In the United States, a growing number of women are discovering advantages in midwife- assisted childbirth over delivery with a physician. Midwives promise less technological intervention, lower costs, more intimate care, and, in general, an experience of pregnancy and childbirth as a normal, positive life process rather than as a medical emergency in the making.

In 1998, the most recent year for which data are available, nearly 300,000 U.S. births were attended by midwives, according to the National Center for Health Statistics. Ninety-three percent of these occurred in hospitals. Although midwife-assisted births account for only 7 percent of total U.S. births, they number almost twice as many as a decade ago. And while most of the increase is among more affluent, better-educated women, the trend is starting to take hold among lower-income mothers-to-be as well.

In Latin America, where midwifery has a longer history, the profile of both midwives and the patients who choose them is very different. For women in remote rural areas, lack of access to hospitals and physicians means midwives are often the only maternity care available. For higher-income and urban women, the delivery of choice is much more likely to be with an obstetrician. Indeed, in much of Latin America, the trend in childbirth seems to be toward more technology rather than less. For example, in nine countries of the region, the rate of caesarean section is higher than 20 percent (15 percent is considered reasonable). To the alarm of many public health officials, that rate is increasing.

Yet just as in North America, midwives in Latin America are at the forefront of efforts to reverse such trends. Dr. Marilia Largura, a Brazilian parteira (midwife) with a doctorate in nursing and 40 years of obstetrics experience, sees the problem as the overinstitutionalization of technology in childbirth.

"The true meaning of birth has been lost little by little in the morass of institutional rules and regulations," she complains. "As soon as a baby cries they measure its length, they take its weight, they take digital fingerprints, they give it a shot, they use strong electrical suction to clear the mucous-all in the name of science."

What gets lost, she says, is "the mother's first embrace of her baby, the parents' first glimpse of their new child, their getting to know each other-all that counts for nothing."

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