Childbirth is no longer the mystifying, women-only topic it used to be. Nowadays, fathers are allowed in the delivery room, and sometimes even “catch” the baby. That is, if the hospital allows it, and if the hospital allows men in there at all. And only if there is a baby to catch, rather than a baby that is pulled out surgically by the obstetrician.
To avoid all these “ifs,” many families are choosing to work with a midwife who will help them deliver their baby in the comfort and security of their own home. It used to be so in day’s past and today’s high standard of hygienic care, nutrition and available information make the homebirth option safer and more appealing than ever.
There are several different types of midwife. The nurse midwife (CN and CNM) require college degrees and/or a nursing degree. These nurse midwives are required to have a working relationship with a practicing doctor. They are trained in the medical model of health-care and are not familiar with natural childbirth. They seldom participate in homebirths because it is difficult to get doctor back-up. The CPM, or certified practicing midwife, is a direct entry midwife who has completed training in midwifery school or through midwife curricula, and who has had ample experience attending normal deliveries.Midwifery Saves $
As many families know, the cost of delivering a baby in the hospital can be very high. The average cost of a midwife-attended birth in the U.S. is $1,500, compared to up to $4,200 for a physician-attended vaginal birth. The midwives’ lower rates do not reflect lower quality of care or standards of births. In fact, they clearly represent the opposite. Educating a direct-entry midwife typically costs between $300 and $15,000, compared to $150,000 to $200,000 to educate one obstectrician-gynecologist. This high cost of obtaining a medical education often requires an Ob/Gyn to serve a great many patients and charge high fees to pay back his or her debt.
The majority of a midwife’s training is assisting and attending normal births, whereas an obstetrician may never have seen a normal delivery. The World Health Organization (WHO) recommends that “the curricula for the education of all health professionals should reflect the role of the midwife as primary caregiver in maternity care.”
What about the savings? Midwifery care is financially rewarding. Our nation could save a great sum of money — not thousands, not millions, but billions of dollars — by implementing the midwifery model of care. According to Dr. Frank A Oski, director of pediatrics at the Johns Hopkins University School of Medicine in Baltimore, from $13 billion to $20 billion a year could be saved in health care costs by developing midwifery care, de-medicalizing childbirth, and encouraging breastfeeding. Oski estimated the health care cost savings obtainable by utilizing midwifery care for 75% of pregnancies in the US at $8.5 billion per year.
Despite these financial rewards, relatively few midwives practice in the U.S.. Only 6 percent of U.S. births are attended principally by midwives compared to 75 percent of births in European nations. As of several years ago, only between 2,000 and 3,000 direct entry midwives were recorded as practicing midwifery in the United States, and only 3,000 certified nurse-midwives. The U.S. lags behind other countries in its level of midwifery care; for instance, to meet European numbers of midwives, the U.S. will need to increase its current level by 125,000. These numbers are especially revealing when we recognize that 100% of those countries that provide universal prenatal care have lower infant mortality rates than the United States.
The World Health Organization says that the preferred location for most births is outside the hospital, either at home or in a birthing center, and that the out-of-hospital birth should be implemented and maintained as the basic standard for all midwifery education and training programs. But sufficient services must be available for women to be able to choose homebirth. In many rural areas this is not the case. According to the official directory of board certified Ob/Gyns, in 1998 only 25 of the 100 counties in North Carolina had practicing obstetricians. That left 75 percent of the state’s counties without direct access to obstetrical-and thus prenatal-care. Certified Professional Midwives helped to fill in this gap, but without legal support, their effort is limited.Creating Options
Money, of course, is often the basis of a family’s decisions. But childbirth involves so many facets that a family must consider other aspects, such as emotional well-being, comfort, distance from caregivers, religion, maternal and fetal health, privacy, and independence. Carolyn Weaver, CPM, a practicing midwife in northeastern Tennessee (where midwifery is neither regulated nor illegal), promotes the option of homebirth for families.
“Midwife attended births are as safe or safer than hospital births,” she says, citing many European statistics and pointing to the incredibly low infant mortality rate in countries where midwifery is the norm. “Homebirth should be safe and accessible to all women, though so many women don’t even think of it as an option. Families need more education.
“People don’t know what happens in a hospital birth,” she says. “The epidural rate is around 90% in the United States. With an epidural, a woman often spikes a fever. If this happens, hospital staff treat the newborn baby as a sick baby, they separate him or her from the mother, they give ‘routine’ antibiotics ‘just to be safe’, and they interrupt the bonding process. Women don’t realize this. They’re not informed.”
Many people are confused as to how a midwife’s care differs from obstetrical care. Even though nurse midwives might be present in a hospital, Weaver emphasizes that this is still very different from an out-of-hospital experience. The midwifery model of care typically consists of lengthy prenatal visits (averaging 45-60 minutes versus 10-15 minutes with Ob/Gyns), emphasis on nutrition, out-of-hospital birth options, practitioners trained in normal birth, and continuity of care (one caregiver who sees a woman prenatally, who is a continuous presence during labor and birth, and who visits after her birth to help with breastfeeding and the transition into parenthood).
The religious right movement is responsible for a huge amount of homebirths today. Midwifery is one area in which the religious right and the radical left come around to meet in the middle — they agree on the issue of homebirth.
“This is not just a women’s issue,” says Weaver. “It’s a family issue. A global issue. When women give birth in a safe environment with minimal drug and medical intervention, our communities reap the rewards with smarter babies, healthier children and lower health costs (less asthma, ear infections, allergies), less autism, a higher incidence of breastfeeding, less ADD and ADHD. Homebirth, breastfeeding and bonding save money.
“There is also the ecology point of view,” she adds. “Homebirth generates minimal waste, while hospitals are pro-waste and use a great deal of ‘disposable’ materials. It’s an artificial environment, the family is cut off from nature. In a hospital, things are done TO you, not with you.”
Finally, says Weaver, it’s important that doctors utilize equipment and machinery only when it is necessary, “not just because it’s a bright idea or a routine.” This is called evidence-based practice. She cites as an example the overuse of Electronic Fetal Monitoring (EFM) during labor.
“EFMs do not improve outcomes and they actually increase Cesareans,” she says. “Their use increases a doctor’s interventions in what might otherwise be a normal delivery; EFMs are really used for litigation purposes.” Studies published in the last few years in such prestigious journals as The New England Journal of Medicine and The Lancet have shown that, in the absence of specific indications for its use, Electronic Fetal Monitoring not only has no demonstrated benefits in reducing childhood disabilities, but may even be dangerous.
Johns Hopkins University School of Medicine’s Oski estimates health care cost savings obtainable by eliminating the routine use of continuous Electronic Fetal Monitoring at $675 million per year. This may have a dramatic effect on reducing North Carolina’ current Cesarean section rate, which is 23%. “Commercialism and consumerism are propelling forward the surgical, medical, intervening, demoralizing model of hospital births,” says Weaver, “even for completely normal pregnancies.”
Jeannie Lucas, a Democratic Senator for North Carolina, is promoting a bill to legalize midwifery (CPM) in the state. Legality is state-by-state, which makes it difficult to gain national recognition and support. Weaver says there have been backhanded ways of stifling midwifery in the past. For instance, in a particular state midwifery may be “legal,” but the state stops issuing permits while still requiring midwives to have a permit to practice. To support the bill to legalize midwifery in North Carolina, email, call or write your congressmen, representatives and senators.
To find out your reps, go to www.ncga.org and use your zip+4; to find out your zip+4, go to usps.gov. Two worthwhile organizations to contact are The North Carolina Friends of Midwives at firstname.lastname@example.org or (252) 747-7785, and the North Carolina Midwives Alliance (NCMA) at email@example.com.