The United States, the most expensive place in the world to give birth, has a higher infant mortality rate than any of the other wealthy countries, according to a recent report from the Centers for Disease Control and Prevention, a statistic condemned by The Washington Post as a “national embarrassment.”
Yet even with maternal mortality on the rise and access to affordable health care shrinking, the majority of Americans turn away from a potential solution: midwifery. While in the United Kingdom midwives deliver half of all babies, in the United States midwives attend only about 10 percent of all births. Despite the surge of celebrities who have embraced midwifery and the home-birth experience — Gisele Bündchen, Demi Moore, Julianne Moore, Meryl Streep — Americans still overwhelmingly turn to hospitals and the traditional medical establishment to give birth, even though it is more costly and not always safer.
Why has midwifery not been more successful? The problem stems from America’s fraught relationship with midwifery and home birth. Once a staple of American society, by the 20th century both midwives and home birth were portrayed by organized medicine and the media as outdated and potentially dangerous. Why would anyone endure the pain of childbirth at home with a midwife when they could have a painless experience in the sterile environment of a hospital under the care of a trained obstetrician? This assumption that midwives are a relic of the past rather than part of an integrated health-care system of the future has had a profound effect on 21st-century attitudes toward birth, as well as on the health of millions of women and new babies each year.
Before the development of obstetrics, childbirth was an entirely female affair under the direction of female midwives. Beginning in the 1760s, American physicians developed an interest in normal obstetrics and gradually replaced — and nearly eliminated — female midwives. “The usual midwife of today,” claimed obstetrician Joseph Delee in 1916, “is a very ignorant, unconscientious and really impossible person.”
As a result, by the mid-20th century the practice of home birth and the profession of midwifery appeared destined for extinction, used only out of economic necessity for the less fortunate. In 1940, nearly half of all U.S. births took place in a hospital, and by 1970 that figure had reached an all-time high of 99.4 percent. Obstetricians assumed nearly complete control over what had become an entirely medicalized procedure, convincing the American public that the science of obstetrics was superior to “meddlesome” midwifery.
“What should have been the most exalting and exulting of experiences was riddled with horrors,” reflected one woman in the early 1970s as she compared the delivery room to a “butcher shop where everyone was wearing rubber gloves and I was in the middle like a trussed-up turkey.”
When another woman requested an unmedicated birth, “the doctor was a little unhappy because, as he reminded me, if I was knocked out he could just slip in those forceps and have that baby out in a minute.” The actions of the hospital staff, which included throwing a sheet over her head (“since women were knocked out for delivery, nurses were used to just concentrating on the other end”), strapping her wrists to the delivery table and whisking her baby off to the nursery as soon as she was born prevented her from enjoying the experience. As she recalled later, “The only thing I didn’t like about having a baby was where I had to have it.”
These experiences inspired a significant number of white middle-class parents to opt out of the standardized medicated hospital birth beginning in the 1970s. By doing so, they recast home birth as a legitimate choice for those seeking more control over the birthing process, rather than a low-cost alternative for the poor or geographically isolated. A quiet revolution spread across cities and suburbs, towns and farms, as consumers challenged legal, institutional and medical protocols by choosing unlicensed midwives to catch their babies at home.
Who were these self-proclaimed midwives and how did they learn their trade? Because the United States had virtually eliminated midwifery in most areas by the mid-20th century, many of them had little knowledge of or exposure to the historic practice. Instead they learned their craft from obstetric texts, trial and error, and, occasionally, instruction from the few remaining home birth physicians. While their constituents were primarily drawn from the educated white middle class, their model of care (which ultimately drew on the wisdom and practice of a more diverse, global pool of midwives) had the potential to transform birth practices for all women, both in and out of the hospital.
In the 1970s and ‘80s, those in support of midwifery and home birth formed organizations, hired lobbyists, organized conferences and published newsletters to educate the public about out-of-hospital birth. The growing visibility and the increasing popularity of home birth triggered a regulatory backlash in many states, resulting in new and more restrictive licensure laws requiring education and certification that continue to restrict the practice of midwifery.
This problem is unique to the United States. In places such as Canada, home birth is integrated into the health-care system, whereas in the United States it is entirely separate, and American midwives face a variety of legal and economic barriers.
As a result, many women do not have access to midwifery care, and their birthing options are limited. And yet studies have shown that states that have integrated midwifery care into their health-care systems have better birth outcomes than states that have not. Those states with a higher density of midwives and a higher proportion of midwife-attended births also had lower rates of Caesarean section, low-birth-weight infants and neonatal mortality.
These findings suggest that greater integration of midwives into the health-care system can also reduce health disparities, notably the shocking statistic that African American women experience two to four times higher risk than white women for maternal and infant mortality.
Medicine in the 21st century thrives on scientific evidence to ensure best practices. So why don’t we use this research to fundamentally transform the delivery experience? Why do some continue to view midwives as suspect, as outsiders, rather than trained professionals who can help transform the birth process and provide more options for laboring women?
It is well past time that Americans shake off the superstitions and stereotypes of the profession to enable parents to make well-informed decisions about where and how to give birth. We need to view midwives and doctors as collaborators, rather than competitors. And we need more midwives; 56 percent of all U.S. counties do not have any. Midwifery organizations have done a lot to promote their profession (such as the “I am a Midwife” public education campaign), but without increased funding and greater awareness, this “national embarrassment” will continue.