Each year, more than four million babies are born in the US, the lion's share of them in hospitals. Indeed, childbirth is the most common reason for hospitalization within the 50 states.
It wasn't always this way. At the turn of the 20th century, more than 95 percent of newborns entered the world at home, with the aid of midwives. Today, however, the tables have turned. According to statistics from the Centers for Disease Control and Prevention, less than 1 percent of births are presently done outside hospitals. In fact, in 2009, only 29,650 were tallied. Surprisingly, this tiny number represents a 29 percent jump, from .56 percent of births in 2004 to .72 percent five years later.
Before we address this trend, let's step back. According to Ina May Gaskin, winner of the 2011 Right Livelihood Award - aka The Alternative Nobel Prize - and the so-called "mother of modern midwifery," midwifery fell out of favor following its demonization in the decades after the Civil War. "Midwifery was destroyed a century ago, in large part, because US midwives had not organized and established midwifery as a profession. The anti-midwife propaganda campaign carried out by organized medicine was not countered by any collective argument from midwives. This is why medicine was able to destroy midwifery with so little expense and effort," her web site states. Add that era's pervasive xenophobia and the fact that most midwives were European-born and trained and you had an ample breeding ground for political backlash. In addition, doctors argued that the pain of childbirth would be diminished if "modern" obstetricians in "modern" facilities handled it. The campaign worked: By the middle of the 20th century, most states had outlawed midwifery, and in-hospital births, attended by university-trained male physicians, became the norm. Female midwives, who had practiced for decades, were shunted aside.
The results have been horrific.
According to Amnesty International, the US presently ranks 50th in terms of safe labor and delivery. Said another way, this means that women in 49 countries have better birth outcomes than women in the US of A. "Deadly Delivery," a 2010 Amnesty study that was updated last year, reports that despite annual expenditures of $98 billion, 12.7 of every 100,000 American women die in childbirth. Predictably, if we look at communities of color, rather than overall numbers, the findings are worse: Women of color are three to four times more likely to die giving birth than their white counterparts.
Midwives and natural childbirth advocates agree that poverty, poor nutrition, inadequate prenatal care and substance abuse factor into the maternal death stats. At the same time, they add that the medical system itself is at least partially culpable for the deplorable numbers. By treating pregnancy as an illness to be cured, they argue, medical professionals typically bristle at the idea of letting nature take its course. Instead, nearly one-third of babies - 32.9 percent, more than double the 15 percent recommended by The World Health Organization - are presently delivered by Caesarian section (C-section). According to Gaskin, this puts women at risk of infection and is rarely needed. "U.S. women today face at least double the chance of dying from pregnancy or birth-related causes than their mothers or grandmothers," she wrote in her 2011 book, "Birth Matters." "No one can point to any real gain that has come from the increased numbers of surgical births. We can't say, for instance, that it has made birth safer for babies. Credit for the reduction in newborn death rates that have taken place since the seventies belongs to innovations in neonatology, not to higher C-section rates."
Now, let's turn back to midwifery and the business of birthing babies. Experts agree that approximately 85 percent of US women begin labor at low risk of complications. Nonetheless, costly high-tech interventions are more rule than exception. Sadly, though, induced labor using synthetic hormones to speed up contractions, epidurals and other drugs for pain management, continuous fetal monitoring and escalating numbers of C-sections, have done little to reduce mortality rates for either mother or child.
When the process is flipped to in-home, midwife-assisted deliveries - with transfer from home to hospital only when complications arise - outcomes improve. To wit: More than 50 studies conducted since the mid-1980s have concluded that home births involving low-risk women are as safe or safer for mother and child as hospital deliveries. Midwifery is also cheaper: Approximately $4,500 versus $10,000 for a vaginal delivery or up to $30,000 for a C-section.
Full Circle Family Care, a midwifery practice in Mamaroneck, New York, outlines the philosophical difference between medical and non-medical care models: "The medical model and the midwifery model are essentially different ways of looking at women and birth ... Midwives understand that pregnancy is not an illness. Midwives trust in women's bodies and their capacity to give birth successfully with little to no intervention. Obstetricians tend to focus on what can go wrong during pregnancy and birth." In short, midwives focus on the normal and spend time mothering expectant moms. Prenatal visits, for example, can run 60 to 90 minutes and address everything from managing stress to watching for possible pre- and post-delivery complications.
And midwives are well trained to do this. At the present time, midwives fall into two categories. Certified Nurse Midwives (CNMs) are advanced practice registered nurses who have studied ante-natal and postpartum care as well as gynecology. This enables them to provide a range of well-woman services to females of all ages. While most focus on labor and delivery, they are qualified to offer care both in and outside of hospitals. CNMs work legally and their services are usually insurance reimbursable.
Certified Professional Midwives (CPMs), on the other hand, practice legally in 27 states only and risk arrest for "practicing medicine without a license" in the 23 states that disallow their work. Like CNMs, they are highly skilled, typically putting in 1,350 clinical contact hours, apprenticing with an experienced midwife and passing numerous certification exams before setting up shop. Their training emphasizes when and how to move a patient to the hospital in case of complications and they frequently work in tandem with CNMs and other medical professionals.
"Most people are under the impression that birth is unpredictable and treacherous," says Jana Studelska, a Minnesota CPM and press officer for the Midwives Alliance of North America. "It's not. What we're up against is fear-mongering that tells people that home births are inherently dangerous. This is a social justice issue. After I had a home birth, I saw with such clarity that a bill of goods was being sold, that parenting has been turned into a commodity and sold back to us."
Fear-mongering, of course, can be potent and make even the most resolute parent to be questions their decision to give birth at home. The arguments of activists like Dr. Amy Tuteur appeal to emotions by describing worst-case scenarios. Taking issue with CPMs like Studelska, Tuteur wrote, "Since childbirth is inherently dangerous, interventions are simply preventive medicine ... Childbirth is and always has been a leading cause of death of young women. For babies, the day of birth is the single most dangerous day of their entire 18 years of childhood." Other anti-home-birthers take a different tack, implying that only back-to-nature hippies with an aversion to technology choose to avoid hospital delivery rooms.
"There are a lot of stereotypes about women who give birth at home," says Katherine Prown PhD, campaign manager for an advocacy group called TheBigPushforMidwives.org. "Research shows that they are not only crunchy granola types, but college-educated women and members of the Amish, Mennonite and Orthodox Jewish communities."
Mary Ann Griffin, a CPM active in the Indiana Midwives' Association, becomes incensed when Dr. Amy and others raise the issue of safety, as if to imply that midwives are careless or lackadaisical. "The evidence has been repeated again and again," she began. "Homebirths with well-trained CPMs are safe, but if the doctors who argue that this is a safety issue are so concerned, they should establish a mechanism to work with CPMs when necessary. We should be licensed to practice. Licensure Boards would allow care to be managed efficiently and would mean that every midwife in every state would be held accountable for her work."
Until this occurs, however, CPMs in 23 states will continue to work in the shadows, functioning as an underground network of caregivers. Several recent arrests highlight what's at stake for those who defy the law. "No CPM enters the profession to be an outlaw," Prown of TheBigPushforMidwifery.org quipped.
But in essence that's what at least some of them have become. Just ask Ireena Keeslar or Jeannie Stanley, Indiana midwives who were arrested this spring. "It's important to understand that they were not arrested because of a bad birth outcome," Griffin continued. "Stanley had been a CNM, but had let her license lapse, so that gave the state an opening to go after her. Still, I think the arrests happened because local hospitals would like all the business for themselves. Indiana is one of the states with substantial criminal penalties for practicing midwifery without a license. It's a class D felony. If these women are convicted, they'll have to pay a huge fine and could serve three to five years in jail. The solution is licensing. We've had a CPM licensing bill stalled in the Indiana statehouse since 1995 - 17 years."
Griffin also pointed out that, despite the arrest risk, CPMs continue work because, if they don't, low-income and rural women will have little access to obstetrical care. "Numerous small local hospitals, especially in the country, have closed their maternity care units because of financial pressures," she said. "People in these areas have to travel 40 to 60 miles for a hospital delivery."
For Griffin, the key is licensure, which is why she is pushing not only for state regulation, but for Congressional passage of HR 1054, The Access to Certified Professional Midwives Act. The Act would allow Medicaid to reimburse CPMs for their work, regardless of setting and is a top priority of MAMA, Midwives and Mothers in Action.
"Out of hospital midwifery care is still reserved for the affluent in most states," said Robin Hutson of the Foundation for the Advancement of Midwifery. "We need a federal mandate for Medicaid reimbursement, so midwives can legally do what they were trained to do. We know that racial and class disparities shrink when midwifes provide prenatal care and deliver babies. The poor deserve access to midwifery, which is why passing HR 1054 is so important. It's a matter of justice."
Medicaid currently pays for CPM services in just 12 states, and while the Affordable Care Act requires reimbursement for licensed practitioners, unlicensed CPMs are currently unable to receive funding. "Forty-five percent of US births are paid for by Medicaid," Prown said. "Babies born under the care of CPMs and CNMs are more likely to be full-term and normal birth weight. If we extend midwifery to women on Medicaid, it will address some of the racial disparities in birth outcome."
Miriam Zoila Perez is a doula, trained to offer emotional support to women during pregnancy, childbirth, abortion or following a miscarriage. High infant and maternal mortality rates and the overuse of medical interventions need immediate attention, she said. "We're up against a 100 year PR campaign on behalf of obstetricians and gynecologists. US healthcare follows a business model and the question is whether this is best. There's a maternity care crisis in this country and if you compare our system to international models the numbers are clear. Given how much we spend and how bad the outcome is, something pretty radical is needed."