Friday, July 9, 2010
Midwives vs. Doctors in U.S. Maternal Mortality Crisis
She speaks of her experience tenderly. "I felt like giving birth was in my hands, having it at home," she says, "not on a doctor's schedule, in somebody else's hands. By the time my daughter was born, I felt like my midwife was a part of my family."
Kristine is one of more than 300,000 women in the United States who choose to give birth with the help of a midwife each year, and one of approximately 40,000 women who give birth at home. Both of her daughters, now aged 22 months and 11 weeks, were attended at birth by a midwife in Kristine's home. If she has another child, Kristine says, she will plan a home birth with a midwife.
The practice of midwifery in the United States is not a new phenomenon - the first midwifery school, the Frontier Graduate School of Midwifery, opened its doors in 1939 - but has been gaining popularity in the past three decades. Midwife-assisted births now account for approximately eight percent of all births in the United States.
Because midwifery as a profession is subject to individual state regulations and licensing, a wide spectrum of midwife qualifications exist, from Certified Nurse Midwives (CNMs), who most often hold bachelor's degrees and work in hospital settings, to Direct-Entry Midwives (DEMs), who train through apprenticeship and work in individual homes.
What all types of midwives have in common is a shared philosophy about birth experience.
Carolyn Keefe, a board member and consumer advocate for the organisation Citizens for Midwifery, explained to IPS that what underpins the profession of midwifery is a doctrine called the Midwives Model of Care, which is "a traditional approach that starts with individualised care and looks at the specific mother and her baby, her pregnancy, and her family - not as another cog in the wheel - and makes assessments based on what the mother needs."
The Midwives Model of Care is based on four practices: monitoring the physical, psychological, and social wellbeing of the mother throughout the childbearing cycle; providing the mother with individualised education, counselling, and prenatal care, continuous hands-on assistance during labour and delivery, and postpartum support; minimising technological interventions; and identifying and referring women who require obstetrical attention to the hospital.
In the United States, where adherence to traditional Western medicine is the norm, midwifery's emphasis on minimising technological intervention in the birth process has been viewed with scepticism and, in some cases, anger. Midwife- assisted home births in particular, where medical intervention is not an option, have sparked criticism from the medical community.
In 2008, the American Medical Association (AMA) passed a resolution stating that "the safest setting for labour, delivery and the immediate post-partum period is in a hospital or a birthing centre within a hospital."
The same year, the American Congress of Obstetricians and Gynecologists (ACOG) released a statement condemning the practice of home birth, asserting, "Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre."
Proponents of midwifery have been vocal in response to these decrees. Élan McAllister, president of the New York-based organisation Choices in Childbirth, told IPS, "The ACOG and the AMA have no control over home birth and little control over midwives. They have a long history of holding the authority when it comes to maternity and health care respectively and are not interested in giving away any of that power."
"The midwifery model, which views birth as normal rather than pathological, is such a departure from the more medical approach that it is difficult for them to view it as anything other than a challenge," she said.
Both doctors and midwives rely on raw data to bolster their arguments, but the significance of the numbers can be interpreted in a variety of ways. Both sides cite the appalling increase in maternal mortality rates in the U.S. as evidence to back up claims - in 2006, the last year for which data is available, the maternal mortality rate reached 13.3 deaths per 100,000 live births, double the 6.6 deaths per 100,000 live births in 1987.
In addition, one in three babies in the U.S. is now delivered via Caesarean section, a procedure that carries risks of complication.
In light of next week's World Population Day on Jul. 11, members of the international community have been focusing on issues such as maternal mortality rates.
An Amnesty International report entitled "Deadly Delivery: The Maternal Health Care Crisis in the USA" details a shocking statistic: In the U.S., women have a higher risk of dying of pregnancy-related complications than in 40 other countries, despite the fact that the U.S. spends more on health care than any other nation.
The medical community believes that hospital delivery will minimise such risks to the mother and baby; the midwife community stands in direct opposition to this claim.
One point that both sides can agree on is that a woman who chooses to deliver at home with the aid of a midwife must be a "low-risk" pregnancy, with no outstanding risk factors that could threaten the pregnancy, such as gestational diabetes or a history of gynecological problems. "High-risk" pregnancies need to be supervised in a hospital setting by a medical professional.
For women like Kristine, who had low-risk pregnancies, the idea of delivering a baby at home with the help of a midwife is not only preferable, but innate.
"I see a midwife as a woman who assists a mother in birthing," she says. "It's something she can do herself. The midwife is there if any problems should arise."
She pauses, adding, "Birth is a natural process. Since the beginning of man, women have given birth by themselves." She smiles. "That's what we do."
Violence against women is a worldwide yet still hidden problem. Freedom from the threat of harassment, battering, and sexual assault is a concept that most of us have a hard time imagining because violence is such a deep part of our cultures and lives.