When Charlotte, fourth in line to the British throne, was born last spring, she dropped into the waiting arms of a midwife. Americans may find it surprising the royal family entrusted the little princess to anyone short of the best medical doctor in the realm. Charlotte’s subjects, however, barely batted an eye. After all, midwives attend most births in England.
Now, the British National Health Service has gone as far as to recommend healthy women with low-risk pregnancies are better off out of the hospital, giving birth at home or at a midwife-led birthing center. American obstetrician Dr. Neel Shah, a professor at Harvard Medical School, set out last spring to rebut that counsel in the pages of the New England Journal of Medicine. Instead, his article ultimately argued that giving birth outside a hospital with a midwife could be safer and much cheaper for many American women, too.
“We’re taking excellent care of high-risk women, but we’re leaving low-risk and normal women behind,” Shah told NPR in July. “We’re on the only continent on Earth with a rising maternal mortality rate.” Indeed, British guidelines suggest the risk of over-intervention, such as unnecessary caesarean sections — rife in US hospitals — may outweigh the risks of under-intervention at a birth center or at home for most mothers.
British women are generally referred to a midwife as soon as they’re pregnant. In the United States, midwives only attend about 9 percent of births. Only slightly more than a century ago, the Bay State — in the spectacularly named Commonwealth v. Porn case; the defendant was a Gardner midwife named Hanna Porn — outlawed midwifery altogether.
Home births today are even more rare, but the numbers are growing rapidly. But what would it take for midwife-led births to become commonplace here?
Gene Declercq, a professor at Boston University’s Schools of Public Health and Medicine, has studied childbirth practices in the United States and aboard and has tracked trends in midwifery and home birth for three decades. He also founded the website Birthbythenumbers.org.
Ideas spoke with him by telephone. Below is an edited excerpt.
IDEAS: What is the perception of midwifery outside the United States?
DECLERCQ: In the industrialized world, midwives typically focus on lower-risk births, which is, of course, most mothers. But an integrated system is the ideal. In the Netherlands, for example, midwives are the gatekeepers. Women go to a midwife first. Then the midwives have a whole array of indications wherein the mother might be then referred to an obstetrician. The idea is that, because birth is normal, the people who are used to dealing with normal births should attend them, and that is a midwife.
IDEAS: At the turn of the last century, Massachusetts led the charge to eliminate the practice of midwifery. Why?
DECLERCQ: For some, it was a business decision. At the outset, it wasn’t obstetricians trying to drive the midwives out, but family doctors. Birth was how a family doctor established a business. They would say things in their professional literature like, “. . . attending births is the center around which much general practice is built.” And so midwives had to go.
But for some, the impetus was ideological. All of this was happening right at the same time that the medical establishment was upgrading its training. To have these women — at the time, often immigrant women — who were able to successfully attend most births was an affront to all the training the doctors went through. If the women like Hanna Porn could do it, why are we spending all this money and time on getting educated?
The key was a public relations campaign to convince mothers that birth was inherently a disaster waiting to happen. In that context, you needed someone trained to deal with medical emergencies at every birth. But being ready to intervene at a moment’s notice leads to a lot of unnecessary interventions, which have negative health consequences as well.
IDEAS: But midwifery didn’t vanish entirely. Today there are some 11,000 nurse-midwives — registered nurses who’ve studied at least an additional two years to get a degree in midwifery — in the United States. Certified professional midwives, although much less common, attend most home births.
DECLERCQ: It almost did die out by 1920, expect black granny midwives in the South because no one else would attend to black mothers. But then it starts to come back in the mid-1920s as nurse midwifery, which was much more acceptable to doctors because they were accustomed to being in charge of nurses. There was an implicit expectation of compliance on the part of the nurse midwives. A lot of the state laws were rewritten with explicit language requiring midwives to work under the direct supervision of a physician. So it came back in a controlled kind of way.
A century later Americans still don’t know as much about midwives as they might. No one is trying to force midwives on people, but you can open up opportunities for those who do want access to a midwifery approach to care. There are still several states where midwives attend barely any births because of legal or policy restrictions.
IDEAS: As a single-payer system, the British NHS can suggest more home births and make it happen. But any movement in that direction in America would still have to overcome major physician opposition.
DECLERCQ: Definitely. At one level it is still about business. We have a huge number of obstetricians in the United States. Where we have more than 30,000 OBs and maybe about 11,000 midwives, in England they have about 1,600 OBs and 30,000 midwives. So that is a lot of business American doctors stand to lose.
If it was just that, however, it could be confronted as a political issue. But it remains an ideological opposition to this day. Obstetricians train for years to identify all the things that could go wrong. That tends to make most of them worry that anyone who can’t treat all those things that could go wrong isn’t ready to treat a mother. That feeling is really intense — it goes to their core beliefs. That’s what makes some of them so opposed to home births.
IDEAS: Midwife-led births tend to be less expensive than those in hospitals, right?
DECLERCQ: Again, it’s never simple. It’s not just that midwives get paid less, it’s that they tend to intervene less. Lower caesarean and epidural rates are where the greatest savings can arise. That is a trade-off for the hospital because interventions are income for the hospital. For example, if a hospital staffs up to have 24-hour obstetrical anesthesia, a major way they offset that cost is by doing epidurals.
IDEAS: Should cultural change then start in medical schools?
DECLERCQ: If you talk to OBs in other countries, their status doesn’t come from treating everyone — it arises from only treating high-risk cases. They look at it like: Why would I attend a normal birth? I’m a specialist who only deals with high-risk births. That’s what lets them feel good about the training that they’ve invested so heavily in. There is a line in England that says, “Every mother needs a midwife, and some women need a doctor, too.”
We do need a system where we can identify the woman who does need an obstetrician, and make sure she has access to the highly skilled care they provide. We just don’t need that system to apply to everybody. The US system as it stands, is looking for reasons to intervene, and it will.
IDEAS: What about convincing mothers-to-be?
DECLERCQ: We’ve spent a century telling people that birth is dangerous. Only if mothers start from the premise that they can successfully have their baby without all that intervention will they start to question the existing US system. Our research suggests more and more women are starting to believe that. Probably because it’s true.