MIDWIFERY IS NOT THE PRACTICE OF MEDICINE

by Suzanne Hope Suarez

RN, BSN., J.D., AAUW Educational Foundation National Fellow, 1991-1992. chair, Healthy Start Coalition Advisory Board for Florida, 1991. Florida Bar Foundation Public Service Fellow, 1989-1992

 

from the Yale Journal of Law and Feminism

 

Note: the Footnotes (in red) are listed separately so that you may read them simultaneously with the text of the article. Click here to move to the footnotes page.

 

For the great majority of American women, the right to choose the place and manner of giving birth has quietly, but continually, narrowed.1 In just half a century, allopathic physicians2 in the United States have enticed ninety-nine percent of us into their places of business (hospitals) for childbirth, forced on us a medical model of birth that has never been proven safe or beneficial, raised the price of services which have diminished in quality and quantity, and lobbied state legislatures for laws that would require us to submit to their exclusive control during pregnancy and childbirth.

 

Unfortunately, the role of obstetrics has never been to help women give birth. There is a big difference between the medical discipline we call "obstetrics" and something completely different, the art of midwifery. If we want to find safe alternatives to obstetrics, we must rediscover midwifery. To rediscover midwifery is the same as giving back childbirth to women. And imagine the future if surgical teams were at the service of the midwives and the women instead of controlling them.3

 

Although obstetricians worldwide use the same sophisticated technology and drugs in pregnancy and childbirth as American physicians, doctors in other countries use them differently.4 Doctors in the country with the lowest infant mortality rate, Japan, use little or no drugs and are much slower to interfere with the natural process of birth.5 In the United States, the economic alliance between doctors and the producers of technological equipment has obstructed preventive maternity care. "Medical priorities are set by the medical industrial complex, which focuses on providing health care at a profit.6

 

In Europe, the infant mortality rate is significantly less than in the United States.7 An important attitudinal difference accompanies this statistical difference. Europeans consider birth to be a normal event, and midwives deiiver the majority of babies.8 The European Economic Community standards for midwifery education and training programs require three years of intensive study and apprenticeship.9 Many European'midwives10 work without physician supervision and are not required to study nursing as a prerequisite to rnidwifery training.11 Decades of misinformation and misapprehension, on the other hand, have taught women in the United States that birth is a dangerous and pathological event, requiring care by medical specialists.12 Obstetricians far outnumber midwives in our country and the excellent statistics of the midwives are a well-kept secret.13

 

Significantly, Dr. J. G. Kloosterman, former Professor of Obstetrics and Gynaecology at the University of Amsterdam and Director of the Midwives Academy in Holland from 1947 to 1957, has noted that obstetricians cannot improve upon nature: "By no means have we been able to improve spontaneous labour in healthy women. Spontaneous and normal labour is a process, marked by a series of events so perfectly attuned to one another that any interference only deflects them from their optimum course.14 The capacity to intervene has led to the notion that intervention is always desirable, even though "[t]here is strong evidence that modern western obstetrics is perverting the physiology of human parturition.15 The obstetrician, says Kloosterman, is always on the lookout for pathology, eager to interfere, and the interferences themselves cause pathology that then needs further "treatment."16 Dr. Marsden Wagner, Director of the World Health Organization's (WHO) European Regional Offlce, told doctors at an international medical conference in Jerusalem that hospital births "endanger mothers and babies&emdash;primarily because of the impersonal procedures and overuse of technology and drugs."17 The very surroundings and equipment in hospitals increase the risk of iatrogenic, or "doctor-caused" complications18 which result in excessively high costs to consumers.19

 

In her 1975 book, Immaculate Deception, Suzanne Arms described the manner in which obstetricians justify preventive interferences during childbirth "to [turn] sloppy old nature into a clean, safe science:" [J]ust in case you hemorrhage, we'll give you simulated hormones before you expel the placenta; just in case your perineum tears, we'll make a nice clean incision before delivery; just in case labor tires you out, we'll give you an early sedative; just in case you need a general anesthesia [for an emergency caesarean], we'll keep a vein open [put in an IV] and stop you from eating and drinking throughout labor, even if it takes twenty-four hours; and just in case you totally lose control, we'll knock you right out ...20

 

According to Arms, it is no wonder that a pregnant woman believes that birth is "loaded with unpredictable horrors that only her doctor can prevent.21 The "normal" length of the stages of labor has been shortened in medical texts, allowing for earlier medical intervention.22 The length of the stages of labor for hospital births in the 1940s and before was actually longer than the length of labor in home births in the early 1970s in which nature was allowed to "take its course."23 Nevertheless, by the late 1960s and 1970s, labor in hospitasl births was nearly five hours shorter than in home births, with an apparent increase in fetal distress and other complications.24 Hospitals and doctors push the birth process along to assure that a certain number of deliveries will occur when the meximum number of personnel are available&emdash;in other words, during office hours. Waiting for the natural process to occur spontaneously does not serve "institutional needs."25

 

Although prolonging a pregnancy beyond forty-two weeks can be risky, inducing labor does not increase the baby's chances of survival.26 Drug-induced labor after forty-two weeks, however, is a routine practice.27 Hospital rituals and interventions in the birth process comfort the obstetrician who may otherwise have to deal with feelings of uncertainty about the birth.28 By managing normal birth in the same way as 'abnormal birth,' doctors make each birth more predictable.29

 

If professional midwives conducted the majority of births, women with completely healthy pregnancies could feel protected from unnecessary obstetrical interferences. The midwife screens her clients carefully so that she takes only low-risk cases. She is trained to recognize abnormalities and is fully capable of transferring a woman to a hospitai safeiy during labor if necessary. Dr. Kloosterman estimates that under midwifery care, only three to five percent of healthy mothers would require physician care during delivery.30 If physicians were consulted in only three to five percent of cases, he states, the infant mortality rate would drop to between two and four in one thousand.31

 

Most women attended by nurse-midwives in our hospitals are poor African Americans.32 The white population, which generally tends to be healthier, is more likely to be attended by specialist obstetricians. It seems no coincidence that this healthier, and thus lower-risk, group which is nevertheless more likely to be treated by an obstetrician, has more caesarean sections.33 If mothers and babies were the paramount concern of the physicians, the increased incidence of caesarean sections would statistically peak within the "higher-risk" black population where their use could be justified. Instead, these expensive interventions are applied to those who can pay the most.34

 

Economics is the hidden agenda when midwifery regulation is discussed in state legisiative sessions. In testimony before legislative committees, the medical lobby overemphasizes the potential of pregnancies to become pathological.35 Though pathology occurs in only a small minority of pregnancies, many legislators are convinced that physician treatment should be required for the safety of mother and infant.36 Implicitly, under this medical model of pregnancy and birth, the profession of midwifery is subordinated and maternity care becomes "the practice of medicine" subject to state statutes that regulate the practice of medicine. No evidence exists, however, that this system is actually safer than home birth with a competent midwife. Public health experts and researchers are recognizing that midwifery will not disturb the system of obstetrics. Instead, international research indicates that the two professions are compatible, complementary and necessary to each other for an efficient and cost-effective system of care.37 The fallacy-ridden dominant belief that "home birth is dangerous"38 makes it relatively easy for the medical lobby to convince lawmakers that pregnant women who reject doctor control endanger themseives and their babies and that midwives are safe practitioners only if they are also nurses. Physicians cite the safety of the infant (and, secondarily, the mother) as a primary concern. Doctors have successfully prioritized the rights of the unborn39 and maintained control over the wishes of the parents who pay their fees. Ironically, consumers are afforded little control even though they, not the physicians, bear the ultimate responsibility of pregnancy and birth.

 

Strained economic times and grossly high infant mortality rates have led states to consider midwifery as a way to make maternity care accessible and affordable in spite of doctors' protests. In the 1992 Florida legislative session, House Bill 553, proposing the legalization of three-year training schools for direct-entry (non-nurse) midwives, was heatedly debated.40 Although the direct-entry schools were based on the European training model and the Senate Health Care Committee had studied and recommended passage of the bill, the Florida Medical Association (FMA) opposed it.41 The FMA told the lawmakers that "Many midwives do not have the education nor the training to practice without posing [a] serious threat to the public."42 When asked by tbe Senate Committee to verify their position with statistics or facts they could not do so. The space for that information was left blank. The FMA wanted the penalty for unlicensed midwifery in the state of Florida increased from a misdemeanor to a felony. The physicians claimed that, unless these "other" midwives were legally placed under obstetrical supervision (like the nurse-midwives), they would refuse to provide emergency back-up services.43 The bill passed anyway.44

 

Independent, non-nurse midwives, not subject to doctor control, are unwelcome business competition. ln 1990, the U.S. Department of Health and Human Services reported that "female with delivery" was the most common hospital discharge category.45 Since hospital birth is a major source of revenue for most public and private hospitals,46 it is understandable that hospital associations join with physicians to lobby against out-of-hospital births.

 

When independent "direct-entry" midwives attend a laboring woman at home, the facility fee (for a room in a hospital or birth center) is nonexistent. The difference in cost between a home birth with a licensed midwife and a normal hospital birth is considerable. For example, licensed direct-entry midwives in Florida charge $700 to $1600 for their services,47 compared with an average of $4500 for a normal hospital birth.48

Nevertheless, economic disincentives often discourage even nurse-midwives from providing home birth services. Even if they can locate physicians who will work with them, insurance companies in most states do not cover the cost of midwifery services if birth is not performed in a hospital or birth center.49 Medicaid often does not reimburse midwives for home deliveries.50 The National Center for Health Statistics reports that in 1989, out of 4,040,958 births (national total for all races), only 11,383 (.28%) were planned home births attended by midwives. Of these births, nurse-midwives attended only one-third (.09%).51

 

Birth centers52 provide a practice place for nurse-midwives who reject the subordinate role forced on them in hospitals. With increasing physician ownership, these centers have been reclassified as "safe" alternatives to hospitals in most states even though physicians are usually not in attendance. A recent study demonstrated that birth statistics of nurse-midwives in birth centers are better than those of nurse-midwives working with obstetricians in hospitals.53

 

Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational.54 According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society's extreme fear of birth.55 Specific cultural services are performed when obstetricians "bring forth a new social member through a maze of wires and electronic bleeps."56 Obstetrical rituals convey core values that center around science and technology. Belief in them as "necessary" sustains patriarchal institutional management.57 We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into "machines."58 Faith in technology provides a comfortable refuge from the unknown.59

 

The entrance of women into the field of obstetrics has not made a significant difference in the way obstetricians preside over birth.60 As a group, female obstetricians tend to conform more to the philosophy of their male colleagues than to that of female midwives. Medical school selection processes, socialization during medical education, the stresses inherent in obstetric residency programs, and the minority status of women in medicine are all factors likely to contribute to female physicians' unwillingness to buck the system. Moreover, medical schools convey the consistent and pervasive message to medical students that technology is always an advantage.61 There is apparently little difference in the degree to which this "indoctrination" affects female and male obstetricians.62

 

In physician-chosen settings, nurse midwives must work under "doctor's orders." Outside the hospital, nurse-midwife services are constrained by requirements for supervision by physicians. One commentator, discussing restrictions on nurse-midwifery in the context of malpractice insurance policy, compared physicians and hospitals to lawyers who have worked to prevent paralegals and others from the practice of law:

 

[M]any professions, including both medicine and law, have erected rather stringent barriers to prevent entry by others who would like to practice in the field. In pure market terms, that cuts directly against private enterprise. In effect, the professionals do not allow open and free competition... I happen to think it's not right.... [A]ccess [to independent midwives] is generally contained by requirements for supervision by physicians .... If the public were allowed to choose the lower-cost alternative freely, knowingly accepting the risk, I think that there would undoubtedly be more competition in the medical field. I believe nurse-midwives have lower claims frequency and severity rates.63

 

In hospitals and physician-controlled birth centers, the physician defines what is normal and what is abnormal. Physicians control the training of midwives and the services they can provide.64 As such, hospital-based nurse-midwifery is thus no real threat to medical control.

 

The distinction between nurses and midwives has been pointed out by researchers who find the combination of the two professions disturbing.65 A nurse is trained not to make decisions but to defer to physician authority. Like the physician, the nurse has been taught to expect problems and complications in every birth. The midwife, on the other hand, understands that the birth process seldom requires intervention. Her forte is normal birth, although she is well-trained to recognize and address abnormalities.66 Her experience at handling normal birth gives her skills that obstetricians do not possess. She serves the mother, not the physician, and although she will quickly transfer the mother to the hospital when the labor deviates from normal expectations, her main role is support and protection so that unnessary interventions do not occur.67

 

From Europe, there is also evidence that a strong independent midwifery profession is an important counterbalance to the obstetrical profession in preventing excessive interventions in the normal birth process. Consequently, it is perhaps not surprising that in the U.S. one finds the highest obstetrical intervention rates as well as a serious problem with malpractice suits. The European experience and our data strongly support the urgent need for the introduction of widespread, independent midwifery practice in the United States as a most important counterbalance to the present situation.68

 

Midwifery, with its shift of control from the doctor to the mother, is seen as a threat by organized medicine. The superb safety record of birth centers, with their popular "home-like" atmosphere, has been such a threat that hospitals have annexed "birthing rooms" and expanded midwifery service.69 Most nurse-midwives, however, are employed by physicians who forbid them from providing home-birth services.70 Control of the practice setting for other nurse-midwives is also strictly regulated by doctors."71

Part I of this article will describe the history of the elimination of the American midwife and the concurrent takeover by organized medicine. Part II defines types of midwives in the United States and provides a modern definition. Part III analyzes the differences between the medical model of birth and midwifery. Part IV argues that the legisisture is the appropriate forum for reform, especially since attempts at change through the judicial process have failed. Moreover, strong policy arguments exist for reforming the current regime of medical hegemony over childbirth.

 

I. HISTORY OF THE ELIMINATION OF THE AMERICAN MIDWIFE

 

The midwife's traditional role in childbirth went unchallenged until delivering babies became both a science and a business. In the Colonial period, midwives attended the majority of births.72 Childbirth was a social, not a medical event, in which women offered aid and comfort to each other during the delivery. Women relatives and friends served and assisted the laboring mother.73 Physicians' participation in childbirth in this period was limited to attendance at the most difficult births, and was prompted by the perceived need for the use of instruments.74

 

After 1750, men with European medical training began to practice in the American colonies.75 The first colonial medical school was founded in 1765, and by the first decade of the nineteenth century, midwifery was taught at five American medical schools.76 By this time, physicians were beginning to call their participation in childbirth "obstetrics"&emdash;"a scientific-sounding title free of the feminine connotations of the word "midwife."77 Physicians in both England and the United States were transforming childbirth into a medical/scientific event.78 Nevertheless, American doctors first assumed that midwives would continue to handle normal deliveries and that they would intervene only in difflcult cases.79 Some limited training opportunities in the "obstetrick art" were extended to female midwives;80 by 1820, however, physicians' interest in instructing midwives had ceased to exist.81 As early as 1760, a well-known journalist stated that the growing popularity of the "medical men" and their instruments was directly related to the ability of men to convince women that they had superior skills, that childbirth was dangerous, and that midwives were incompetent.82 Physician-assisted birth became an isolating experience for the mother.83 The doctor often dismissed family and supportive friends because they were a hindrance to his practice.84 Despite the disruption to traditional rituals of childbirth that the physician's presence caused, upper- and middle-class women appreciated his superior skills in managing pathological cases and his reputation for having acquired scientific knowledge.85 Dramatic rescues by doctors convinced large groups of people that the physician was necessary to childbirth.86 Increasingly, physicians were called to attend normal deliveries as well as problematic ones. In the nineteenth century, upper- and middle-class families became convinced that normal pregnancy was so potentially or actually abnormal that it constituted a medical condition.87

 

The American midwife gave way to the medical doctor as the chief birth attendant for the middle and upper classes during the nineteenth century.88 Physicians endorsed more extensive interventions in birth, moving away from the conservative approach of the midwives.89 In spite of this more interventionist care, the maternal and infant death rates were much higher in the United States than in European countries.90

The successful strategy of the physicians was to develop a demand for a "higher standard of obstetrics"; normal pregnancy and delivery were said to be a fallacy.91 The actual dangers of birth were greatly exaggerated,92 and routine medical intervention during birth was firmly established as "necessary."93 Upper- and middle-class American women who could afford to use male practitioners were taught to value obstetric skills and fear the dangers of childbirth to the point that no precautions were considered excessive.94 At the same time, most newly graduated doctors had no clinical experience in attending birth.95

 

Early twentieth century studies disclosed that "maternal mortality rates were lowest in those localities reporting the highest percentage of midwife attended births."96 The Children's Bureau published articles that alerted the country to the many "preventable" deaths that were occurring in childbirth, and their reports prompted studies of the outcomes of both physician and midwife care.97 A national conference was held at the White House in 1925 to announce that "the record of trained midwives" actually "surpasses the record of physicians in normal deliveries"; midwives, the conferees reported, took better care of women inlabor because they exhibited patience and let nature take its course.98 Dr. Josephine Baker, who served with the New York City Department of Health for 25 years, established a school in 1911 to train midwives and utilized their services extensively in the City for that time period. By 1921, the infant mortality rate for ail of New York City had decreased by one-half.99

 

Despite strong evidence that the new obstetrical practices were not improving the outcome of childbirth,100 the move toward physician-controlled childbirth continued. Many women perceived hospital stays as the way to alleviate the risks of childbirth.101 "By 1930, only fifteen percent of births were attended by midwives."102 Nevertheless, puerperal fever, an often fatal condition resulting from infection acquired during labor and delivery,"103 was widespread in the maternity wards as well as in physician-assisted home birth.104 This dreaded disease contributed to the image of pregnancy as an illness, even though it was spread by the doctors themselves.105 By the mid-1930s, several factors had contributed to reduction in the incidence of puerperal fever: a reduction in needless operations; the discovery of antimicrobial drugs such as sulfa and penicillin; blood transfusions; shortening of pathologically long labors; and "a general improvement in women's health."106 At the same time that hospitals were becoming safer, women were turning to hospitals to avoid pain during childbirth.107 By the 1940s, more than half of all births occurred in the hospital;108 and by 1950, eighty-eight percent of the public used hospitals for births.109 By this time, hospital birth resembled a "production line," characterized by physician supervision and control, wilh "every precaution ... taken to prevent disaster."110 Women often experienced hospital birth as dehumanizing and cruel.111

 

During the 1960s, women pushed for reform, striving for increased autonomy.112 "Natural childbirth" gained popularity as women sought greater safety for themselves and more control over their bodies during the birth process.113 The medical profession reacted negatively to this new interest.114 From the 1940s to the 1970s, a woman entering the hospital who insisted on natural childbirth was considered "hostile."115 Her request was considered unreasonable because it required too much time. Only private patients who could afford to pay higher prices could convince obstetricians to deliver their babies "naturally."116 In the 1950s, husbands were allowed to stay with their wives during the early stages of labor, but until the 1970s they were forbidden to accompany their wives during labor and birth.117 The Lamaze program of "prepared childbirth," initially lauded for transferring some control to the laboring woman, was adopted by hospiitals because it helped them promote medical interventions as "natural."118 Instead of being educated as to which of the hospital routines were unnecessary or arbitrary, the pregnant woman was taught breathing exercises to help her accept whatever was done to her.119 Lamaze instruction continued medical domination over women during labor and birth.120

 

As long as women continued to give birth in hospitals, doctors accepted some parts of the new movement toward "naturalness." The Lamaze method did not significantly interfere with rnedical control over birth.121 By 1970, "prepared childbirth" in the hospital was "natural" and included episiotomy, outlet forceps, demerol, and epidural anesthesia, in addition to the Lamaze method.122 Unlike the home-birth movement and the midwifery model that support control during birth by the mother herself, "prepared childbirth" does not challenge physician control.123

 

II. TYPES OF MlDWIVES & MODERN DEFINITION

 

According to D . J. G. Kloosterman, former director of the Midwives Academy in Holland the modern midwife should have at least three years of training.124 Part of her training should be in the hospital so that she becomes very familiar with pathology in order to recognize it early and refer cases to obstetricians. Midwives can thus free obstetricians to concentrate on their real task of studying human parturition and handling pathology.125

 

There are several types of midwives in the United States. Some midwives are formally educated while others are not. Some are tested and certified while others are not. Some enter directly into midwifery training126 without becoming nurses first and some have been formally educated in both nursing and midwifery. This can be confusing for consumers since, until recently, there have been no agreed-upon professional standards for non-nurse midwives.

 

To develop those standards has been a challenge for the American College of Nurse-Midwives (ACNM)127 and the Midwives Alliance of North America (MANA),128 the nation's two largest midwifery organizations. There has been controversy within these organizations regarding the use of the term "professional" to describe midwives since some believe that it should require formal education, while others assert that the term should also be applied to midwives trained through apprenticeship. Nevertheless, members of the organizations, working in tandem, have developed the following definition:

 

The professional midwife is a primary care provider who independently renders care during pregnancy, birth and the postpartum period to women and newborns in her community. With additional education and training, the professional midwife may render well-woman care and gynecological care. The midwife works with each woman and her family to identify their unique physical, social and emotional needs. Midwifery care occurs within a variety of settings and includes education and health promotion. When the care required extends beyond her abilities the midwife has a mechanism for consultation, referral, continued involvement and collaboration.129

 

"Traditional" birth attendants in the United States are empirically or apprentice-trained midwives. Direct experience constitutes the majority of their training. Some states regulate and register them, while many others have made their practice illegal. Their competence and training varies from state to state. Many are well trained and competent, but are not allowed to practice under their state's laws.130 The term "lay midwife" has no "specific meaning that is widely understood or accepted. It [has been] used to describe all kinds of midwives who may or may not be formally educated, may or may not have met some legal requirements for the practice of midwifery, and may or may not share [a commom or near-common] philosophy regarding birth.131 Thus the term may be used erroneously to discredit well-trained direct-entry midwives.

 

Modern midwifery in the United States has been thought of, for the most part, as a function performed by nurses. Registered nurses, whether they possess an associate's degree (generally two years of college) or a bachelor's degree (generally four years of college), can complete a certificate program in nurse-midwifery in fourteen months.132 If a nurse desires a master's degree in midwifery, however, she must first earn a bachelor's degree (which can be in another discipline) and complete a two-year graduate midwifery program. Whether the midwife trains by the direct-entry route or by the nurse midwifery route, the American College of Nurse-Midwives states that she must achieve certain core competencies: "The [American College of Nurse Midwives] believes that the standards for professional midwifery practice should be identical whether nursing is a base for midwifery or not."133 Unlike some nurse professionals, the ACNM values competency as the ultimate goal of training and does not push for or require college degrees:

 

[The ACNM] has adopted a policy of opposing mandatory degree requirements for state licensure for certified nurse-midwives. This position is stated in the "Guidelines for State Statutes and Regulations" ... approved by the ACNM Board of Directors in July 1984 .... Because there is no evidence that degrees enhance the clinical competence of a nurse-midwife, the ACNM believes that the requirement for a degree should not be in the law or in rules which have the force of law.134

 

Leaders in the field, such as Jo Anne Myers-Ciecko, Executive Director of the Seattle Midwifery School, feel that midwifery must be redefined depending on the country and culture where it is practiced. The Seattle School trains direct-entry midwives, and few of the students have had nursing training previously.135 In its philosophy, the school recognizes first, that the principles of normal birth are best learned in non-institutional settings, and second, that the best way to learn the art and science of midwifery is from experienced midwives. The School is known for its high standards of education. While Myers-Ciecko recognizes the importance of village midwives in Third World countries, she believes that "in the United States, where the population is highly mobile, culturally diverse, and generally relies on professionals for everything from food production to health care, more formal, explicit, and standardized requirements for entry into a service field involving life and death decisions are appropriate."136 The Seattle School program is based on the European three-year, direct-entry model in which the required nursing skills are built into the program.137 Like that of the American College of Nurse-Midwives, the educational philosophy of the Seattle Midwifery School is based on teaching the core competencies necessary to the entry-level practice of midwifery. 138 Two schools similar to the Seattle School are expected to open in Florida in the fall of 1993.139

 

Ernest L. Boyer, President of The Carnegie Foundation for the Advancement of Teaching, and Senior Fellow of the Woodrow Wilson School at Princeton University, is responsible for instigating a meeting and collaborative effort of the American College of Nurse-Midwives (ACNM) and the Midwives Alliance of North America (MANA). Representatives of the ACNM and MANA have held several controversial meetings over the last few years. Boyer recently explained the reasons for his midwifery project: "In education, public policy isn't just turned over to teachers to decide, yet for decades physicians have shaped the debate for health care. We should first look at the interests of mothers and babies."140 According to Dr. Boyer, the time has come for midwifery in the United States to become an independent profession.141 He has proposed "a decade-long national crusade" describing midwives as "the noblest [c]hoice."142 Dr. Boyer wants the crusade to "tell the truth" about midwifery and describe vividly the impeccable credentials and the outstanding achievements of this profession."143

 

Conferees of Boyer's program, who came from many backgrounds, agreed that multiple entry routes are required to increase the numbers of professional midwives.144 As direct-entry programs are approved, midwives hope to shape a core curriculum that will define clearly and coherently the fundamentals of the profession. As well as agreeing on a modern definition of a professional midwife, midwives have defined "core competencies" in which all midwives, regardless of the entry pattern, should be versed by the end of their training. The vice-president of the ACNM has noted that nurse-midwives and direct entry midwives trained in comprehensive programs have very similar requirements:

 

[A] comparison of the ACNM core competencies for the practice of nurse-midwifery and the statement of core competencies from the MANA midwifery educators' group [proponents of the direct entry/non-nurse schools] resulted in almost complete agreement. Although the two documents were written differently, the essential content is the same.145

 

The collaboration of these two organizations has great potential for developing midwifery as a profession in the United States and making it available to many more thousands of American women. Even greater responsibilities for these broad-thinking midwives include bringing all types of midwives together and promoting midwifery as an independent and autonomous profession.146

 

A 1982 survey by the ACNM indicates that ninety-two percent of all nurse midwives would like to provide services in birth centers or in the home. But by 1987, only fifteen percent of nurse-midwives worked in birth centers,147 and far fewer provided home birth services.148

 

III. A COMPARISON OF THE MEDICAL

AND MIDWIFERY MODELS OF BIRTH

 

The two philosophies of childbirth&emdash;the medical model and the midwifery model&emdash;differ distinctively, as the following chart illustrates:

 

Pregnancy is normal. ..Pregnancy is a "condition."

 

Pregnancy includes physical ..Pregnancy causes "symptoms."

changes.

 

The pregnancy is part of the .The pregnancy is "external"

woman. ....to the woman, not a part of her.

 

Pregnancy is a "working norm" Pregnancy is almost entirely a

for any woman. ....mechanical event" and is a

.......stressor.149

 

Both before and after birth, the medical model conceives of the baby and the mother as conflicting entities with conflicting needs&emdash;the baby needs attention and feeding; the mother needs rest. In contrast, the midwifery model treats the needs of the mother and the needs of the infant as interlocking, during pregnancy and labor and after birth. The midwife interprets the mother's need for "rest" as the need for relief from activities other than caring for her baby. The baby needs to be with the mother.150

 

A. The Medical Model

 

In the Netherlands, a doctor who wants to handle normai deliveries must study midwifery formally for one year.151 But U.S. medical schools do not consider midwifery training necessary for American doctors,152 who have little or no knowledge of the midwifery model of birth. Physicians in our country can graduate from medical school without having delivered a single baby. They can become board-certified in obstetrics and gynecology having never seen a normal birth conducted without interventions.153

In contrast, nurse-midwife and direct-entry midwife trainees manage a substantial number of births prior to certification or licensing. The ACNM does not mandate a minimum number of deliveries for a student nurse-midwife to manage during her educational experience,154 but some university-based nurse-midwifery programs require trainees to manage up to forty deliveries.155 Direct-entry trainees at the Seattle Midwifery School and in the Florida midwifery-schools must manage fifty births prior to graduation.156 Midwife trainees in the European Community are required to manage forty normal births and assist with forty complicated births in order to graduate.157

 

While midwifery can be described as primary care, obstetrical care is acute or tertiary care, developed specifically to treat genuinely pathological pregnancies and emergencies. Physicians determine the need for acute care by calculating the perceived risk; "the definition of risk is ... central to the medical model of birth."158 In the calculation of risk approach, childbirth is seen and described as a life-threatening situation.159 This approach creates fear in the minds of the public, which then demands acute care.160

 

Acute care, with its many interventions and drugs, ensures that the risk approach becomes a self-fulfilling prophecy.161 The infant mortality rate in the United States far exceeds that in Japan and Europe, where birth is considered normal and midwives are the attendant of choice. The following table provides infant mortality rates for many "First World" countries and shows how poorly the United States has done:

 

INFANT MORTALITY RATES 1989: 162

 

COUNTRY ..........NUMBER OF DEATHS PER 1000 LIVE BIRTHS

 

................ Japan . ................................4.4

................ Finland.................................5.8

................ Sweden ...............................6.0

................ Switzerland...........................6.8

................ Netherlands .........................6.8

................ Canada................................ 7.1

................ Hong Kong ...........................7.4

................ France ................................7.4

................ Singapore............................7.5

................ Germany .............................7.6

................ Australia .............................7.7

................ Norway................................7.8

................ Spain ...................................7.8

................ Austria ................................8.3

................ Denmark .............................8.4

................ England & Wales (U.K.) .........8.5

................ Italy....................................8.8

................ Belgium ...............................8.6

................ United States .......................9.7

................ Greece ................................9.8

 

Obstetricians do not provide primary care to the majority of the healthy pregnant women in any European country.163 In a hospital birth, the mother's efforts become a means for helping the doctor deliver the baby.164 As soon as a pregnant woman enters the hospital, "active management of labor" by the obstetrician begins. The physician is the one who performs. He or she delivers the baby at the appropriate time, while the woman in labor is required to remain passive.165

 

Expensive diagnostic tests are the rule rather than the exception for hospital births, even when the procedures have not been tested over the long term. An example of this is ultrasound scanning. The benefits of ultrasound have never been found to outweigh the potential risks to the fetus. Scientists theorize that routine ultrasound may cause fetal brain damage, visual and hearing impairment, chromosomal damage, or may result in childhood cancer. Studies to determine whether, in fact, these effects are occurring have been insufficient.166 The World Health Organization recommended against the regular use of ultrasound in 1984.167 Nevertheless, it has become routine. Traditional methods of assessment, however, usually work just as well as ultrasound scanning.168

Obstetrical procedures have become standardized. Obstetricians rely on interventions and drugs extensively during the birth process. For example, the use of fetal heart monitors is now commonplace, although the advantages of using them are unclear. They often restrict a woman's movements during labor.169 They have been related to increasing caesarean section rates and impersonal treatment.170 Electronic monitoring is no more accurate than the use of the traditional fetal stethoscope.171 Monitoring requires that the woman remain in the dorsal position. This places weight on blood vessels that carry oxygen to the fetus and thus possibly contributes to the distress that the monitor is designed to measure.172 In 1978, the National Center for Health Services Research (NCHSR) announced that "electronic fetal monitoring may do more harm than good" and expressed concern about the lack of medical evaluation before its introduction.173

 

Similarly, researchers are beglnning to be concerned that the use of drugs during labor may interfere with the ability of the infant to function after birth. 174 Hospitals use a powerful synthetic hormone, Oytocin (Pitocin, Syntocinon), to induce labor artificially or to stimulate contractions. Inducing birth with pitocin subjects the woman in labor to increased pain, and she consequently incurs greater risks to herself and the baby from analgesic (pain-relieving) drugs administered to decrease her discomfort. Induced birth has been shown to relate to longer retention of the placenta, post-partum hemorrhage, prolapse of the uterus, and post-partum depression.175 Induction is not normally necessary. Studies have shown that alhough a pregnancy prolonged after 42 weeks can affect perinatal outcome, induction of labor does not improve uhe baby's chances of survival.176

 

The medical model assumes that relieving pain is always a worthy goal. Until recently, demerol (meperidine) was the analgesic drug most frequently used during labor. Demerol is still used in some hospital obstetrical units, despite wording in the package insert explaining that the drug crosses the placenta and can depress the respiratory and psychophysiologic functions of the newborn. In a well-controlled investigation, John Morrison, an obstetrician at the University of Mississippi, found that one of every four infants of mothers who received only 50 milligrams of meperidine within one to three hours before delivery required resuscitation at birth.177 Stadol (butorphanol) and nubain (nalbuphine) are commonly used to control pain during labor today. The body eliminates stadol faster than demerol. Like demerol, however, both stadol and nubain have serious respiratory-depressant effects on the infant.178

 

Epidural anesthesia is another highly acclaimed intervention; it allegedly allows a pain-free birth without interfering with the mental state. Hospitals use bupivacaine most frequently. Most or all sensation below the waist is removed by injecting the anesthetic at the mid-back, making it beneficial in caesarean sections and for difficult births. In normal birth, however, it deprives the mother of the ability to push her baby out and can easily complicate the labor.l79 Most obstetricians quietly agree that epidural block increases the rate of cesarean section.180 It is also-associated with significantly longer labors, higher use of oxytocin, and more deliveries using forceps. 181

 

As the overuse of fetal monitors and drugs during labor and delivery illustrates, premature intervention can create a "snowball effect," requiring more and more interventions and increasing perinatal risks. 182 The resulting iatrogenic or "doctor-caused" injuries result in extraordinarily high costs.183 A recent Oxford University study found that doctors and hospitals often make the wrong decisions in treating pregnancy and labor, causing both medical and economic harm. 184 Pointing out the dangers of the current system of obstetrics, the authors of the study noted that doctors are disease-oriented and that normal pregnancy, when treated like a disease, has a very poor outcome. 185

 

The current frequency and likelihood of malpractice litigation orients doctors toward preventing lawsuits; this orientation adversely affects women and babies. Induction of labor at or before forty-two weeks, for example, has become common to prevent the poor infant outcomes that are sometimes associated with the delivery of infants born post-term (beyond forty-two weeks gestation).186 But induction itself increases the likelihood of a caesarean section, which in turn increases the risks to both mother and infant. "Caesarean delivery is associated with much higher material morbidity and mortality rates than vaginal delivery."187 Ironically, liability may actually increase due to induction of labor, which clearly has the potential to backfire as a means of avoiding liability.

 

Most women who deliver in the hospital will experience a surgical technique.188 If they do not experience episiotomy, they are likely to deliver via caesarean section. Four obstetrical procedures - caesarean sections, episiotomy, repair of obstetric lacerations, and artificial rupture of membranes - accounted for eighteen percent of all surgical procedures

 

performed in hospitals in 1990.189 Diagnostic ultrasound comprised ten percent of all nonsurgical procedures, while fetal EKG and fetal monitoring accounted for eight percent.l90 Episiotomies were performed routinely in the United States by the 1950s, and even today are very common in spite of research showing the assumptions underlying the routine practice to be unjustified.191 The surgical incision heals no more easily than a natural tear and does nothing to insure a healthy baby in an uncomplicated delivery.l92 In 1976, the first empirical study to determine the long-term effectiveness of episiotomies found that they were associated with prolapsed uteri, tears in the vaginal wall and sagging perineums. They were previously believed to prevent these conditions.193 Episiotomies, however, continue to be performed to facilitate stitching after the birth since repairing a tear can be more time consuming.l94

 

Whether an episiotomy is"necessary" is often left to the discretion of the doctor. In 1990, episiotomies were being performed at the rate of 55.8 per 100 vaginal deliveries.l95 During labor, if the obstetrician decides that the woman is "failing to progress," there is a high likelihood that she will undergo a caesarean section. One out of every four women who are in labor in hospitals is taken for major obstetrical surgery. Physicians' rationale for this statistic is that operative deliveries "minimize the risk of injury, disease or death for mother and child."l96 In fact, delivery by caesarean section carries a greater risk of illness and death for the mother, and perhaps for the infant as well.l97 The risk of death to the mother alone is two to four times that associated with vaginal birth.l98

 

Caesarean sections are also associated with a risk of abnormal blood clotting, injuries to the surrounding organs, higher rates of infertility, and much slower recoveries after the birth.199 Caesarean-born babies are at a greater risk for low birth-weight, premature birth and birth injuries than those born vaginally.200 The overuse of caesarean sections also adversely affects the skill of obstetricians, depriving them of experience in delivering babies vaginally in complicated cases.201 Rather than risk potential problems of vaginal delivery, obstetricians often opt for the caesarean section as an easy way out.202

 

Errors by doctors in the timing of elective caesarean sections contribute to respiratory distress syndrome (RDS), a condition caused by immaturity of the lungs that can lead to fetal death. One study found that one out of every eight caesarean sections results in RDS, the most common complication of caesarean sections.203 RDS is also one of the major factors associated with Sudden Infant Death Syndrome (SIDS).204 Despite the obvious fact that avoiding unnecessary caesareans is the most effective means of avoiding physician-caused prematuriy and RDS,205 a recent study at Oxford suggests that more than fifty percent of the caesarean sections performed in United States hospitals today are unnecessary.206

 

There are other costs associated with the overuse of caesareans. Normal sized babies delivered by caesarean section frequently have lower Apgar scores than babies delivered vaginally.207 The increased use of caesarean sections does not contribute to a reduction in infant mortality.208 Moreover, women who have caesareans must be hospitalized twice as long as those who deliver vaginally.209 Thus, the incredibly high rate of caesareans in the United States results in awesome human and financial costs. In 1988, the national caesarean section rate skyrocketed to 24.7%, from 5.5% in 1970.210 By 1990, of the 2.83 million live births, 23.5% were caesarean sections.211 Yet, rates higher than ten or fifteen percent are unjustifiable.212 For example, in the United States, the estimated cost of unnecessary caesarean sections for 1986 was just under two billion dollars.2l3 In the mid-1980s, doctors estimated that when the caesarean section rate increases by just one percent, U.S. hospital costs go up by over $54 million.2l4

 

It is notable that countries with some of the lowest perinatal mortality rates in the world have caesarean section rates of ten percent or less.215 The following chart compares caesarean section rates for various countries:

 

C-SECTION RATES 2l6 ....

 

..............COUNTRY...........NUMBER OF C-SECTIONS PER 100 BlRTHS

 

.......... Czechoslovakia............................................7

.......... Japan.........................................................7

.......... Hungary....................................................10

.......... Netherlands...............................................10

.......... England and Wales (U.K.)............................10

.......... New Zealand..............................................10

.......... Switzerland...............................................11

.......... Norway.....................................................12

.......... Spain........................................................12

.......... Sweden.....................................................12

.......... Greece......................................................13

.......... Portugal....................................................13

.......... Italy.........................................................13

.......... Denmark...................................................13

.......... Scotland....................................................14

.......... Bavaria.....................................................15

.......... Australia...................................................16

.......... Canada......................................................19

.......... United States.............................................23

.......... Puerto Rico................................................29

.......... Brazil........................................................32

 

Studies have found that women beginning labor under the care of midwives experienced well under half the number of caesarean sections than carefully matched women receiving care from obstetricians.217

 

Our high-tech society has not yet realized that there are limits to the desirability of technology, especially with regard to its impact on a natural event like birth.2l8 Between 1984 and 1987, the number of obstetrical procedures increased enormously. Use of diagnostic ultrasound increased by 350%; vacuum extraction increased 132%; manually assisted delivery increased 300%; fetal monitoring increased 42.7%; artificial rupture of membranes increased 107%; medical induction of labor increased by 162%; repair of obstetrical lacerations increased by 39%; and caesarean sections increased 16%.219 Almost all of these interventions - many of which were unnecessary - occurred in the hospital. The interventions make hospital birth far less safe than our technology-loving society would expect.220

 

The need for maternity services by well-trained providers is escalating, especially in rural areas. In 1987, a survey of members of the American College of Obstetricians and Gynecologists (ACOG) found that forty-one percent of them had limited their obstetric practice, and twelve percent were no longer accepting pregnant patients.221 Many specialists have stopped delivering babies because of the high cost of malpractice insurance. 222 Moreover, obstetricians providing care are extraordinarily busy. The short amount of time that obstetricians spend with their patients has been proven unsatisfactory to many women, and significantly deters communication. Some patients also dislike authoritarian physician mannerisms.223 Obstetricians have notoriously "poor doctor-patient relationship[s]" in the obstetrician's office and the hospital delivery room.224 A 1981 study found that nurse-midwives spend an average of twenty-four minutes per visit with their clients. In contrast, a 1975 study found that prenatal care office visits with a physician lasted ten minutes, and thirty-two percent of obstetrician visits lasted five minutes or less.225 One recent study compared the satisfaction levels of women with midwives and obstetricians as primary-care providers: eighty-eight percent of midwife clients were "very satisfied," as compared with only forty-five percent of obstetrician patients.226

 

B. Midwifery Model

 

Midwifery is indispensible and an essential part of good obstetrical organization, since midwifery means: protection of health and normality, whereas obstetrics, as part of medicine, be!ongs to the "department of knowledge and practice, dealing with disease and its treatment".... To care for pregnancy and childbirth, you need a midwife and a doctor. I hope that they will ... respect and admire one another and will know that they are both needed and complementary.227

 

All the European countries with perinatal and infant mortality rates lower than that of the United States use midwives as the sole birth attendant for at least seventy percent of all births.228 In Japan, the country with the lowest infant mortality rate in the world, midwives are the primary birth attendants.229 Researchers agree that countries that rely heavily on professionally trained midwives consistently have the lowest infant mortality and the lowest birth trauma rates.230 In order to improve its perinatal mortality rate and the health status of women and infants, the United States should emulate policies in countries that have lower infant mortality rates.

 

Programs to decrease poverty, provide good nutrition, and offer social support are the most effective, cost-saving ways to avoid poor outcomes of pregnancy and improve infant health.231 Traditional prenatal care alone is not enough.232 Midwifery is socially oriented preventive care, which incorporates prenatal care and a concern for the social and emotional aspects of pregancy and birth in order to meet the individual needs of each woman.233 Midwifery presumes that childbirth is a healthy and normal event. A holistic approach in which the mind and body are mutually important to the outcome,234 midwifery recognizes that in childbirth, mind and body cannot be separated: "A woman's body works best when she feels confident, secure, emotionally supported, and on her own ground."235

 

Midwives focus on providing primary maternity care rather than on what can go wrong in the pregnancy. Primary care involves education, health promotion, nutritional screening and counseling, and social support, as well as climcal asessment.236 Midwives do the same kind of screening as physicians during prenatal visits, but they have a broader emphasis and spend more time with each woman. Midwives encourage self-help and personal responsibility as goals for each woman. The midwife spends time teaching in order to remove the mystique surrounding pregnancy and to empower the client. She teaches the woman or couple that pregnancy is a time for "psychological as well as physical growth and development."237 In comparison with obstetrical care, this type of personalized prenatal care results in better client participation and satisfaction.238

After a midwife determines that the pregnancy is normal,239 she becomes familiar with her clients' lives in order to inform the woman or couple of the available options regarding the setting and type of birth.240 The care is woman-centered and, since the fetus is thought of as part of its mother, midwives assume its needs are met when the mother's needs are met.241

 

Midwives believe that the birthing woman has a right to responsibility over her own body, her baby, and her birth.242 At the birth the midwife "catches" the baby; she does not "deliver" it. She assists the laboring mother; she does not control her. Midwives let nature take its course, intervening only when clearly necessary. Intervention or "doing something" to the woman to try to push the progress of the labor is avoided for as long as possible. The midwifery model of birth has no strict time limits. Each woman's labor and delivery is seen as unique.244 Skilled midwives claim that the biggest lesson they've had to learn is to "sit on their hands and not do anything."245

 

Midwives recommend benign methods to stimulate labor when a woman's pregnancy approaches the "post-mature" stage. Enemas, nipple stimulation, or sexual intercourse sometimes work as well or better than drugs.246 The woman is sent to the hospital for induction only if these measures are ineffective.

 

In a midwife-attended home or birth-center birth, the woman is not required to lie down. She is not "attached" to the bed and has no IV poles or monitors attached to her.247 She can get up and walk to the bathroom in privacy and is encouraged to empty her bladder frequently during labor.248 She can eat in the first stage of labor, and is offered drinks frequently.249 Vaginal exams are done periodically, but not on a rigid schedule as in hospitals. The laboring woman's support person may be intimately involved, massaging or Iying in bed with her.250

 

Experienced midwives usually recognize that the psychological condition or comfort of the woman may cause her labor to start and stop. This frequently occurs when a laboring woman enters a hospital for childbirth. Her contractions, though strong and regular on entry, may become weak and spasmodic.251 If a woman is worried while she labors, she may stop having contractions until her concern is resolved.252 For this reason, home birth may be ineffective for some women. A woman who thinks that hospital birth is safer than out-of-hospital birth may stop having contractions until she is hospitalized.253 During the second stage of labor, from full dilatation of the cervix through the birth, the woman is wide open, usually not in acute pain, but anxious not to be moved.254 As she enters the second. stage, she may experience an uncomfortable low backache and a drop in morale. The midwife empowers the-laboring-woman-with-encouragement, sincerity and understanding.255 To be certain that the baby is experiencing no distress, the rnidwife uses a special stethoscope to keep track of its heart rate.

 

At "transition," when the woman's cervix is fully dilated, the midwife helps her into positions that facilitate the downward movement of the baby. At this point, most women feel a strong urge to push the baby out. Some women may deliver without any deliberate pushing. The actual length of time and amount of work required to deliver the baby differs with each woman.256

 

In the medical model, the second stage of labor currently lasts fifty minutes.257 Once labor starts, it cannot stop and start again and still be considered "normal." Any pause in labor triggers medical intervention. In the home or birth-center environment, the midwife understands that the second stage may last up to three or occasionally four hours.258 When the baby's head is emerging or "crowning," the midwife often exerts gentle pressure to guide it out slowly and carefully without damage to the perineum. Experienced midwives deliver breech babies and large babies without tears by repositioning the woman to facilitate the birth. Shoulder dystocia or "stuck shoulders," frequently a side effect of drug-induced labor, is common in hospitals but rarely occurs in home birth.259

 

Episiotomy is not routine in home birth. When they are necessary, midwife episiotomies are generally much smaller incisions than physician-performed episiotomies.260 When the baby emerges, it is immediately placed in its mother's arms. Midwives often clean and diaper the baby for the mother. Then, if necessary, the midwife administers local anesthesia and repairs the perineum .261

 

Most American midwives observe the respiratory status of the infant and record an Apgar score. Babies whose mothers were undrugged during labor usually breathe spontaneously. For the rare exception, the midwife uses portable resuscitation equipment that she carries to each birth.262

 

If the third stage, the expulsion of the placenta, takes longer than twenty minutes, the midwife suggests non-interventive techniques such as breast stimulation. Breastfeeding the baby may help expedite expulsion by stimulating contractions of the uterus. The midwife monitors the woman for excessive bleeding during this period, prepared to arrange a safe transfer should measures within her scope of practice prove ineffective.263

 

After the mother and child are clean, safe, and comfortable, the midwife offers counseling and support and makes an appointment to see them both the following day. She often makes home visits for up to six weeks after the birth. According to Sheila Kitzinger,

 

A carefully planned and lovingly conducted home birth, in which the rhythms of nature are rcspected and the woman is nurtured by attendants who have the knowledge and understanding to support the spontaneous unfolding of life, is the safest kind of birth there is, and the most satisfying for everyone involved.264

 

Although obstetricians and family practice physicians sometimes do provide midwifery service as identified by the midwifery model, the limits of medical education and practice coupled with fear of punishment by colleagues for not following obstetric specialist standards make physician-provided midwifery services rare.265

 

IV. MIDWIFERY AND PUBLIC POLICY FACTS, CRISES, SOLUTIONS

 

Legislators and other policy makers in the United States, under the influence of medical lobbyists, frequently treat birth as an event requiring the mechanisms of acute medical care. Many states continue to restrict the practice of midwifery to medically trained nurses. The prospects for judicial reform of the medical hegemony over childbirth are dimming. A 1977 California case and a recent Illinois case both suggest that courts are unwilling to entertain arguments about constitutional issues surrounding the practice of midwifery.266 Arguments about both the individual woman's privacy right to choose the circumstances of her delivery and the due process right of midwives to practice their profession have failed in the judicial arena.

 

At the same time, evidence suggesting that midwives and obstetricians are both necessary to a working system of care - that they are "not interchangeable as providers of care"267 - continues to gain prominence in the health care field worldwide. The media have focused on the national crisis in obstetric care, but have regularly ignored midwives.268 It is time for legislators and other policy-makers, as well as the national media, to recognize the advantages of midwifery.

 

A. Evidence Regulators Should Consider

 

A 1991 article in the Journal of the American Medical Association stated that "the continuous presence of a supportive female companion during labor and delivery could significantly reduce the need for Caesarean section."269 According to the authors, studies in Guatemala had shown that not only did women with a female companion experience far fewer c-sections, they required fewer obstetrical interventions, [had] shorter labors, and [experienced] fewer perinatal problems [with] the fetuses and the neonates."270 The implications for the quality and cost of perinatal care, were said to be "highly significant." The challenge, the doctors said, is to "turn to obstetric technology only when necessary, relying instead on the practice of continuous labor support to help the birth process follow its natural, normal course."271

 

In a speech to the U.S. Commission to Prevent Infant Mortality, Marsden Wagner, regional director of the World Health Organization in Europe, charged that the United States' focus on medical care as an answer to high infant mortality has never been effective.272 Instead, he recommended that the United States spend less money on medically oriented prenatal care and interventionist obstetrical care, and devote more resources to developing a strong, independent midwifery profession.273

British statistician Marjorie Tew demonstrated that "high techno;ogy can rarely make birth safer, whether the predicted risk is high or low."274 Tew's scientific analysis of thousands of births in Holland revealed that after thirty-two weeks gestation, the perinatal mortality rate was far lower when the mothers were under the care of midwives than when obstetricians were the primary caregivers.275 For premature babies, midwives had similar outcome statistics to those of physicians; the chance of survival for these very small babies was about the same regardless of attendant or place of delivery.276

 

Studies aimed at proving the hypothesis that midwife-attended home birth is dangerous, on the other hand, are old and unreliable. The most commonly used "study" was published by the American College of Obstetricians and Gynecologists in the 1970s.277 The study claimed that "out-of-hospital births pose a two to five times greater risk to a baby's life." But the cited study lumped miscarriages, premature births, taxi cab deliveries, and other unplanned precipitous births together with out-of-hospital births that were planned and attended by trained midwives.278

 

A true scientific study, however, was performed at about the same time. The 1970 Mehl study matched 1046 women who were planning home birth with 1046 women who were planning hospital birth for age, social parity, socioeconomic status, and riak factors. All outcomes in the home birth cases that had to be transferred to hospitals were attributed to home birth. The results of the study were remarkable:

• The hospital births had five times the incidence of maternal high blood pressure (possibly an indication of greater physical and emotional stress);
• The hospital births had three and one-half times the amount of meconium staining (fetal bowel movement expelled into the amniotic fiuid, indicative of fetal distress);
• The hospital births had eight times the shoulder dystocia (the fetal shoulder getting caught after the head is born; midwives handle this by turning the woman to hands and knees position which is still not frequently used in the hospital);
• The infant deaths, both perinatal (during birth) and neonatal (after birth) were essentially the same for the two groups;
• Apgar scores (indicative of the condition of the baby) were better for the home birth babies (though caregivers in either setting may introduce biases into these readings);
• More than three times as many babies in the hospital required resuscitation;
• Four times as many hospital babies became infected;
• Thirty times as many hospital babies suffered birth injuries (attributable to forceps);
• Fewer than five percent of the home-birth women received analgesics or anesthesia, while seventy-five percent of the women in the hospital group were administered such drugs;
• Caesarean sections were three times more frequent in the hospital group;
• Nine times as many episiotomies were performed in the hospital group and nine times as many severe (third- and fourth-degree) tears occurred in the hospital group.279

B. Existing Statutes and Regulations

 

Despite the convincing evidence in support of midwifery, state laws differ radically regarding licensing and practice requirements. Nineteen states and the District of Columbia place legal prohibitions on midwifery and only allow its practice by nurse-midwives. In four states - Maryland, Ohio, West Virginia, and Wisconsin - midwifery is statutorily defined as a function of nursing, so practice by non-nurse midwives is illegal.280 Midwifery (except for nurse midwifery) is prohibited in Illinois, Nebraska, and the District of Columbia because it is defined by statute as "the practice of medicine."281 Statutes require midwives to be certified nurse-midwives in five states: Hawaii, Indiana, New York, North Carolina, and Virginia.282 In seven other states - Alabama, Delaware, Georgia, Kentucky, New Jersey, Pennsylvania and Rhode Island - only nurse-midwives may practice, because licensing is performed by medical authorities.283 Direct-entry and lay midwives do not practice in Iowa because in 1978 the state Attorney General defined midwifery as "practicing medicine without a license."284

 

Colorado, Florida, Louisiana, Montana, Texas, and Washington have elaborate statutes governing the practice of direct entry midwives; a bill passed by the California General Assembly governing the practice of direct-entry midwives is expected to be signed into law.285 In nine states Alaska, Arizona, Arkansas, Minnesota, Missouri, New Hampshire, New Mexico, Oregon, and South Carolina - statutes allow midwives to practice under the authority of state agencies.286 Sixteen states have no specific regulatory statute. In ten of these states - Connecticut, Idaho, Kansas, Maine, North Dakota, Oklahoma, South Dakota, Tennessee, Vermont, and Wyoming - "the practice of medicine" is defined narrowly, limiting its scope to the treatment of abnormal conditions.287 In Mississippi, midwifery is defined as part of the practice of medicine, except in the case of "females engaged solely in the practice of midwifery."288 Michigan, Nevada, and Utah construe "the practice of medicine" broadly,289 increasing the vulnerability of midwifery to tighter medical control. The state of Washington was first to grant true professional autonomy to direct entry midwives.290 In an exciting move toward legislative recognition of an independent professional midwifery organization, the 1993 Colorado statute governing the practice of direct entry midwifery suggests that the state utilize a professional competency examination designed by the Midwives Alliance of North America, Inc., an organization formed to support direct entry midwifery as well as nurse-midwifery.

 

C. Examples of Judicial Action

 

The U.S. Supreme Court has never decided a constitutional issue regarding midwifery. In 1977, the California Supreme Court held that a woman has no privacy right to choose "the manner and circumstances in which her baby is born."291 According to the California court, Roe v. Wade's trimester system precluded such a right.292 Since the state's interests are paramount over the woman's privacy rights in the final trimester of pregnancy, the court reasoned it follows that her privacy rights cannot prevail during labor and birth.293 Thus, the state may require that birth attendants have valid licenses (and presumably may regulate midwifery in other ways as well), even when it has no laws prohibiting unattended childbirth outside the hospital.294 The court suggested that "further arguments as to the safety of home deliveries are more properly addressed to the Legislature than the courts."295

 

A recent federal case concerning the statutory treatment of midwifery similarly suggests that independent licensing standards may be best achieved through intensive state-by-state lobbying, and not by claiming in courts a "right" to practice midwifery. In Peckmann v. Thompson,296 two unlicensed midwives challenged the constitutionality of the Illinois Medical Practice Act,297 under which they had been indicted for practicing midwifery without a license. Although the court found the statute unconstitutionally vague with respect to whether or not the legislature had intended to include midwifery in its definition of the practice of medicine, the court supported the constitutional validity of such a policy based on the police power of the state.298 The court deferred to the legislature:

 

Under the 1987 Medical Practice Act, Illinois eliminated the separate licensing procedure for midwives which it had previously employed. Although the wisdom of the change in treatment of midwives may be debated, there is nothing in the Constitution which prohibits Illinois from rationally exercising its police power toward midwives; the Constitution does not demand that midwifery be recognized or licensed in Illinois.299

 

Unless proponents can convince skeptical courts that midwifery is a fundamental constitutional right, prompting strict scrutiny of state regulations restricting its availability, activists should focus on convincing legislatures that independent licensing of midwifery is in the best interests of the state. Proponents should present to legislators the evidence that changes in midwifery could save lives and money. Low birthweight is the major cause of infant mortality in both Europe and in the United States.300 Low birthweight infants "are forty times more likely to die within the first twenty eight days of life than normal weight infants."301 Half of low birthweight babies have some degree of mental retardation; they also have a high incidence of epilepsy, cerebral palsy, and learning or behavioral problems.302

 

The most logical and fiscally responsible way to deal with low birthweight is to prevent it in the first place. The alternative is to reduce the impact with expensive, "high tech" neonatal intensive care units (ICUs) and expanded medical care.303 The cost of saving these babies by the latter route is astronomical. In Florida, the medical costs for a premature, low birthweight baby has been estimated at between $16,136 and $174,278, 304 and the approximate lifetime cost for custodial care of a low birthweight baby with complications is $500,000, not including costs for education and social and economic services.305

 

Dr. Thomas Brewer, a leading expert on metabolic toxicity in pregnancy, says that the presence of more than six hundred neo-natal intensive care units in the United States today is "a crime against the health of our people.... A child in a neo-natal intensive care unit is an abused child. We don't need 600 neo-natal intensive care units in a country that is as rich as ours. We have no standards."306 Five years earlier, activist Angela Davis had testified before the California Department of Consumer Affairs about the prevailing approach of the medical establishment to solving the crisis:

 

As growing numbers of medically indigent women are forced to go without prenatal care and proper nutrition, thus producing very low birth weight babies, every effort is made to keep those infants alive ... through the use of expensive, profit-making technology .... The medical establishment's ... solution to an embarrassingly high rate of infant mortality in this country's poor and Third World communities is increased reliance on the technological miracles that keep low birth weight babies alive, many of whom are born prematurely because their mothers could not obtain early equal respectful care ....307

 

Professor Davis highlights the way in which NICUs are in fact an exorbitantly expensive and inadequate "band-aid" for a mostly preventable injury.

 

A large group of practicing midwives could increase participation in prenatal care and reduce the incidence of low birth weight and the need for neonatal intensive care units by providing more affordable, accessible services than the medically-oriented status quo. The National Commission to Prevent Infant Mortality has suggested that even small improvements in preventive care would result in an immediate national savings of 70 to 95 million dollars.308 Requiring midwives to first become nurses is unnecessary and counterproductive to the goal of increasing the number of midwives. Such a requirement would slow down the education process considerably, and might discourage those people who would like to become midwives but are not interested in nursing. The idea that midwifery is nursing is an unfortunate but correctable misconception. Midwife Caroline Flint writes,

 

"As a nurse you will learn to take care of bedsores and to prevent them, you will be able to scrub ... amputations ... Iook after diabetics ... learn about congestive cardiac failure, how to make a bed, the care of ... coronary thrombosis, subarachnoid hemorrhage, concussion ... kidney dialysis, giving medicines - all thoroughly useful knowledge which no sane person could do without before becoming a midwife? Or is it? 309

 

A 1981 World Health Organization Organization Regional Office report noted that, because midwifery and nursing are separate disciplines, they should be studied, considered, and regulated separately.310 The weight of the evidence and statistics suggests that states should create a system of regulation or certification to govern the practice of qualified, trained midwives.311 The ideal statute would allow a midwife to qualify as a professional if she had completed nursing and midwifery training, as required for nurse-midwives, or if she completed midwifery training and a comprehensive apprenticeship program.312 With statutory authority, midwifery could finally claim its rightful place as an independent profession.3l3

 

VI. CONCLUSION

 

Because the safety of hospital and medically oriented birth is so questionable, the state's interest in protecting mother and child is not served by a statute allowing total control by allopathic physicians over maternity care. The challenge is to create a system of regulation that ensures competence, involves consumers, and allows for independence.3l4 Using Washington's midwifery laws as a model, states should design public policy to allow and encourage the development of an independent midwifery profession.

 

Five recent legislative events indicate that the international movement to recognize and promote midwifery is accelerating. Two populous states have passed bills allowing the training and licensing of direct-entry midwives - Florida, in 1992 and California in 1993; Oregon law now authorizes a state agency to license direct-entry midwives. In 1993 Colorado enacted a law that requires registration of direct-entry midwives and recommends that registration be premised on passing an examination designed by a professional midwives' association. Finally, the House of Commons Health Committee in the United Kingdom published new findings regarding maternity care.

 

A study conducted by the Florida Senate Committee for Health and Rehabilitative Services recommended prescribing core competencies for licensed midwives, encouraging hospitals and physicians to establish collaborative relationships with licensed midwives, developing collaborative relationships through county public health units to provide services to Medicaid clients, and encouraging physicians and certified nurse-midwives to provide more home birth services.3l5 Committee Substitute for House Bill 553 passed and was signed into law by the Governor on April 8, 1992.316

In 1992, in a move that the United States would be well-advised to emulate, the British House of Commons Health Committee issued recommendations that strongly favored the profession of midwifery:

 

On the basis of what we have heard, this Committee must draw the conclusion that the policy of encouraging all women to give birth in hospitals cannot be justified on grounds of safety.

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We conclude that the experience of the hospital environment too often deters women from asserting control over their own bodies and too often leaves them feeling that, in retrospect, they have not had the best labour and delivery they could have hoped for.317

 

Lawmakers can afford to ignore neither the risks involved in hospital birth nor the research and statistics validating the safety and importance of the midwifery profession. State power is supposed to provide for the general welfare of citizens and secure them against the consequences of ignorance, deception, and fraud.318 Broad medical practice acts that protect unsubstantiated medical assertions and make criminals of competent midwives provide no such security. If public policy is to improve the health of mothers and children, it must allow the profession of midwifery to develop fully, independently, and in its rightful place - the home.

The author wishes to thank the following people for their assistance and personal attention to this project: Mary Chaisson, Larry George, Maura Ghizzoni, Doris Haire, Sheila Kitzinger, Bill Lewis, Tom Marks, Becky Martin, Jo Anne Myers-Ciecko, Michel Odent, Nal Stern, and Beth Swisher.

This paper is dedicated to American midwives who have suffered injustice in the struggle to preserve informed choices in childbirth for all women.

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