have been closed in recent years, not because they were not popular, but because, as one hospital administrator pointed out, "midwives are not good money-makers," or because of enormous increases in malpractice insurance rates (even though midwives are hardly ever sued). Additionally, midwives are unevenly distributed, with none in many areas. Restrictions in health insurance policies also impose barriers for women desiring midwifery care in or out of the hospital.

In the United States, certified nurse-midwives (CNMs) practice almost entirely in hospitals, a few in free-standing birth centers, while non-nurse midwives such as Certified Professional Midwives (CPMs) specialize in out-of-hospital births, mostly in homes. For a woman having a normal pregnancy (most women), and attended by a well-trained midwife, the evidence shows that a planned home birth (PDF) or birth center birth is as safe for the woman and her baby as a planned hospital birth, but with much lower rates of all interventions as well as injuries and complications. Non-nurse midwives such as CPMs are licensed in many states, where midwives and their supporters worked hard to pass legislation.

Women who have educated themselves about the evidence regarding the many practices and interventions included in standard hospital-based maternity care often want to avoid the "cascade of interventions." They seek alternatives including in-hospital midwifery care, free-standing birth centers staffed by midwives, and midwives who specialize in attending births at home.

Today a pregnant woman can not assume that the care offered by obstetrician and in hospitals will be in her and her baby's best interests. Maternity care is "business," and women need to be well-informed and careful consumers. For one example, cesarean sections are more efficient and convenient for obstetricians and hospitals, resulting in more income. A recent Philadelphia Inquirer article points out that cesarean section rates have increased dramatically to nearly one third of all births, but there have been no changes in maternal risk factors to justify the increase, nor are any significant number of women demanding cesarean sections for no medical reason, contrary to the widely circulated myth. Other practices, such as early induction of labor, lead to more cesarean sections (PDF), and ACOG's recommendations about vaginal birth after cesarean (VBAC) have lead many hospitals to ban VBACS (PDF). Epidurals have been popularized, but based on my experience, women rarely are informed about the economic incentives for selling epidurals, the risks for themselves and their babies, or alternative and non-invasive pain-management techniques that are often sufficiently effective with virtually no risks.

For a variety of reasons, however, most women will continue to give birth in hospitals. Those who want a safe birth, even a somewhat natural vaginal birth, will need to thoroughly educate themselves about the risks and benefits of interventions, learn how to exercise their rights to informed consent and informed refusal , know their rights, and "just say no" to unwanted, unnecessary interventions. Women planning a hospital birth can help to optimize their labor and delivery as much as possible by arranging for a labor support person, such as a doula, to work with them throughout labor, and by having a nurse-midwife as their primary care provider if at all possible.

When women have the choice, many prefer the respectful, empowering, evidence-based, woman-centered care described as the Midwives Model of Care and as Mother-Friendly Childbirth. This kind of care could be the standard for all maternity care providers in all settings, but at present is most frequently found in midwife-attended out-of-hospital births.

For consumer-oriented information about maternity care and resources for bringing about change, check out the following:

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  • invalid-0

    We are half-way through 2007. My local hospital has a 50 % surgical delivery rate : ( isn’t that unbelievable…and it’s only continuing to rise at this point.

    I’m so gladdened to see a great article & information source like this in yet another spot. Thanks for writing it Susan ! I hope a whole nation of women read it, consider it, and act on it.

  • http://www.bnnhartford.com invalid-0

    Susan,

    Thank you for pointing out that birth is big business, and while most women think that their doctor and hospital are working in their best interest as a patient, more often the doctor and hospital are just moving them through the system in the most expeditious and cost effective way possible. Friendly service with a smile does not equal good medical care. The more that women know about mother-friendly care and the midwifery model of care, the better they will be able to advocate for themselves in a system that functions based on the bottom line, not on the health and well-being of its clients, as the maternal and infant mortality rates report.

    The midwifery model of care provides a different outlook towards birth, one that views birth as a normal, healthy process that usually requires no interventions.

    Women should be aware that this other model of care is an excellent option that serves their needs and best interests, and provides quality care for them and their babies.

  • invalid-0

    Susan,
    You are painting a true picture which is familiar to any doula who’s frequent at the hospital scene. It is hard to believe that, although the evidence is out in the open, maternal health management stays as it is.
    However, the stats you mentioned about the state of midwifery was not familiar to me, and now I am rethinking my dream of becoming a midwife… What would be the future of this ancient profession?

    • susan-hodges

      My apologies for taking so long to respond.
      I hope you hold fast to your dream of becoming a midwife! No matter how hard the medical profession has tried in the past, midwifery has NOT been obliterated. Many people and organizations are working together to change antequated statutes and rules. We are not giving up, ever. I firmly believe that healthcare based on private enterprise in the US is eventually going to implode. Once the profit motive is no longer a primary factor for hospitals and other entities involved in the provision of maternity care, it becomes absolutely clear that midwives are the appropriate primary health care providers for pregnant women — the results are better and the costs are much lower. All that said, it may be that things still have to get worse before they get better…
      Susan

  • susan-hodges

    Thank you for your comments Michal. I think the kind of work BirthNetwork National is doing, along with several recent new books (see orginal blog), will help more and more women understand how careful they must be when it comes to maternity care. It will take many, many women becoming aware and knowledgeable, and acting on that knowledge and awareness in many different ways, to bring about change.

    A friend of mine is pregnant. She lives in a state that licenses direct enty (ie, home birth) midwives, but there are none in the area where she lives. She carefully searched out an OB that would support her in a natural childbirth in a local hospital with a terrific staff. A week before her due date, her OB started talking about induction, and then, as he was about to conduct a vaginal exam, said he was just going to strip her membranes (a relatively minor procedure that can sometimes encourage labor to start). Being informed, she said “I don’t think so!” Actually, she was lucky because her OB actually said something BEFORE he did the procedure (many don’t), and she was able to stop him. But what was really important was that she went back to speak with him a few days later, to clarify that she needed him to speak with her about ANYTHING like that well before he was going to do something, and that she did not need to be worrying about him doing something without her permission. He got the message. Having informed consent process is the most basic aspect of humane medical care, and a foundation of the respect that is inherent in the Midwives Model of Care.

    Women who choose OBs and hospital births have a great burden of communication if they do not want hospital birth “as usual.” But women who switch to midwives (in or out of the hopsital) also need to communicate to hospitals and OBs why they are are choosing different care providers or settings. Without this kind of feedback — to providers and to hospitals — there is little hope of anything changing.

    Some of us don’t figure all this out until after a less than satisfactory birth. People can file complaints! You can find some ideas about doing this at http://cfmidwifery.org/Resources/Item.aspx?ID=1.

    Obviously, communicating and filing complaints may not be enough, but it is a start, and informed individuals can do this by themselves. Organizations like BirthNetwork chapters and ICAN chapters can help women learn what they need to know about maternity care so they can clearly communicate their needs, and file complaints when appropriate. And where women want access to out-of-hospital births and midwives, it may take banding together to work on legislative changes. If enough of us do these things, it will be a wake-up call to the “business” and marketing of maternity care.

    Susan