Why America Needs More Midwives

The United States currently spends more money on health care than any other country, but still has the highest maternal mortality rate of 49 other developed countries[1]. This high rate is due, in no small part, to how medicine is practiced in the United States. To reduce these rates and join the developed world, a major shift towards the forgotten practice of midwife-led care needs to occur.

Midwifery has been a commonplace practice throughout recorded history and across every culture. Even today, developed nations across Europe and in Japan use midwives in a large number of births3. Since its founding, women in the United States also relied on midwives to assist in childbirth. However, the nineteenth century saw advances in medical knowledge and hygiene which were disseminated in university teaching, but not to the informal training received by midwives.

By the early twentieth century, the homeopathic and traditional practice of midwife-led maternity care seemed to be in stark contrast to the “modern” techniques practiced by physicians[2]. Medicine became more hospital-centered and pathology-oriented, as such midwives were thought of as undereducated and ill-prepared to deal with the dangers of childbirth. Attitudes quickly changed regarding the role of midwives resulting in obstetricians increasingly taking their place.

Midwifery soon became a relative novelty in the United States, and by 1935, less than 15% percent of births were attended by a midwife, even though infant mortality increased by 41% due to obstetrical interference in birth[3]. In fact, a project conducted in the early 1970s found that when midwives were sent to a rural, medically underserved community in California, prematurity and infant death rates decreased significantly only to increase again once the midwives left and were replaced by physicians2.

Despite this, the vast majority of births in the United States continue to take place in a hospital and are attended by a physician. In general, Americans are skeptical of homebirths and midwifery as only 1% of births are conducted at home, and only 8% of total births were attended by a midwife. In the modern age, the role that midwives used to play in the birthing process has been largely forgotten.

One of the major causes of the U.S.’s high maternal death rate is the use of potentially unnecessary surgeries and other interventions. A third of all births in the U.S. are C-sections, despite the World Health Organization stating that cesarean section rates above 10% increase infant and maternal mortality rates.

When medically necessary, a C-section can save the life of the mother and child, but physicians in the U.S. perform them to expedite the labor process. Elective C-sections can open a mother up to complications like infections and blood clots which could increase the risk of maternal mortality.

Conversely, the midwifery model of childbirth focuses on allowing labor to progress naturally, using medical interventions only when absolutely necessary. This model seems to have worked in other developed countries that have a much lower infant and maternal mortality rates. In England, for example, midwives are the primary care providers in about half of all pregnancies, with obstetricians providing care to patients who require special attention.

Medically unnecessary C-sections are not the only reason to adopt a midwife-led model of maternal care. To reduce infant and maternal mortality rates, maternal care must be treated as a continuum wherein we address “maternal health from wellness to morbidity to severe morbidity to death” to reduce pregnancy-related causes of death. Unfortunately, in the United States, quality health care that would cover this continuum is often restricted due to high costs, lack of insurance, and discrimination.

Considering that access to quality health care remains woefully inaccessible for some American women (forcing them to forgo even basic prenatal care), midwives can help fill the gap. Thus, a move must be made to a model of health care where midwives play a central role in maternal care through pregnancy, childbirth, and the postpartum period to reduce infant and maternal mortality rates.

One of the major causes of the high maternal death rate in the U.S. is the overuse of non-medically necessary medical interventions like episiotomies and cesareans1. Studies have concluded that a midwifery model of care reduces the amount of unnecessary medical interventions and out-of-hospital births “generally provide a lower risk profile than hospital births.”[4]

Also, a shift to a midwifery model of care in the U.S. will introduce a greater diversity of care for American women. Midwifery and obstetric care can complement each other and give women greater choice and knowledge when they plan their prenatal, delivery, and postpartum care. This could also help reduce the large price tag associated with giving birth by reducing the need for costly hospital stays.

Transitioning to a midwifery model of care, similar to the one in England mentioned previously, would not be difficult. We have written extensively on how simulation can provide learners with the opportunity to rehearse and master vital medical skills in a safe environment. Through simulation training, a new generation of certified nurse-midwives (CNMs) and certified midwives (CMs) could meet the health care needs of women.

Skills trainers like ZOE® and Super OB Susie® can help trainee midwives learn, practice, and master essential gynecological examination and labor and delivery skills through hands-on training. Through simulation, midwives can address the continuum of maternal care that is out of reach for many women in the U.S.

Starting from basic gynecological care, midwives can use Zoe to assess a patient as part of a routine gynecological exam, so they recognize normal and abnormal physiologies like polyps and cysts. Super OB Susie can help learners become familiar with how a normal pregnancy should progress and rehearse lifesaving maneuvers like McRoberts’ and Pinard’s.

These skills trainers are portable, inexpensive, and require no power to run meaning they can be used anywhere. This making them a valuable teaching tool in poorer and rural communities that are especially underserved due to a lack of practicing physicians. Introducing trained midwives into these communities could have a significant positive impact on the lives of women in these communities.

For universities and midwifery schools, an advanced full-body simulator like Victoria can bring a substantial level of realism and fidelity to a training program. Students can rehearse a full range of obstetrical events, so they hone their critical thinking and medical skills. Not just midwives, but obstetricians can use Victoria to refocus their training to use surgery only when necessary. When surgery is needed, Victoria’s lifelike features allow learners to practice surgical skills like a C-section and episiotomy repair.

Midwifery was once an important profession in the United States. Considering the failure of the U.S. health care system to reduce maternal mortality rates, the U.S. should return to a midwifery model of care. Change is already happening gradually. Since 1989, the percentage of midwife-attended births has risen every year and so has the percentage of out-of-hospital births attended by a midwife. Although small, a growing number of people recognize the importance of midwife-led care. An effort must be made to increase these numbers because childbirth should never end with tragedy.

[1] Amnesty International. Deadly delivery: the maternal health care crisis in the USA. Amnesty International Publications, 2010.

[2] Brucker, Mary. History of Midwifery in the US. UT Southwestern Medical Center, 2000. Web. 19 Feb. 2018.

[3] Rooks, Judith. “The History of Midwifery.” Our Bodies Ourselves, https://www.ourbodiesourselves.org/health-info/history-of-midwifery. Accessed 19 Feb. 2018.

[4] MacDorman, Marian F., T. J. Mathews, Eugene R. Declercq. “Trends in Out-of-Hospital Births in the United States, 1990–2012.” National Center for Health Statistics, https://www.cdc.gov/nchs/products/databriefs/db144.htm. Accessed 8 Feb. 2018

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