Born in the USA (37 page)

We can look to other countries for models of how midwives can be the primary care provider in low-risk births. In Scandinavia, a woman's family doctor (not an obstetrician) confirms her pregnancy and rules out any serious medical problems. From then on, the woman receives maternity care from local midwives, and in most cases, will not be seen by a doctor again during the pregnancy. The midwife handles all prenatal visits, and when the woman goes into labor, she chooses either a hospital or a home birth. If she chooses a hospital birth, the midwife attends her in the hospital, admits her, assists her during the labor, assists her at birth, assists after the birth, and discharges her from the hospital without the woman ever having seen a doctor.

In some areas of Western Europe and Scandinavia, a low-risk pregnant woman can choose a small group of midwives who share a practice. The woman will usually get to know all of the midwives during prenatal visits over the course of her pregnancy, and when she goes into labor, one of them will come to the home or hospital and assist for the entire time, even if the labor is thirty-six hours long. This allows the woman to receive one-on-one continuous care with a known midwife—so this scientifically proven ideal scenario is not pie in the sky, but quite feasible. All those countries in Western Europe and Scandinavia where midwives handle prenatal and birth care for low-risk women exclusively have lower mortality rates for birthing women and their babies than the United States does.

In Japan, the network of midwife birth houses provided a significant cadre of independent midwives in the first half of the twentieth century. But after World War II, during the American occupation, the Americans not only insisted that birth houses be closed but insisted that all midwives must train first as nurses and must work under the supervision of obstetricians. Until then, Japan had not medicalized birth but handled it as a normal part of the life cycle and as a normal part of Japanese family life. The country had a large, strong, independent midwifery profession. The U.S.-imposed
restrictions resulted in the tragic loss of this cultural tradition, but independent midwifery did not die. As it was not against the law, a few obstinate, independent midwives maintained their birth houses. As soon as the Americans left, a resurgence of birth houses in Japan began, and more and more midwives are leaving hospital practice to work as community midwives in birth houses. This Japanese experience confirms what we have seen in the United States, that in the end, attempts to eradicate midwifery are not successful. In every society, there will always be midwives working to maintain women's freedom to control their own reproductive lives, and there will always be women who will avail themselves of midwifery services.

In July 2001, while in Tokyo, I met with fourteen leading obstetricians from the Japanese Society of Obstetricians and Gynecologists (all men). We discussed current obstetric practices in Japan, and they voiced their opposition to birth houses. When I asked why they opposed birth houses, they replied that they are dangerous. I then asked if they had scientific evidence that birth houses are dangerous, and they admitted that they did not. The resurgence of birth houses in Japan continues, despite this obstetric disapproval. There are many lessons to learn from Japan. Two that are particularly relevant: It is difficult for an occupying army to impose changes to something as basic to a country's culture as childbirth, and even in a society as patriarchal as Japan, women still play a central role in their own reproductive lives and are somehow intuitive enough to ignore unjustified warnings from high-ranking men.

In New Zealand, the maternity system is similar to Scandinavia's, but a woman having a low-risk pregnancy can choose either a midwife or a family physician to provide her prenatal and birth care, and whichever provider she chooses receives the same flat fee for all the woman's maternity care, covered under the country's national health service.

Canada is a particularly relevant model for the United States for using midwives for primary maternity care for low-risk women. Until recently, Canada was the only country in the world besides the United States to banish midwifery, making it possible for doctors to take over the care of low-risk pregnant and birthing women. But then something extraordinary happened. In the 1980s, a midwife in Toronto transported a woman having a home birth to the hospital, where the baby died. The obstetricians in the hospital notified the police, and shortly after, an inquest was called to investigate the midwife because midwifery was illegal. As in the United States, midwives had gone underground decades earlier, due to persecution by a coalition of doctors, nurses, and politicians. But, of course, some
women still wanted to have home births, and there were always underground midwives to attend them.

The lawyer defending the midwife in Toronto had great difficulty finding a Canadian physician willing to testify at the inquest, and I was invited to come and testify.
²⁷
The inquest had a jury of twelve, and I spent about six hours on the stand. My goal was to educate these twelve Canadians about midwifery, a profession they knew nothing about. At the end of the inquest, the jury recommended to the government that it investigate the possibility of legalizing midwifery—the opposite of what the obstetricians who reported the midwife to the authorities had intended. This case was the beginning of a long struggle to reestablish midwifery in Canada. This struggle was not always easy. At one point, a top physician/official in a medical organization in Quebec Province stated that if Quebec legalized midwifery, it might as well legalize prostitution too. Today, twenty years after the coroner's inquest in Toronto, midwifery is legal in every province of Canada and there are midwifery schools gradually training enough midwives to attend all low-risk pregnant and birthing women in Canada.

As part of this process, the editor of the
Journal of the Society of Obstetricians and Gynecologists of Canada
contacted me and told me that he, like most Canadian-born obstetricians, knew nothing about midwifery until he was lucky enough to be exposed to the profession while doing postgraduate training in the United Kingdom, where midwives are the designated professionals assisting all woman having low-risk births, as they are in other parts of Europe. He wanted to help educate Canadian obstetricians about midwifery and asked if I would write an article for the organization's journal reviewing all aspects of midwifery, including the scientific evidence for midwifery practice. I agreed and wrote the article, which was published in his
Journal
.
²⁸

Canada's experience in reestablishing direct-entry midwives as primary care providers for low-risk women has lessons for the United States. Even in countries such as the United States and Canada, where the present generation of doctors has no experience with midwifery, nor does the public, it is still possible to introduce midwifery, although it takes time. If a few obstetricians understand the importance of midwives, it is important to use them to promote changing attitudes. In time, educating the public and politicians leads to legislation, which essentially forces doctors to adapt to the change, and over time gradually come to accept it.

As described earlier, there are also areas of the United States where midwives provide primary care to low-risk pregnant and birthing woman,
specifically Taos, New Mexico, and The Farm in rural Tennessee. There are also hundreds of independent direct-entry midwives and nurse-midwives across the United States assisting women in planned home births. And an even larger cadre of nurse-midwives in the United States are bringing midwifery care to a significant group of women having hospital birth. So inroads have been made.

It is interesting that some of the important innovations in maternity care in the United States have occurred in the country's more remote areas. Midwifery made a comeback in the United States when no one else wanted to attend births in Appalachia. A group of nurses trained to become nurse-midwives and created a new profession.
²⁹
In
chapter 5
, I discussed a case where the value of midwifery was proven in Madera, California, in a natural experiment that compared midwife-attended birth with doctor-attended birth in a rural community hospital.

Some of the most progressive legislation and practice of midwifery in the United States continues to go on in rural, less populated settings such as New Mexico and Oregon. In these two states, not only are direct-entry midwives licensed, there are state midwifery boards separate from the state nursing boards, and the midwifery boards are made up of direct-entry midwives who investigate complaints. So in these states, midwifery practice is regulated by true peers. I was invited to observe a meeting of the New Mexico State Midwifery Board. As I left, there was no doubt in my mind that the midwives on the board were committed to strengthening midwifery in their state.

In sharp contrast, I have attended meetings at the state nursing boards in Washington State and South Dakota. These boards are responsible for regulating midwives as well as nurses, but both boards are made up entirely of nurses. In these board meetings, the members were openly hostile to direct-entry midwifery and repeatedly expressed the opinion that only nurse-midwives should be allowed to practice.

In more rural states, there may occasionally be a local doctor who manages to get a local district attorney to bring groundless charges against a local midwife (as happened in a small town in Oregon in 2005), but generally, the public and the authorities are quite positive about their midwives. This suggests that midwifery can flourish in the United States in areas where there is less pressure from organized obstetrics to limit midwifery practice because practice in those areas is less attractive to doctors. Perhaps a key to shifting to midwifery for low-risk births is to establish laws or other disincentives that make that practice less appealing to doctors.

Throughout the United States currently, there are group practices that include obstetricians and nurse-midwives, and some of these groups allow a woman having a low-risk birth to choose a midwife rather than a doctor as her primary birth attendant, if she prefers. In some of these groups there is tension because the midwives find it difficult to practice full midwifery with obstetricians looking over their shoulders, but these tensions can often be worked out with a great deal of learning on both sides. These groups represent another precedent, a proven track record for having midwives provide pregnancy and birth care for low-risk women in the United States. Although these mixed groups are not by any means an ideal model, they are certainly a step in the right direction on the way to having all low-risk women assisted by midwives. Gradually the mix in these groups can evolve to increase the number of midwives and reduce the number of obstetricians, so that midwives handle all low-risk pregnancies and births and obstetricians handle only high-risk pregnancies and births.

Some believe that women should always have the right to choose to have an obstetrician “attend” their childbirth, and I would expect those opinions to continue for awhile in a future in which midwives are the primary care providers for women having low-risk pregnancies. In response to these people, I believe we must look to the precedents that already exist for limiting patient choice to safe and appropriate alternatives.

If I have a brain tumor and want my general practitioner to do the brain surgery, it will not happen. Even if the general practitioner agrees to do it, there is no hospital that would allow it because of the high risk involved. There are many regulations and protocols in place in hospitals and states that govern what the various health care providers can do and how and when they can do it. The entire prescription drug system is also predicated on controlling which drugs a patient can purchase—without patient choice. So for reasons of safety, there are limits on what a patient can choose. If a practice is out of the scope of training and experience for a practitioner, as attending low-risk birth is for obstetricians (and will become more so over time), hospitals should not allow the practitioner to do the practice. When we consider the case of obstetricians handling low-risk birth, it is not only that they do not have the proper training and experience, it is not possible for them to give one-on-one
continuous
assistance throughout a woman's entire labor and birth. If it is not possible for them to provide what we know to be the safest service, they should not be allowed to provide the service. In the future, neurosurgeons will do brain surgery and midwives will attend low-risk births.

Obstetricians are absolutely essential in the overall system of care during pregnancy and childbirth. They are the experts in high-risk maternity care and should have primary responsibility for managing serious medical complications. However, midwives are the experts in normal birth and high-risk women still have many of the normal needs associated with all pregnancy and birth. For this reason, the team assisting a woman with a high-risk pregnancy should include a midwife.

Incorporating obstetric and midwifery expertise in an egalitarian team effort will be a key challenge in the maternity care of the future. How can midwives and obstetricians communicate effectively when they have such different models for birth and such different experience and skills? Who decides when a low-risk birth becomes high-risk?

One answer to the question of who decides is illustrated by my daughter's childbirth in a large hospital in Copenhagen, Denmark. She was having her first baby and received all her prenatal care from midwives. At 6
A.M.
on her due date, she began having contractions, so she went to the hospital. Because her labor was not yet active, a midwife at the hospital ruptured her bag of waters and sent her home. At noon she returned in active labor and was admitted by the midwife, who then attended her labor. Her cervix dilated slowly but steadily, until there was just a lip left.