Rebirth for Midwifery

Rising costs and feminism bring back an ancient art

For most of the human species' existence, the delivery of babies has been the exclusive prerogative of women. It was only at the turn of this century that U.S. physicians, most of them then male, decided to put the delivery business into masculine hands.

The move was not sexist. It was simply part of the notion that all life's problems could best be corrected through technology. In difficult births, a midwife was clearly no match for a trained obstetrician, often backed by hospital facilities. In the U.S. at least, a steady shift to doctor, and then doctor-plus-hospital deliveries soon threatened to turn midwifery into a lost art, and in many states an outlawed one. Old-fashioned "granny" midwifery is still in decline. But delivery by professional nurses and trained lay midwives is now becoming more popular in the U.S., though the practice remains less common than in such countries as Sweden, Britain and The Netherlands.

As medical costs skyrocket and more American women choose natural childbirth, often at home, over the impersonal facilities offered by many hospitals, it seems likely that the trend will accelerate. A bill, currently pending in Congress--sponsored by Senator Daniel Inouye of Hawaii--would authorize Medicaid payment of fees to nurse midwives. Next week the California assembly will consider a bill, backed by Governor Jerry Brown, legalizing the practice of mid wifery by adequately trained people whether or not they are also registered nurses.

Touching as it does matters of love and money, health and deep feminist feeling, the question of midwifery has stirred strong argument, with more to come: an incredible patchwork of wildly inconsistent state laws now govern, ignore or tacitly condone various kinds of midwifery. Setting adequate licensing and training standards, therefore, will not be easy.

Much of the organized medical profession, including the American Academy of Family Physicians, has opposed most midwifery for a variety of reasons. Among them: the difficulty in regulating midwife procedures, the belief that women get better basic care in hospitals and the fact that many deliveries may require aid that few midwives can provide in the home. Examples: anesthesia; delivery by cesarean section; forceps delivery; episiotomy, a surgical procedure in which an incision is made from the vulva through the perineum to widen the birth canal.

The advocates of trained midwifery, many of them women who have experienced childbirth in hospitals, are passionately unimpressed by such arguments. Where prenatal screening is properly practiced, they say, most of those births likely to need specialized care can be anticipated--and handled in hospitals. But at least 90% of births are uncomplicated, they assert, and in those cases women often find themselves in the hands of an overworked hospital staff and subject to perhaps unnecessary procedures. Says a registered nurse and lay midwife in California: "Just in case the woman tears, the hospital does an episiotomy; just in case she bleeds, they give her an intravenous solution during labor; just in case she may need a cesarean, they don't feed her." Another frequent complaint concerns the mother's position during labor. In hospitals, the complaint runs, women are strapped to delivery tables, though some women who have practiced natural childbirth find that other positions can be as effective and more comfortable.

Such statistics as exist seem to indicate that midwife-assisted birth is generally safe. During a test period in Santa Cruz County, Calif., 10% of the deliveries were at home by lay midwives. The infant mortality rate was lower than for the county as a whole (3.2 deaths, v. 15.1 per 1,000), though such figures may be misleading because predictably hazardous births were handled in hospitals. To support their claims, proponents of midwifery point to The Netherlands, where midwifery is widespread and the national infant mortality rate in 1975 was only 10.6 per 1,000, v. 16.1 per 1,000 in the U.S., a country admittedly with a much larger and less homogeneous population.

In public at least, those doctors who oppose licensed midwifery do not often speak of one reason that may be on their minds--money. Obstetrics is one of the largest and most lucrative specialties in U.S. medicine. Parents and proponents of midwifery are voluble on the subject of money, however. In California, for instance, the cost of having a baby has risen from $16 per hospital day in 1950 to $175 in 1976, and now stands at about $1,500 per birth. By contrast, the cost of birth at midwife-run institutions like the Los Angeles Childbirth Center is as little as $300. The California department of consumer affairs asserts that even if only 10% of needy parents were allowed to use Medi-Cal money to pay licensed midwives, the state would save $10 million a year. State officials also report that only 37% of California's obstetricians will deliver babies for the poor because they can only pay the $300 allowed under Medi-Cal.

There are always dangers in childbirth, and clearly, in the event of an unexpected medical crisis, both mother and baby are safer with immediate access to hospital facilities. Still, if money talks, and it usually does, the use of properly trained midwives is a service that U.S. medicine and U.S. mothers can hardly afford to do without. Says Dr. Donald Creevy, a California obstetrician who favors the new bill: "The medical profession can't go on saying, 'If you don't accept good care on our terms, you don't get good care.' "

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