Krystina Friedlander: U.S. spends more than other nations on childbirth, yet has a relatively high maternal mortality. There is another way
She says midwife attended births produce better outcomes. Yet they are from routine in U.S., as they are in other developed countries.
Editor’s Note: Krystina Friedlander is a professional childbirth doula in Cambridge, Massachusetts. She blogs about her work at Baraka Birth. The opinions expressed in this commentary are solely those of the author.
When we think of women dying from childbirth, the image that often comes to mind is of a mother dying in a small remote village, somewhere in a developing country. She is likely poor, not in a hospital, and has no access to the latest medical interventions and technologies that could have saved her life.
That mothers die around the world from a lack of access to modern health care is well known. Less known is how our own country’s excessive dependence on modern health care for the natural process of childbirth can harm and in some cases kill.
According to the United Nations, between 1990 and 2008, the global rate for maternal mortality decreased by 34%. During that same period however, the maternal mortality ratio – that is, deaths per 100,000 live births – nearly doubled within the United States, from 12 to 24. Despite spending more per birth than any other nation in the world, cumulatively over $50 billion annually, in recent studies of maternal mortality rates, the United States is ranked just 28th overall, behind countries like Kazakhstan and Montenegro.
How did we get here? I would argue that as childbirth in the United States moved from the home to the hospital, mothers lost one of the most effective resources for healthy childbirth: midwives.
Midwives are trained professionals who specialize in pregnancy and childbirth. In most countries, they also provide prenatal and postnatal care. Midwifery has existed as an occupation for millennia. One of the first recorded references to midwifery is in the Ebers Papyrus from Ancient Egypt, which recognized midwifery as a female profession. In Ancient Rome, midwives were highly valued by their male doctor counterparts.
That respect, however, waned with the creation of the modern hospital in the 18th and 19th centuries as medical men asserted that modern scientific techniques were better for mothers and their babies, even though that wasn’t always the case. (Doctors at the time were still regularly carrying out barbaric procedures like symphysiotomies, which involved using a hacksaw to break a pregnant woman’s pelvic bone, and routinely passed deadly infections on to laboring mothers.)
By the early 20th century, doctors and medical associations began to push for legal monopolies on obstetrical care and launched smear campaigns against midwives, labeling them “incompetent and ignorant.” Midwifery became regulated and even outlawed, nearly disappearing from the American birthing experience altogether.
Although consumer demand led to a reintroduction of midwifery to the United States in the 1960s, as of 2009 midwives were delivering 8% of U.S. births.
This number represents mostly certified nurse-midwives, who specialize in midwifery after completing a nursing degree and graduate studies at an accredited nurse midwifery program and work mainly in hospitals and birthing centers – and attend a relatively small number of home births. The remaining midwives are professionals who attend births in people’s homes. These home birth midwives can have a range of professional certifications and trainings, which vary from state to state.
We know midwives’ presence is linked to better birth outcomes, especially for low-risk women. In the United Kingdon, where the maternal mortality rate is a third of the U.S. rate and childbirth is a fraction of the cost, midwives attend 68% of all births. A 2014 study by the UK National Institute for Health and Care Excellence found that healthy women with low-risk pregnancies are safer giving birth under the care of midwives than doctors. The study further recommended that regardless of where a woman chooses to give birth, a midwife should always be present.
Why? One likely factor is that midwives are far less likely to use unnecessary medical interventions, whether in a hospital maternity ward, an independent birthing center or in a home setting. The midwifery model of care regards childbirth as a normal process, which for most women and babies happens safely with minimal intervention, or ideally none at all.
Pregnant women in the United States, however, are exposed to a wide variety of medical procedures during the prenatal period, childbirth, and postpartum, despite the fact that the American College of Obstetrics and Gynecology found only a third of these procedures are based on quality scientific evidence.
For example, while a cesarean birth can be a life-saving operation when necessary, a number of nonmedical factors influence why American women have C-sections, including the culture of the hospital, medical practitioner’s preferences and beliefs, and hospital liability policies. Although nearly a third of births in the United States today are cesarean births, there are no studies that show C-sections improve birth outcomes. In fact, the American College of Obstetrics and Gynecology recently stated that the rising cesarean rate among low-risk women actually contributes to maternal mortality.
It’s an unsurprising assessment, given that we already know surgical birth is associated with increased risk of infection and the potential development of lifelong health challenges for mothers. Babies born by C-section are also at risk for various health issues, such as obesity and asthma. Elective inductions, another medical procedure that is often unwarranted, can increase the likelihood of a cascade of interventions that ultimately ends in a C-section
For the vast majority of women who die from childbirth in the world, access to doctors, hospitals and the latest medical interventions and technology would likely have saved their lives and the lives of their babies. The same is true for women with high-risk pregnancies. But for the 85% of American women every year whose pregnancies are considered low-risk, there need to be viable alternatives to standard hospital delivery practices.
Midwifery should be incorporated into pregnancy care at hospitals across the country, so expectant mothers can make a fully informed decision on how and where to give birth. True, the United States has better maternal care than many other countries. But to decrease our maternal mortality rates, midwives could be, for the U.S. health care system, just what the doctor ordered.