Back to Marilyn's Midwifery Page The rhetoric is flying concerning the future of American health care. Many problems have been identified and supposed solutions volunteered. One thing seems certain to all involved. If we do not come up with a viable solution, health care is going to bankrupt the nation. We have all heard of the many problems that the current system has. They include skyrocketing costs, lack of universal access, overuse of technology and poor outcomes in such areas as infant mortality. This paper will offer suggestions to help improve one facet of the American health care system. By looking into the current state of Obstetrics and offering an alternative, this paper will examine the past and make suggestions and predictions for the future. In examining midwifery history, we can identify areas that can help us improve the future. In our nation’s zeal to embrace technology, we have let our hospitals become factory oriented. Our focus is on the product, and we rely heavily on testing and technology to replace common sense and human contact. In many of our hospitals, the mother is seen as a danger to the child. This view has replaced her traditional role as protector of her child. Midwives, through their unique perspective, see pregnancy as a natural condition. They recognize the need to monitor the woman, to screen for abnormality, but know that if they do not intervene unnecessarily, the woman's body has an innate knowledge to successfully carry out the pregnancy. In this country, we have redefined pregnancy as an illness. Midwives do not accept this definition and staunchly defend pregnancy as a normal healthy component of a woman's life.
In the past, both here in the United States and in all other nations, women were cared for by other women. This caring may have come from members of the family, friends or a specially designated woman usually known as the midwife. Many cultures have given these midwives different names and many translate to a variation of wise woman. The midwife's training was usually through an apprenticeship. How these women were chosen varied cross-culturally, and many women described it as a calling that sometimes had a spiritual connection. These women were always known by the mothers they cared for and held to high moral character. They usually did not practice what we today would identify as prenatal care. They did establish a bond with the pregnant woman during her pregnancy and were available to the woman for support and reassurance. When labor started, they would go to the woman's home or a specially designated birthing hut where they would stay until the baby arrived. Very little intervention was practiced, and both the laboring woman and the midwife had a deep instinctual faith that birth was a well-designed process even though they understood little about body physiology. Most births went well, and those that had poor outcomes were accepted as the will of their higher power.
In this century, a change in this birthing perspective has occurred. We now think we know all about birth. In an effort to control the process, much time and money has gone into the development of expensive tests and technology. An atmosphere has evolved that overlooks birth as a healthy condition and transforms it into a diseased process. Has this change in philosophy brought about an improvement in outcome? If we look at the current statistics, we can only interpret the answer to be negative. The United States lags behind all the other industrial nations in infant mortality. We hold this distinction even though we spend more per capita on health care than any other nation. The number of women who are denied access to prenatal care continues to rise as are the number who have no health insurance. If we look at the nations that have the best statistics for infant mortality, we find that those at the top use midwives as a vital component of their health care system. In her recent book titled "Safer pregnancy?", Margery Tew, through the use of detailed statistical analysis, explains that the benefits we have seen in improved pregnancy outcome have come not from the move of birth to the hospital but from public health measures. She identifies improved nutrition and sanitation practices as the major reasons we have seen any improvement in our infant mortality statistics over the years.
We still trail behind the other industrial nations, and it is becoming clear that by continuing to increase our technology we are not solving the nation’s problems. One part of this rise in technology is the alarming cesarean section rate in our country. It is not unusual for some obstetricians to have c-sec rates from between 25 to 50 percent. Does this mean that American women's bodies have lost the instinct to birth vaginally? If we examine these same c-sec rates in published midwifery data, we find much lower rates that are usually below 10 percent. What can we attribute this difference to?
There have been several theories to try to explain this difference. Midwife proponents cite the time that a midwife spends with her client. It is not unusual for a midwife to spend from 45 minutes to one and one-half hours per visit answering questions and alleviating fears. I personally know of one Obstetrician who schedules four women every fifteen minutes. Another is the perceived avoidance of litigation. Many doctors feel that if they do a c-section and have to go to court in the future, they will be seen as doing everything they could to avoid a poor outcome. In reality this mentality is taking a great toll in increased operative delivery, increased costs and undermining women's confidence in their bodies. Money has also been identified as a motivating factor in this c-section explosion. Most doctors charge more to deliver a baby by cesarean section. Lastly, there is the convenience factor. Performing a c-section allows the doctor to plan his or her schedule and assure attendance at planned leisure activities.
How will a return to traditional midwifery skills help our current situation and what will be the future of midwifery education? By returning to a midwifery-based pregnancy orientation, we will redefine pregnancy as a healthy condition. In embracing this new/old philosophy, we will replace our love affair of technology with a prevention based woman-oriented one. We will take the time to answer all the woman's questions, and we will appreciate how knowledge can alleviate fear. In identifying fear as counter-productive to good outcome, we will aid in helping more women achieve a sense of trust in their bodies. We will teach them the importance of prevention and the responsibility they have in their own positive outcome. By screening out the small percent of women who need a specialist's care, we allow these specialists more time to get to know their clients. We as a nation need to adopt a policy of midwifery first and specialized obstetric care for the relatively few that need it.
Should we follow the lead of current medical training to assure the nation has enough midwives so that all women can be guaranteed prenatal care and an optimum birth experience? Doing this would only produce more practitioners in the current system that is not working. We need to look to new models that mirror the old established practice of apprenticeship. We need to create opportunities that blend classroom type learning with hands-on experience. In identifying the current midwife population, we find that many become midwives after they have started their own families. These women add a component to the care they give by having experienced what their client is going through. This adds credibility to the suggestions that the midwife makes to the client she is caring for. We must make training available to those women who need to learn in or near their communities. In exploring learning situations, such as class room without walls and incorporating computer technology, we can create specialized learning environments. It is important to identify the role of different learning styles. We may find that it is as crucial for the perspective midwife to develop her interpersonal and intrapersonal skills as it is to only develop the factual data memorizing ones that are held so important in traditional medical preparation.
If we examine current trends, we can predict that prevention and life-style awareness will continue to increase and be seen as important to the American public. More women are and will be seeking alternatives to the hospital delivery experience. The reasons for this are varied. They range from the increasing costs to a desire for more personal control. The rise in communicable diseases make more families desire to staying home with their own germs instead of entering an environment loaded with everyone else's.
Midwives are waiting to see where they fit in the national health care scheme. Will our nation see the disastrous course that lay ahead or plunge blindly on? Will we be able to learn from the past to prepare for a better future? I hope for the benefit of all pregnant women and society as a whole the answer is yes.