Quality Care

In the United States, midwives are fighting a similar battle. "We shouldn't be treating childbirth like it is a medical risk waiting to happen," says Dr. Carol Sakala, of the regional office of the Association of Maternity Centers of New England. She advocates building "a climate of confidence instead of a climate of doubt." She adds, "We have so much to learn from midwives, who haven't been strongly influenced by the medical approach."

For U.S. patients, midwives make sense for purely practical reasons as well. "One of these has to do with insurance and the costs of medical care," says Ms. Elisabeth Howard, a nurse-midwife at the Vanderbilt University Medical Center in Nashville, Tenn. "People are trying to reduce their health costs, and midwives have proven to be very cost-effective."

Research by the Public Citizen Health Research Group shows that in midwife-attended deliveries, the rate of caesarean section is about half the national rate. Other research has found that episiotomies are used only exceptionally in midwife-attended births, and technology is used at a minimum, hence the reduction in costs.

Proponents of midwifery insist, however, that lower cost does not mean compromising on quality of care. In the United States, the level of training of the vast majority of midwives is high. Certified nurse-midwives, who account for 95 percent of midwife-attended U.S. births, are educated in the twin disciplines of nursing and midwifery, must pass a national certification exam, and are licensed by states or state-appointed agencies.

Research on pregnancy outcomes for physician- versus midwife-assisted births puts the latter in a favorable light. A study by the National Center for Health Statistics found that in 1991, among all nonmultiple vaginal deliveries between 35 and 43 weeks of gestation, infant mortality was 19 percent lower in midwife-attended deliveries, neonatal mortality was 33 percent lower, and low birth weight was 31 percent less frequent than in deliveries attended by physicians.

One reason for these results may be that midwives typically stay with their patients throughout labor, whereas physicians tend to appear on the scene intermittently. Midwives also spend more time with patients during prenatal visits and put more emphasis on patient counseling and education. "We do not overload our schedule as physicians do to keep down costs," says Ms. Howard.

But what happens when problems arise? The vast majority of midwife-assisted births in the United States take place in hospitals, making emergency care readily available. Ms. Deanne Williams, executive director of the American College of Nurse Midwives (ACNM), says that midwives do not deny that problems of pregnancy and childbirth can require technological interventions. However, she says, mainstream obstetrics has taken such concerns too far: "We have been seduced into systems that provide high-tech care to all women and babies rather than to the small percentage who really need it. In the process, we have separated birthing women from their families, separated families from their newest member, created barriers to breast-feeding, and made the process of entering motherhood much more difficult. Without discounting the importance of technology and intervention when needed, we need to support women in the normal processes of labor and birth."

Professor Linda Walsh, of the University of San Francisco's School of Nursing, says that women who choose midwives tend to share that view. "If you look at women in the United States who actively seek midwifery care, they tend to be better educated and, as a result, they tend to question the interventive medical model of obstetrical care."

She adds, however, that lower-income women in the United States are also turning in increasing numbers to midwives. "Particularly poor women are introduced to nurse-midwifery care because the clinics they attend are often staffed by nurse-midwives," she notes. "For immigrant women, this is a good fit, since the use of midwives is consistent with their traditional beliefs." She cites studies showing that although midwives treat proportionately more poor women, their health results are nevertheless better than those of doctors.

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By Midwives, for mothers A few years ago, whenever midwife Nancy Zelnik introduced herself to new acquaintances, she had to explain in detail just what it was she did. "No one understood how I could deliver babies without being a doctor," recalls Ms. Zelnik, who works at the Maternity Center in Bethesda, Md., U.S.A. "Now lots of people know about midwives because they've heard about someone who's been attended by one." The Maternity Center was launched in 1975, the year U.S. insurance companies announced they would no longer pay for home births attended by midwives. "Suddenly midwives found themselves with dozens of patients about to give birth with no place to do it," explains Ms. Zelnik. "So they bought this house and converted it into a maternity center."   Nurse-midwife Nancy Zelnik attends a mother-to-be   at the Maternity Center in Bethesda, Md., U.S.A.   "Your midwife will be with you throughout your   delivery," she promises patients.   (Photo ©Armando Waak - PAHO/WHO) At an orientation session for new patients, Ms. Zelnik promises "more time and more personalized attention" than they might receive from obstetricians, as well as more control over decisions during pregnancy and delivery. Moreover, "Your midwife will be with you throughout your delivery," she says. Most of her patients give birth at the center, but they can also deliver at nearby Shady Grove Hospital, where the midwives have full admission privileges. Ms. Zelnik notes that in Maryland, certified nurse-midwives may prescribe medicine for patients. "This has helped us a lot in terms of confidence and credibility with patients and their families," she says.