In childbirth politics as in all politics, extreme viewpoints make the news, and sensible centrists are ignored. A couple of years ago, Ricki Lake provoked a firestorm of debate about home birth with her film, The Business of Being Born, which showcased gloriously crunchy New York City home births, and made the case for the home birth option. Obstetricians responded with censorious anger, shouting at Lake via condescending statements from the American College of Obstetrics and Gynecology. Recently, obstetrician and blogger Amy Tuteur published Push Back: Guilt in the Age of Natural Parenting, in which she made fun of women stupid enough to believe that they might have a better birth experience without an epidural, and excoriated anyone who would refuse any of the bells and whistles of modern obstetrics. Her title was a response to journalist Jennifer Block’s, Pushed: The Painful Truth about Childbirth and Modern Maternity Care, an exposé of callous obstetricians who damaged women and their babies with the thoughtless overuse of standard obstetric interventions such as the induction agent cytotec and the drastic overuse of major abdominal surgery (cesarean section).
All this shouting. Is it getting us anywhere? Mightn’t there be some middle path for women who see the appeal of “natural” birth, or who at least would like to minimize their chances of cesarean section, but who are not confident about giving birth without immediate medical back-up?1 Could there possibly be a way to combine the emergency backstop of modern medicine with the caring values of home-birth midwifery? Given the way the conversation usually unfolds, you’d think that such a middle path is at best a distant dream.
In fact, there is someone ready and willing to escort birthing women along that middle path: the nurse-midwife. Calm and sensible, evidence-based and gentle, she is too easily effaced by the competing romantic dreams of natural bliss and technological perfection. We need to notice that she’s there, and we need to figure out how to connect her services to more women.
Nurse-midwifery is largely invisible because of the vagaries of obstetric history, not because of any lack of merit. In the United States during the nineteenth century, middle-class couples gradually shifted their allegiance from midwives to doctors in the birth room. Doctors’ dominance was looking increasingly likely, when suddenly midwifery saw a resurgence in big cities around the turn of the century, as an influx of immigrant women turned to familiar birth attendants and practices they brought with them from the old country. Physicians railed against these practitioners, calling them dirty and ignorant, and demanding that they be outlawed. In some places, they were. Doctors had no solution, however, for a big problem: many women could not afford a doctor, so without midwives, they would be bereft of any knowledgeable birth attendant.2
A patchwork of private and public efforts were made to serve women who could not afford a physician’s fees. Several southern states licensed “granny midwives” in rural African-American communities. Some northeastern cities trained and regulated traditional midwives. And a couple of organizations experimented with a new kind of practitioner, the nurse-midwife.3
The Maternity Center Association of New York City, a pioneering organization in pregnancy and childbirth education and a major force for maternity care and advocacy for poor women, began training public health nurses in midwifery skills in 1932. Kentucky’s Frontier Nursing Service, a critical health services provider for rural women, began formally training nurse-midwives just after World War II. Practitioners organized to found the American College of Nurse-Midwifery in 1955. Their numbers have risen in the past 30 years, and today they attend more than 10% of low-risk births. While in many states they are permitted to attend home births, the vast majority of births they attend are in hospitals, as members of obstetrician-led medical practices.4
Since the 1930s, physicians’ guilds allowed nurse-midwifery to exist with the understanding that it was specifically for poor women, who would not pay a physician in any case. Until recently, nurse-midwifery was largely confined to public hospitals and patients who were not privately paying for care. Nurse-midwifery was established as a specialty with the implicit understanding that it would not cut in on physicians’ earnings. Indeed, nurse-midwives continue to disproportionately care for underserved women, and hold as a strong value the provision of care to every woman who needs it.
Ironically, nurse-midwifery’s history as a low-cost alternative to the presumably “cutting-edge” and resource-intensive care provided by physicians has provided one of its greatest boons: its ability to embrace evidence-based care when the evidence points to a less-is-more model for low-risk births. In reviews of the medical literature published in the highly-respected Cochrane database and elsewhere, nurse-midwives have been shown to give care that is just as safe and effective as that of obstetricians, with fewer interventions. Compared with low-risk women attended by obstetricians, low-risk women attended by nurse-midwives have fewer cesarean sections, fewer episiotomies, and more success initiating breastfeeding. Nurse-midwives also give much better support for non-medicated birth, though they are also happy to support women who want epidural pain relief while still reducing their chances of having to recover from major surgery (or even minor surgery that makes it hurt to sit down) while caring for a newborn.
It is too easy to ignore the moderate and sensible practices of nurse-midwives when we are caught up in partisan shouting matches, and what look suspiciously like turf wars. I recently spoke with Amy Tuteur about Push Back during an interview for the podcast Distillations, and she surprised me by telling me that she has provided obstetrician back-up for nurse-midwives, and that she respects them very much, even though some of their philosophies differ.
If Amy Tuteur and I can agree on the value of nurse-midwives’ practice, why aren’t we both looking to nurse-midwives as model practitioners? In her book and in our conversation, Tuteur insisted that the high false positive rate from obstetricians’ use of continuous fetal monitoring, which leads to a high c-section rate, is unavoidable if we want to save babies. I suggested that it is, in fact, avoidable: all she and her obstetrician colleagues have to do is walk down the hall and ask the nurse-midwives to teach them how to use intermittent monitoring effectively. Tuteur chose to ignore me, and simply insisted that obstetricians know best. She was not about to give ground in public to anyone called a “midwife,” even someone she privately recognizes is fully competent.
Nurse-midwives are not a panacea for every problematic aspect of hospital birth: they do have to follow hospital procedures that are generally organized around standard obstetric practices, and they do not usually have the time to coach women throughout labor the way a home birth midwife does. But they are clearly practitioners who would suit many more women’s needs, if women only knew about nurse-midwifery and had access to nurse-midwives at their local hospitals. Nurse-midwives are also potential leaders in evidence-based maternity care and health care reform, if only we can convince obstetricians to follow their lead.
In many ways, nurse-midwives represent the best of both worlds: they are able to provide low-intervention, empowering, low-side-effect care to women who have straightforward births, and immediate referrals to obstetricians when emergencies arise. They walk the middle path with women who want to balance high-tech and high-touch approaches to birth. We know that midwives can produce excellent excellent results on a large scale: in the United Kingdom, midwives attend all low-risk births, and have superior outcomes compared with typical obstetrician-led care in the United States. Let’s figure out how to put these centrists at the center of our conversations about childbirth, for the sake of birthing women today and the development and promulgation of better birth practices for the future.
Richard W. Wertz and Dorothy C. Wertz, Lying-In: A History of Childbirth in America, expanded edition (Yale University Press, 1989), chapters 7-8.
The Mama Sherpas (documentary film), Bridgit Mayer, director, 2015.
- And trans men, who often struggle to find appropriate and sensitive care for pregnancy and birth. Return to text.
- Richard W. Wertz and Dorothy C. Wertz, Lying-In: A History of Childbirth in America, expanded edition (Yale University Press, 1989), 211-217. Return to text.
- Wertz and Wertz, 214-218. Return to text.
- Wertz and Wertz, 217-219. Return to text.