Exploring the Alternatives to Hospitalized Childbirth: a Conversation with a Seattle Midwife

 

The present state of childbirth in America is a paradoxical one: even as more babies are delivered in hospitals, more mothers die in them. An unusually high number of American women choose to give birth in hospitals. Nevertheless, the United States has the single highest maternal mortality rate of the wealthy world. How could a country that depends so heavily upon hospitals fail its patients so desperately? The issue isn’t just that the United States has a higher maternal mortality rate than our peers. It’s rather that our maternal mortality rate is rising as that of every other wealthy country falls.

With this in mind, I turned to Cindie Brown, a midwife practicing in Seattle, Washington, to discuss why mothers may choose alternative routes to hospitalized childbirth. We started our conversation by defining what a midwife even is. There are multiple levels of qualification, some of which vary by state. Before this meeting I was fairly sure that the definition of “midwife” was more or less equivalent to that of “friendly helper.” Cindie assured me this wasn’t the case. She explained that there are three classes of midwife: 1)  nurse midwives, 2) licensed midwives, and 3) certified professional midwives.

Of these three classes, nurse midwives––like Cindie––have the most traditional medical training. They attend nursing school and have a master’s in midwifery, and handle pregnancy care and women’s health care; nearly all graduate with the intention of delivering babies in a hospital.

A licensed midwife is licensed by the state she works in, though the process one undergoes depends on the state issuing the license. In Washington State, for instance, you could go to midwifery school without going to nursing school. While the scope of the practice of a licensed midwife may be smaller than that of a nurse midwife, the training midwifery school provides could allow for more specialized knowledge about the processes of pregnancy and birth as a whole. Finally, a Certified Professional Midwife is a federal qualification that attempts to bridge the gap between the two.

A doula, I learned, is not the same thing as a midwife. “Midwives,” Cindie explained, “have medical training––which takes several years to get––and ongoing clinical education so that we can monitor medical situations and make recommendations.” Doulas, meanwhile, do not have the expertise to deal with medical situations. They are better prepared to advise and assist.

Cindie began by explaining that there’s a “basic package of care” that an expecting mother receives regardless of to whom she turns. However, while everyone––doctors, doulas, and midwives alike––has the same standard for care, philosophies vary across disciplines.

“Midwives in general view pregnancy and birth as a normal life stage and a normal process, not a medical one––though we know it can be a medical one,” she told me. Midwives have “more of a focus on prevention” of medical problems, and focus heavily on self-care and nutrition in the months of pregnancy. They also consider social systems and economic differences in specializing their care. Doctors, meanwhile, “are trained to deal with medical events.” When doctors go to school, she elaborated, they are trained to look for pathologies and medical emergencies. They are taught to check the physical parameters, leave the room, and then return for delivery. As a result, they don’t have a sense for the process of birth because they lack the practical experience. This is corroborated by a recent NPR study finding (in part) that “in the U.S, some doctors entering the growing specialty of maternal-fetal medicine were able to complete the training without ever spending time in a labor-delivery unit.” This means that midwives comparatively have greater practical knowledge to a staggering degree when it comes to the birthing process as a whole.

One of the greatest dangers of such a reliance on hospitalized childbirth is the dependence upon medicine and surgery it’s coupled with. “We do know how to use medications, [but] we limit those when we’re out of the hospital,” Cindie said. I was perturbed. I thought the whole point of medication and surgery was that they had inherent value––we created these things as a society because they’re helpful, right? “The medications are great when you need them,” she explained, “but they also come with side effects. They seem standard, but it’s actually something to be cautious about.” I looked this up later, and it’s true––an epidural can make it hard to push, necessitating forceps or a c-section in delivery, for example.

We lean on these types of medical interventions heavily. While the World Health Organization recommends the ideal rate of cesarean sections to be between 10-15%, the rate in the US is 32%. However, not all developed countries operate as we do. Many countries, like the Netherlands or Canada, depend much less on hospitalization. As such, Cindie explained, we can get fairly unbiased studies comparing the quality of life in countries that depend on midwives versus those that don’t. All studies emphasize that midwives should be taking care of 80% of the population, which leads to a “lower c-section rate, longer breastfeeding success, and less trauma and stress around birth for the woman.”

If studies are indeed reporting that it’s more beneficial for midwives to be delivering the vast majority of our babies, then why are so many mothers turning to hospitals? “We are very fear oriented around what could happen to a baby,” Cindie said, “so we do all these extra things [...] that could create harm. [...] We live in a culture where there’s so much fear around childbirth. It’s very focused on risk and harm in a way that’s very distorted. Honestly, there are so many women who are traumatized by their birthing experience in the United States. It’s just horrible. And there are so many women who are harmed by medical events in their birth experiences.” If a woman is considered medically low risk, she explained, she’s better off being treated out of the hospital. For instance, the UK found in a study of 100,000 women that 47% of women would be better having their babies out of the hospital than in it. Moreover, it’s proven that while complications can arise in birth, they happen at the same low rate whether you’re in the hospital or out of it.

This seemed to me to lead to the natural conclusion that all expecting parents should depend on a midwife for their birthing process and forego the traditional hospital route. However, Cindie surprised me by qualifying the statement. Because we don’t prioritize midwifery, we have many states where “there’s no regulation around the midwife,” and therefore the midwives are less trained and cannot access the same emergency medical care. As such, political and systemic changes are needed for this to become a reality.

Finally, I asked Cindie about her experience about being a midwife. I wanted to know what makes the job rewarding for her, since she used to work in a hospital until she transitioned into working for a small practice. “I love the relationship with women,” she began, “at a time that’s really important for them, and I get to step into this intimate thing. I have people who I love and who I’m connected with who I had babies with 12 years ago. You get to know their stories in really personal ways.”

She continued, “I love being able to just see nature unfold and let the baby be on its mom’s belly––without a lot of rubbing and vital signs and medicalizing––and when there’s [been] a problem, seeing the baby’s fine. Guarding women from unnecessary disruption so they can enjoy the fullness. It’s all so gentle. We’re in a unique position to really guard that space. I appreciate we can be a safe place for women when they’re no longer having children. I still get to be a part of their story in personal ways and they can feel safe.”

I thanked her for taking the time to chat with me, and she imparted a few documentaries for me to watch (list at the end). Just as I was sure we had covered it all, she finished with one last thought:

“It’s such a big women's issue––I think it really is a big women’s issue that affects the whole family, because [the birthing process] affects how they attach to their babies, how they feed their babies, how they feel about being a mom.”

“It’s very powerful.”

gretaGreta