Born in the USA (36 page)

There are a number of fine examples of maternity care systems that successfully provide for out-of-hospital births for low-risk women, showing that it can be done. Perhaps the best known is the system in the Netherlands. As I explained in
chapter 6
, the Netherlands has a long tradition of planned home birth. As recently as thirty years ago, half of all births in that country were planned home births. Though the percentage fell to about one-third of all births in the 1980s, it has been climbing again in the last ten
years. The Netherlands does not have significantly higher perinatal and maternal mortality rates than other Western European countries do, and it has lower perinatal and maternal mortality rates than the United States does.

How do the Dutch do it? For one thing, they have a national health care system that provides maternity services to all families with no barriers to care, such as income qualifications to meet. A woman in the Netherlands having a low-risk pregnancy can choose to give birth at home or in the hospital, but there are significant incentives for choosing home birth. If a woman gives birth at home, a home helper (paid by the government) will come for two weeks to help take care of the house and any other children, so the mother can focus on caring for her newborn. (This service is not available after a hospital birth.) A woman giving birth at home is likely to know her midwife because the same midwife will have provided at least some of her prenatal care, whereas if a woman gives birth in the hospital, she will be attended by the midwife on duty, whom she will not have met before. Since hospital midwives usually work eight-hour shifts, a woman giving birth in the hospital will probably have her attendant replaced by another stranger during her labor. With a home birth, the midwife typically comes when labor starts and stays until she has checked the mother and baby after the birth. She then comes to the home once a day for several days to check the mother and baby again and answer questions. These incentives are certainly applicable to a vision of out-of-hospital birth in the United States. Americans could learn a lot by close observation of the Dutch home birth system.

Denmark also guarantees a choice of place of birth to all Danish families. Like every other highly industrialized country except the United States, Denmark also has a national health care system. In Denmark, midwives attend all low-risk births either in the hospital or in the family's home. When midwives in Denmark graduate from midwifery school, they take an oath to attend any birth, anywhere, anytime. If a pregnant women has decided to give birth at home, when her labor starts she calls the local hospital and asks for a midwife to be sent to her home. By law, the hospital must comply with this request. If a complication develops during the birth and it becomes necessary to transfer the woman to a hospital, this transfer is handled smoothly and easily, as the midwife is already well known in the hospital. The home birth rate varies within Denmark (it is around 10 percent of all births in some districts), and Denmark's mortality rates for birthing women and newborn babies are among the lowest in the world,
far lower than those in the United States. The United States could learn a lot from studying the communication between midwives attending out-of-hospital births and hospital staff in Denmark.

An excellent example of how changing the place of birth changes obstetric practice comes, ironically, from Brazil, a country known for its astronomical C-section rates (as high as 80 percent in some regions). The federal government in Brazil is aware of the country's C-section crisis and has been trying to improve the situation even in the face of lobbying efforts from those in the medical profession who want to maintain the status quo. Wisely recognizing that it would be extremely difficult to change hospital obstetric practices under the circumstances, at the beginning of the twenty-first century the government endorsed a plan to build a network of out-of-hospital birth centers and has agreed to help fund it.

The move to out-of-hospital birth in Brazil is supported by Brazilian women, who are getting increasingly angry at how they are treated in hospital maternity care. A group of women scientists in Brazil conducted a study that looks at violence against women committed by health care workers in health care facilities including childbearing services in hospitals.
²⁰
They analyzed all research reports and surveys of patients from the previous decade that revealed how women were managed and treated by heath care workers in hospitals, and identified four forms of abuse of women by doctors and nurses in Brazilian hospitals: neglect, verbal abuse, physical abuse, and sexual abuse. The authors note: “These forms of violence recur, are often deliberate, are a serious violation of human rights, and are related to poor quality and effectiveness of health-care services. This abuse is a means of controlling patients that is learnt during training and reinforced in health facilities. Abuse occurs mainly in situations in which the legitimacy of health services is questionable or can be the result of prejudice against certain population groups.”
²¹
The paper goes on to suggest ways to prevent abuse. It is an important contribution to our understanding of hospital maternity services, and in my opinion, it should be read by every obstetrician, midwife, and obstetric nurse in every country. This paper also makes it abundantly clear that moving childbirth out of the hospital will bring about dramatic improvement in maternity care.

Even within the United States, there are models for providing high-quality out-of-hospital maternity services. One example can be found in Taos, New Mexico, where a group of maternity providers has succeeded in giving women a real choice of place to give birth. Two obstetricians—a husband and wife—and several midwives work together in a group practice.
The group offers pregnant women a choice of giving birth at home, in an alternative birth center, or in a hospital, as well as a choice of birth attendant—midwife or obstetrician—for each location. Because this group is the only obstetric practice in town, it has been able to gather good statistics on its practice. The data show a steady increase in the number of pregnant women choosing to give birth in an out-of-hospital setting.
²²

Another outstanding example of providing out-of-hospital birth in the United States is found in rural Tennessee. For more than thirty years, The Farm, a small community outside Summertown, Tennessee, has offered planned home birth attended by a group of midwives. Of the 2,200 babies born at The Farm between 1970 and 1990, 96 percent of the births were attended only by midwives. Since there were no complications, there was no need for a doctor to be involved. The Farm's excellent track record for home births has been the subject of a scientific analysis that looks at the intervention rates and birth outcomes.
²³

The Farm serves as a model for home birth and has also become a source of inspiration to midwives, doctors, nurses, doulas, and others interested in humanizing childbirth. Ina May Gaskin, the leader of The Farm's midwives, has been a pioneer of the home birth movement in the United States as well as globally. Her 2003 book,
Ina May's Guide to Childbirth
, is a classic that I believe should be read by all in this field because Ina May Gaskin is the most important person in maternity care in North America, bar none. Hundreds of maternity care providers (myself included) have visited The Farm to observe the work done there. Ina May also helped organize the Midwives Association of North America, an organization that has been the driving force in the renaissance of direct-entry midwifery in the United States.

In my vision of a better way to provide maternity care in the United States, midwives would have primary responsibility for women with low-risk pregnancies, while obstetricians would have primary responsibility for pregnant women with serious medical complications. This has always been the system in other highly industrialized countries, and women cherish their midwives and do not see obstetricians as preferable for normal birth. In 2005, the Crown Princess of Denmark gave birth assisted by her midwife. Having obstetricians—surgical specialists—provide primary care for pregnant women has been shown to be one of the reasons for bad maternity care outcomes.
To quote a recent
Health Affairs Journal
article: “Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.”
²⁴

The majority of maternity services would be community-based—located in neighborhoods, not in medical facilities—and the 10 to 20 percent of women with high-risk pregnancies would be cared for in the hospital. If the United States had a national health care system, American obstetricians would no longer be able to maintain their monopoly and negotiate with a wide group of insurance companies, government agencies, and managed care organizations to maintain a good profit. Without this financial incentive, I believe obstetricians' motivation for continuing to manage more than three million low-risk pregnant and birthing women a year would quickly vanish. My decades of personal experience with American obstetricians convinces me that most of them are bored with routine prenatal care and with trying to manage low-risk hospital birth from a distance, and they are tired of the inconvenience. If this practice were no longer highly profitable, I believe that most obstetricians would be more than happy to leave the management of low-risk pregnancies and birth to midwives. In the meantime, it is inevitable that doctors in the United States will let economic issues interfere with their practice decisions.

It will take time for American obstetricians to gain sufficient experience with midwives to develop deep respect for their professional skill and expertise. Removing the economic barriers between obstetricians and midwives would accelerate the process and move the two groups toward the true collaboration we see in countries where they are not competing for patients. It is also clear that in other highly industrialized countries where obstetricians are not struggling to maintain their monopoly over maternity services for economic gain, their tribal qualities, including omertà (see
chapter 2
), are less apparent, allowing a more collegial relationship with their coworkers.

Under the new distribution of labor I've described, it is essential that midwives and doctors work together in harmony, as equals, each recognizing the unique professional contributions of the other. With this equality and mutual understanding would come clarity in the relationship—and an end to the idea that doctors must supervise midwives and are responsible for midwifery practice.

In truth, this strategy of trying to supervise midwives and take responsibility for their practice has already backfired. As I discussed in
chapter 5
, in areas of the United States where obstetricians have insisted that midwives work under their supervision and have succeeded in getting legislation to mandate this, they are required by law to assume some responsibility for what midwives do. Where obstetricians have tried to convince legislators that midwives are not as safe as obstetricians or that home birth is dangerous, insurance companies have bought into the falsehood as well and have raised premiums for backup obstetricians.
²⁵
In countries around the world that have more effective maternity care than the United States does, obstetricians do not supervise midwives, nor are they responsible for what midwives do.

It is also important that all those who provide services to pregnant and birthing women understand that, although midwives and physicians are both highly trained professional “experts,” maternity care is a service and the work of both midwives and doctors is to serve the women in their care. This is a key concept in a modern maternity care system, as it redefines the role of “patient,” understanding that the woman giving birth is not a passive sick person but someone who is experiencing a profound life-cycle event. When we view midwives and doctors as in a service role, it supports the view that the pregnant woman is in the central position—as the one being served.

Some physicians have always understood that their role is to be of service to their patients. Many doctors, however, see the field of medicine not as a service but as a profession. In an editorial, the deputy editor of
Obstetrics and Gynecology
, the journal published by ACOG, wrote: “Keep medicine a profession instead of a service.”
²⁶
By saying “instead of,” ACOG is implying that it is not possible to be a service provider if you are a professional, creating a false dichotomy, as there is general consensus in the United States that medical doctors are service providers. But by calling themselves “professionals”—elite experts providing professional consultation—rather than service providers, obstetricians are giving themselves elevated status, certainly above that of a patient. In U.S. medical schools, medical students model themselves after their professors and learn to view themselves as members of an elite group. There is a lot of emphasis placed on how important doctors are and little discussion of how important patients are, and no one talks about medicine being a service. In particular, it is my experience that many obstetricians/gynecologists chose their specialty without fully recognizing that while they will be playing the role
of highly skilled surgeon some of the time, at other times their role will be to serve—assist and support—a woman and her family as they go through a major life event. So for some doctors, what I'm describing represents a fundamental paradigm shift, which when made cannot help but affect not only their attitudes but their practice. An obstetrician who practices with a strong anti-regulation ethic, for example—taking an attitude of “I can do anything I want”—will find that this ethic breaks down when he views himself as performing a service, because when one is performing a service, one has an inherent obligation to the people one serves.