Saturday, October 8, 2016

Midwifery in American: Providing Choice, Saving Lives, and Reducing Costs by Michael Wilson

Amongst the Native Americans of South Dakota, the infant mortality rate is one the highest in the nation at 11.47 deaths per 1000 live births. In Wisconsin, the infant mortality rate for black children is 14.00. Meanwhile, the infant mortality rate for white infants nationwide is 5.06 deaths for 1000 live births. (
In most of the world when it comes to childbirth midwives are the first to provide care. Here in the United States, it’s a different story. Not only can it be difficult for an expectant mother to find a midwife, but over the decades the male dominated medical profession has done its best to demonize the women who practiced midwifery.
For centuries women handled society’s medical needs as both herbalists and midwives. They brought us into the world, took care of us while we were here and prepared the body for burial as we exited this life. Much of that began to change with the rise of male-dominated, so-called scientific medicine.
In his book Of Foxes and Hen Houses; Licensing and the Health Professions author Stanley J. Gross notes
“[t]he decline in the American midwife’s involvement in the birthing process is not just attributable to enlightenment, new medical discoveries, or to changing tastes, though all three are part of the story. More so, it is the story of how a determined minority of medical men over several hundred years was able to organize itself, inform the public of its point of view, and use education, licensing, and monopolistic power to impose their view on the public” (p. 59).
Midwives naturally were present in the Native American tribes. Midwives came from Europe with the colonists, were involved in establishing a European presence in North America and most likely they were among the slaves brought to the colonies. Midwives dominated the field of childbirth in the early years in colonial America. As Paul Starr mentions in his book The Social Transformation of American Medicine; “(i)n colonial America… most medical care was routinely provided by women in the home” (p 49), but things began to change in the 1700’s.
Before the American Revolution women were involved in many aspects of medical care, but in the period after the American Revolution, the role of women was limited to the home. Now men dominated in politics, business, education, science and medicine. Many doctors from the colonies were trained in Europe and when medicine began to be taught in the United States women were barred from the medical schools.
Middle-class women began to look to men for medical care and assist in childbirth in the mid-1800s. Midwives were thought by some to be poorly educated, and they were reduced to caring for the immigrants in the urban area. Some midwives who learned the trade as apprentices cared for the poor in rural parts of the country, especially the south were the freed blacks women known as grannies provided care for expectant mothers.
Unable to gain access to higher education women midwives were starting to take a backseat to male doctors (American Midwifery 1860 to Present p. 9). It wasn’t until the Boston Female Medical College opened in 1848 that midwives were able to receive formal training. (American Midwives, 1860 to Present, P 12)
The American Medical Association was founded in 1847 ( Amer. Mid. p58)  and “the first modern medical practice act was passed in” 1873 by the State of Texas ( Gross p 57). In those early years, the AMA was dominated by general practitioners. The rise of obstetrics as a medical specialty had a profound impact on midwifery. 
It has only been in the last few decades in the U.S. that doctors have assumed a major role in bringing children into the world.
The image of midwives was as much influenced by the social status of their clients as anything else.   By the early 1900s midwives had been reduced to helping in the delivery of approximately 50% of infants in the U.S.  According to Gross in Of Foxes and Hen Houses; Licensing and the Health Professions “The next thirty years was a period during which midwifery would be outlawed or ignored and turned into an officially despised and discredited occupation…” (p.64)
It was only about 1970 that midwifery began to make a comeback. Thanks in many ways to the rise of feminism, the back to the earth movement and the question authority attitude that was prevalent in those days.  
One of the more prominent voices in the movement to put women back in charge of the birthing process was and continues to be Ina May Gaskin. Ms.Gaskin might best be referred to as the Grand Dame of the Farm, a commune in Tennessee that today has turned into a thriving community of people who have developed a cooperative with a dozen or more businesses.
Over the years Ms. Gaskin has written a number of articles on midwifery. Her first book Spiritual Midwifery was published in 1977. The book, now in its fourth edition, has sold worldwide, and has been a major influence on the birthing movement in the U.S. No longer are so many women looking at birth as a medical problem. 
Depending on whom you ask there are five to six different classifications of midwives from Certified Nurse Midwives to Lay Midwife. All of this depends on state laws and the organization certifying midwives. More information can be found at American College of Nurse-Midwives and Midwives Alliance of North America.
In New Mexico, midwives are the attendant of choice at approximately   24 % of births. However, nationwide in 2014 Certified Nurse Midwives attended 8.3 % of births according to the Center for Disease Control.
A May 1998 article in the Journal of Epidemiology and Community Health (52(5): 310–317) on the web at by M. F. MacDorman and G. K. Singh noted that;
“After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births”. 
Studies from Europe where midwives deliver most infants support this conclusion and in fact a study that compared 529,688 low-risk births from The Netherlands that took place at home and in hospitals showed no significant differences.
In Texas, we see a significant difference in the quality between CPMs and other groups. “Birth and death information from the Texas Department of Health for 1990 -2000 indicate that birth with midwives in Texas has always been a statistically safer option than birth with either a medical doctor or doctor of osteopathy. State maternal mortality rates for all kinds of birth attendants has been under 0.2/1000 since 1977. With midwifery assisted births, infant death rates for 1990-2000 have never exceeded 3/1,000. Births performed by either an MD or a DO have always been at least twice as high as the published rate for midwives.”
            Just over forty percent of all births nationwide are paid for by Medicaid, and in many states, the number is significantly higher. Births by MDs costs two to three times what midwives charge and deliveries by MDs are more likely to result in questionable interventions, such as cesarean sections than with midwives.
Medicaid paid for sixty-three percent of all birth in Louisiana in 2004 ( Obviously where we find poverty we are likely to see more Medicaid payments for childbirth and with the recent recession those numbers have probably increased. So at a time when incomes are dropping for expectant mothers and state revenues are declining, state costs for Medicaid are increasing.
According to  The National Hospital Bill published for 2006 ( which does “not include outpatient care, emergency care for the patient not admitted…or physicians fees” two of the “most expensive conditions treated in U.S. hospitals” for 2006 where “Mother’s pregnancy and delivery” number two at $47,800 million and “Newborn infants” at number three and $38,184 million.  In most areas where midwives practice today their costs are a third to a half of that of MDs.
In her book American Midwives, 1860 to Present, Historian Judy Barrett Litoff, notes, “…a frequent complaint expressed by physicians was that they were poorly reimbursed for their obstetric services. Many doctors feared that this trend would continue as long as midwives persisted in attending 50  percent of all the births for less than one-half the fee charged by medical practitioners”. [p 73]
Can we do something to lower these costs? Yes, we can and for the health of the mother and child we should.  Most agree that the rates of c-section in the U.S. are two to three times higher than they should be. Every surgery carries risk, and unnecessary surgery just leads to possible future problems. Midwives might be a source in helping to lower the caesarean rate and the reduction of other risks as well as helping to decrease the rate of maternal mortality that has been increasing recently.
How infant mortality is defined varies in some degree from one country to the next, but for the most part, there are similarities. However, to avoid problems, I suggest never compare infant mortality rates in the U.S. with any other nation.
So do midwives benefit both mothers and children?  Promoting Midwifery as a childbirth alternative for mothers may prove to be a benefit in a number of ways.
•Mothers should be free to choose a doctor, a Certified Nurse Midwife, a Certified Professional Midwife, a Licensed Direct Entry Midwife or someone else if they wish.
•Midwives may save tax dollars. The costs of births in New Mexico are some of the lowest in the nation and midwives may help reduce those costs significantly. When Medicaid pays for the birth, as it does in New Mexico, and many other states, the costs drop, and the taxpayers benefit.
•The infant mortality rate in New Mexico was below the national average from 1994 until a jump in 2012 to just above the average that year. Today the rate is close to the national average. This is much lower than other low-income states and is an indication that health care providers in New Mexico are among the best when it comes to birth.


This contribution is from Michael Wilson, Activist in the Libertarian Party of Washington.