The Childbirth Monopoly
Commentary: Why the medical industry is dragging its feet when it comes to midwives.
By Laurel Druley
June 2, 1998
If you thought witch trials were thrown out in the 18th century, think again. In the past five years, more than 200 midwives in the U.S. have lost their jobs or have been arrested as a result of groundless investigations and persecutions.
All of which is odd, because midwife-attended births have been proven to be safer than obstetrician-attended births, at a fraction of the cost. Indeed, in many other industrialized nations, midwifery is the preferred method. Why then isn't the midwifery option gaining more respect in the U.S.? It's about money.
Many obstetricians, in conjunction with the American Medical Association (AMA), have been fighting against midwifery because they fear that it will hurt their bottom line. And it's nothing new. When medicine became a profession for profit at the turn of the century, doctors began attacking midwives. Doctors portrayed midwives as drunken, unkempt, dirty, and promiscuous.
The Economic Disincentive
When the little test tube turns blue, the steps that follow are critical to the health of the mother and child. After a woman chooses to have a baby, she then must choose her mode of delivery. What options are available? You can go to a midwife, which means a certified nurse-midwife (CNM) or lay/direct-entry midwife (who are not certified as nurses). That choice allows you to have your child at home. Or you can go to a doctor and have your baby at a hospital. Many women in the U.S. don't even know that they have an option. Why? Because the medical monopoly is trying to push midwives out. "Midwives see themselves as doing a different job [from doctors], as part of a team. Doctors see the whole thing as a hierarchical structure," says Maggie Bennet, a direct-entry midwife.
Most midwifery statutes require them to have a supervising physician. "No one wants to supervise," says Elizabeth Davis, author of Heart & Hands: A Midwife's Guide to Pregnancy & Birth. "Why bother? No revenue for the hospital. When physicians have said, 'I'll back you up,' hospitals say, 'You'll lose privileges here.'"
Marsden Wagner M.D., author of Pursuing the Birth Machine, says, "Obstetricians have to convince the public that they should be the preferred care giver. They have to eliminate the competition. Obstetricians that have been using nurse midwives in their practice are being fired. I've been a doctor for years, so I know. It's a fraternity—a doctor who goes against the norm will get severely punished by his colleagues. We have our ways."
That means that trained CNMs often have no place to practice, because hospitals don't want them. There's a lack of economic incentive.
Midwives use fewer drugs and provide constant attention so there is less need for fetal monitors. According to Dr. Wagner, if the U.S. switched to a midwife-based system the country would save $8.5 billion a year on cesareans, episiotomies, fetal monitoring, and prenatal care. The rate of pregnancies ending in cesarean sections is four times lower when midwives attend the births. In the last 25 years cesareans as percent of total U.S. births have jumped from 7 percent to 20 percent (though it has declined almost 3 percent in the 1990s). The minimum estimated cost for a regular delivery in a hospital is $7,800 with insurance. For a c-section the cost, which includes the price of anesthesia, lab, and operating room time, increases to $16,000.
Since the 1970's, nurse-midwives, otherwise known as certified nurse midwives, have become legal in the U.S., whereas lay/direct-entry midwifery, meaning midwives who are not trained as nurses, remains illegal in many states. CNMs are primary care providers who are educated to give normal maternity, newborn, and gynecological care. A CNM must be a licensed registered nurse and have completed an approved graduate level program in midwifery. She most often practices in a birthing center or hospital. Lay or direct-entry midwives are not always licensed and in some states they cannot practice legally. And doctors rarely are in support of them.
Joan Hall, a lobbyist for the California Medical Association (CMA), says the CMA is "very supportive of midwifery." But Davis tells a different story. She points out that there were seven legislative attempts in California to legalize direct-entry midwifery before it was finally passed in 1993, and the CMA opposed the legislation each time.
Given that doctors often feel competitive with midwives, it's not surprising that they would oppose legislation to make midwives more popular. But why would they sit on a board which is supposed to represent midwives? The California midwifery licensing committee, which has the authority to license certified nurse midwives, is housed in the California Medical Board. It does not have a single midwife representative. Janice Kalman, a policy analyst for midwives explains, "It's not ethical to put a competing entity in charge. Putting obstetricians in charge of midwives is like putting orthopedics in charge of chiropractors."
Going to a Midwife
If doctors seem to be so hesitant about midwives, why go to them? Because mothers often say giving birth with a midwife is a pleasant experience—and it's safer. Sunita Mehta, a former nonprofit worker and current full-time mom, has given birth to two healthy babies—one born in a hospital and the other with a midwife in a birthing center. Because there was a remote possibility a thyroid cyst would interfere with the delivery, the birthing center suggested she go to a physician for her first birth.
"The two experiences are just poles apart. There's no comparison," says Mehta. In the hospital, Mehta explains, the doctor was delivering five babies at once and he showed up the last fifteen minutes of a 22-hour labor to prescribe the Demerol and catch the baby. In the meantime an obtrusive nurse yelled instructions. The second baby was born after an eight-hour labor in a room with jacuzzi, squatting stool, and queen-size bed provided. The midwives were very supportive, which made the mother feel she was in control.
After a mother has found a birthing center or midwife with physician back-up, she wants to know: What happens if something goes wrong? All the midwives interviewed answered the same way: "We go to the hospital." Certified midwives must follow the American College of Nurse-Midwives guidelines, which insist on safe mechanisms for obtaining medical consultation, collaboration, and referral when questions or problems arise.
The approach seems to be working. Says the U.S. Congress' Office of Technology Assessment (OTA): "The weight of the evidence indicates that, within their areas of competence...CNMs provide care whose quality is equivalent to that of care provided by physicians."
The U.S. Compared to Others
The countries that lose the fewest babies have the most midwives. Why? Because the midwife tips the scales for fewer interventions. In a hospital when doctors are caring for more than one patient at a time, deliveries are often rushed. As a result, women in labor often release adrenaline, which can inhibit cervical dilation. Midwifery care also lowers c-section odds. The cesarean rate among patients of midwives is less than 5 percent—half the rate of low-risk OB-GYN hospital births. Midwives credit their low number of cesareans to meticulous labor and delivery management techniques and prenatal care. They also point out that cesarean sections are four times as likely as vaginal births to end in the death of the mother. All this contributes to a disconcerting statistic: The U.S. ranks 24th worldwide for perinatal mortality.
Still, says Ina May Gaskin, president of Midwives Alliance of North America, "America doesn't see midwifery as an essential profession. With the ideal health care system every woman would receive the best maternity care. Most women would have midwives, and obstetricians would be there when something went wrong." When asked where in the world she would most like to give birth, Gaskin responded, "The Netherlands. Measuring all the issues—satisfaction, planning, compassion, good public health sense, and cost effectiveness—they have the best system. They spend 9 percent of their GNP on health care instead of 14 percent like the U.S."
Sunita Mehta, who recently moved to India, has another perspective: "America is a land where there is no such thing as a dabbler or an experimenter. It's the land of the expert. In terms of childbirth, you [the mother] are the expert and I know that for a fact now. I knew how to have my baby. My body was telling me what to do. The baby was telling me what to do. Americans have this insecurity that someone else knows best."
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