The Making of Mothers

"It's not just the making of babies, but the making of mothers that midwives see as the miracle of birth."

-- Barbara Katz Rothman,
Sociologist, Author of The Tentative Pregnancy,
Genetic Maps and Human Imaginations and other books.

Ina May Gaskin has this quote up on her site: http://www.inamay.com
as the "quote of the week," and I just couldn't resist posting it here.

It's so true. People ask me how midwifery care is different from seeing an OB for a monthly prenatal check-up. Sometimes it's hard to articulate exactly what it is about the Midwives Model of Care that compels mothers who have experienced it to do almost anything to find a midwife for their next pregnancy. People in the medical field are baffled as they almost never come back to the obstetrical model of care. Why?

This quote sums it up, I believe.

A Christmas Wish for Birthing Women

As everyone rushes around, gathering with family and friends for Christmas, baking cookies, piling their cars high with gifts, and eating more than ample portions of Christmas candy and sweets, I’ve thought about what I really want this Christmas.

What I want isn’t tangible, and I won’t get it tomorrow morning as a Christmas gift.

But I still wish for it, for my future, and that of every young woman who will someday face the prospect of pregnancy, birth, and motherhood.

I dream of the day….

~ When pregnant women are honored and treasured by society as life-givers and very special people.

~ When all women will be informed and educated about their bodies, birth, and babies.

~ When maternity care providers will believe that parents are good decision makers when presented with accurate information.

~ When every woman will have access to a midwife, a doula, a physician, a circle of supportive friends and anyone else she needs or wants to give her the best pregnancy possible.

~ When pregnant women walking through the grocery story will hear, “You can do it!” instead of, “I hope you signed up for an epidural! You have no idea how bad it hurts!”

~ When women aren’t expected to have perfect bodies that show no signs of having carried and birthed a baby.

~ When birth and babies again belong to mothers and fathers…. Not the state, not the American Medical Association, not the insurance companies, or the hospitals or obstetricians.

It won’t happen overnight, but it can happen when committed people work to change their own little corner of the world.

You may not be able to transform your local hospital’s policies, but you can educate your daughters, the girls in your neighborhood, your classmates and colleagues about birth.

You may not be able to stem the rising C-section rate, but you can help this mother avoid an unnecessary one.

You may not write a book that improves birth for other women, but you can write a letter to the newspaper about women’s birth options in your area.

You may never get everyone to breastfeed, but you can convince some people of the huge difference it can make in the future health of any baby.

You may never appear on a talk show about birth, but you can talk to your friends about improving birth.

You may never change the world, but you can change your world!

Broccoli flavored amniotic fluid and breastmilk?

There is a growing body of evidence that before you ever stick a bite of mashed carrots or peas in your baby's mouth, the way you have eaten during pregnancy and while breastfeeding your infant may greatly influence their eating preferences as babies and toddlers.



In a study reported in the December issue of Pediatrics, babies whose mothers regularly eat veggies and fruits while breastfeeding them, find that their babies are more likely to accept vegetables and fruits when tasting them for the first time as well as consume larger amounts. Sometimes it's obvious that a mother's consumption of various foods is passed on through her breast milk - like when she eats too much garlic, and the next morning the baby screws up his or her face and turns away from the breast. But this research shows that perhaps the baby can also taste green beans and peaches and learn to like them.

Research also shows us that babies tend to have the eating preferences that their mothers had during pregnancy as food flavors from a mother's diet are transmitted to the amniotic fluid that a baby lives in and drinks while in utero.

The 2004 Feeding Infants and Toddlers Study showed that 1 in 4 US toddlers did not consume even 1 vegetable on any given day. They were more likely to be eating fatty foods and sweetened snacks and beverages than any vegetables. And none of the top 5 vegetables consumed by the toddlers was a dark leafy vegetable. I bet their mamas preferred sweet snacks and beverages and fatty foods when they were pregnant.

So, yes, eat your veggies and avoid junk while you're pregnant and on through the breastfeeding phase of your child's life, if you want your baby to grow up happily eating squash, broccoli, and apples instead of Twinkie cakes and Mountain Dew!

How much do nurses learn about natural birth?

A week or so ago, I heard from my friend, "Julie". She's a newly trained doula, finishing up her certification and has been attending births since last summer.

Julie had been invited to speak to a nursing class about the role of a doula* in the delivery room, and comfort measures that can help women cope with the pain of labor. I was excited for her and hoped that she would be a part of helping this whole class of nursing students understand and promote natural birth. I was shocked when she emailed with a report of how it had went...



"The nursing speech went well. I was surprised to learn that even though it's a maternity nursing class, the students never see a mom in labor, never do any type of labor support. Their clinicals cover newborn tests and postpartum work - not actual labor work. The professor said that she has to cover IV medications and epidurals because that's what's on the state exam. They don't have time to work on other comfort measures. It was hard to relate my info to the students since they've never seen a labor[and] can't fathom why anyone would do it without pain meds...
When I mentioned that they can really set the tone for a labor and can really influence how a mom feels, there were lots of nervous giggles. When I said something about how moms look to them for reassurance that everything is ok and that many moms feel like the nurse is in an authority position -- they actually looked panic stricken!
It puts the nurses in a slightly different perspective for me. Maybe they aren't anti-natural birth as much as they just really don't know what to do [for a mother attempting a natural birth]. They aren't trained in it at school."

These are RN students, getting a 4 year nursing degree from what is considered a top nursing school in the midwest. This class is the Maternal/Neonate one that everyone is required to take.
Julie learned that their clinicals include coming in as a women is in the final stages of pushing, just in time to do the baby's Apgar scores, weight, etc. They also do the next day post-partum vitals for the mother (blood pressure, temperature, etc).

They are not required to have any hands-on experience with a laboring woman. The actual non-pharmacological labor support, what happens during labor, etc. is one or two class periods. The professor said that she has to focus on pain medications, when to give them, when to wait, who can have what, etc. because that is what they will be tested on during their state exam. When asked about other comfort measures for laboring women, the professor told Julie that the text book does a "nice job of explaining" comfort measures.

Makes me wonder how much birth - natural or medicated or surgical - the average nurse has seen when she finishes her nursing degree and graduates as an RN! Any nurse readers, please chime in with comments and let me know how much birth you had experienced when you finished nursing school!

Maybe I shouldn't have been so shocked a few years ago when I was working as a doula in a small town hospital, and labor quickly picked up for my client. Before we knew it the mother had gone from being 3 cm dilated to 10 cm and pushing in less than 30 minutes - and the OBs had all gone home for the night.
The young labor and delivery nurse who was covering my doula client for the evening started to scream, "Noooooo! Don't push! You have to hold it in for the doctor! I can't catch a baby! I don't know how! Don't do this to me. Nooooo!" She looked positively terrified, and was visibly shaking.
She didn't catch the baby - he landed at the end of the bed, and she still shaking, picked him up and said, "Well, I guess he's okay." Then she looked at me and said, "This is my first birth as a nurse."

I was shocked. Maybe I shouldn't have been.


* A doula is a professional labor support person who stays with the mother through labor to provide physical and emotional support.

Blood Volume of a Pregnant Woman

In a conversation with a
perinatologist recently, I found
out a couple of neat facts that
you might find interesting....

~A full-term pregnant woman has an
approximate blood volume of 10 liters.
That's five 2-liter soda bottles!



~The uterus has 1/2 liter of blood
flowing through it per minute at the
time of birth/full term.

What is Good Prenatal Care?

Awhile ago I was sitting in a seminar/class for people who work in the world of midwifery and/or obstetrics.
A very wise woman was articulating what prenatal care is all about. She said something profound that I've never forgot. In her words,

"Being a midwife or an obstetrician is not just about catching babies. Being the primary caregiver for a pregnant woman is teaching the mother to be the primary caregiver for herself and her baby. We cannot give prenatal care. We can only give a lot of information to the mother to help her give herself better prenatal care."

US ranking in maternal mortality

TIME magazine recently reported that the United States ranks 41rst out of 171 countries, of women who die from complications in pregnancy or childbirth. The death rate in America - one in 4,800 - far surpasses other developed countries where they average one in 16,400. 1
The notable difference between these outcomes is the extent to which other developing countries provide access to midwifery care for their citizens. In those nations where midwives attend a significant portion of births, their intervention rates are lower and maternal outcomes prove
safer. 2

1. TIME, October 29, 2007, p18
2. Marsden Wagner, MD, MSPH; Fish Can't See Water: The Need to Humanize Birth;
International Journal of Gynecology and Obstetrics, 75, supplement s25-37, 2001

Has the remedy for prematurity been found?

The March of Dimes has done a wonderful job of convincing people that prematurity is a tragedy and must be stopped. In the twenty-first century, it’s so vogue to be fighting prematurity. Who wouldn’t want to be listed as a donor to such a noble cause?

It is a noble cause.

I have friends, actually quite a lot of them, who have suffered from the modern day plague of babies born far too early and far too small. I have friends whose babies only lived a few days as a little struggling bit of humanity, enclosed in glass, full of wires and tubes. As their frail little bodies failed and slowly gave up, their mothers were left only with memories of barely touching their baby’s fragile skin, wishing that for one moment their baby could have nursed at their breast.

I have never been the mother or sister of one of these babies, and I’m sure that being such would make me far more sensitive to the grief that accompanies loosing such a baby. Or even watching the baby survive, but with many struggles to overcome – loss of eyesight, brain function, emotional disorders… and the list could go on.

Babies, even those with remarkable stories of survival, always pay the price for the weeks and months that they had to spend growing in the harsh world outside the womb, before they were ready.

The March of Dimes continues to shout “Find the causes of prematurity! Stop it! No more premature babies!” With such a noble and heart-stirring mission, millions of dollars are donated to the cause. Many of the donations probably come from fathers and mothers who have personally been affected by the bitter memories of their own premature baby, struggling to survive.

And yet, where are the answers?

Our prematurity problem is only growing.

March of Dimes has not found the answer… The world’s most noted obstetricians, perinatologists, and neonatologists don’t know how to end the plague. They sadly tell grieving mothers who wonder if it was their fault that their baby was born at 26 weeks gestation instead of 40 that “nobody knows why. Sometimes these things just happen.”

But some interesting and very promising research is under way.

I spent the weekend with some international scientists and researchers who have spent over a decade focusing on various kinds of maternity care and the resulting outcomes to mothers and babies.

They are not ready to go public with their discoveries yet, as there is still more research to be done, and statistics to looked at, but so far they are finding a correlation between greatly lowered rates of prematurity when a pregnant woman sees a midwife as her primary maternity care provider.

In looking at large populations of low-risk, healthy white women, they noted that:

Of those who received typical obstetrical care, approximately 11.2 % gave birth to babies at less than 37 weeks gestational age.

Of those who received care from a Certified Professional Midwife (planning for a birth in an out-of-hospital setting), approximately only 4 % gave birth to babies under 37 weeks gestational age!

The research is still being done, but the preliminary results are showing a drastic difference in the care of a midwife vs. the care of a physician when it comes to preventing prematurity.

Maybe the March of Dimes should start to look outside the box. Instead of looking to high-tech, high-cost care, maybe they should take a glance at what happens when people use high-touch, personalized care.

Protecting Your Pelvic Floor

Researchers grouped seventy women according to whether they exercised regularly, did postpartum exercises only, or never exercised, and measured the strength of their pelvic floors one year after childbirth.
Regular exercisers fared the best, postpartum exercisers fell in between, and non-exercisers had the weakest pelvic floors. Exercise regimens included fitness classes, walking, jogging, running, dancing, swimming, and yoga.

Gordon H and Logue M;Perineal muscle function after childbirth.
Lancet 1985; 2:123-125



Researchers evaluated perineal and pelvic floor outcomes in 460 first-time mothers according to how much they exercised. Women engaging in weight-bearing exercise more than three time weekly were equally likely to have an episiotomy, but only 16 percent experienced anal injury, compared with more than one-quarter of those exercising less often.

Klein MC, et al.; Determinants of vaginal-perineal and pelvic floor functioning in childbirth. American Journal of Obstetrics & Gynecology 1997; 176(2):403-410

What Do Women Really Want in Birth?

What do women really want in birth?

The answer to this question influences billions of dollars of business in our country every year.

Every wise business person knows that in order to be successful, s/he must develop a product that is what the consumer WANTS and/or NEEDS.

If the consumer wants it, but doesn't need it, s/he may or may not buy it.

If the consumer needs it, doesn't really want it or find the product attractive, s/he probably will go elsewhere to get what they need.

When you combine need and want, you have a powerful product.

Our current maternity care system has convinced most of their customers that what they offer is what the customers need and want.
But is it really?

What basic things have they convinced the majority of mothers to need and want?

Safety

Avoiding unnecessary pain

If you ask nearly any woman why she's having her baby in the hospital, her biggest reason will be "safety."
Ask her what other reasons, and you may get an assortment of answers, but most likely the most frequent answer will be "for pain relief" if she takes a moment to think about what her hospital and obstetrician offer her.

These are two good things for women to want.
Who wouldn't want their baby to be safe?
Who wouldn't want to know that if anything goes wrong, someone will know how to fix it?
And who wants to suffer unnecessary pain?

But are women really getting what they think they are?

Sometimes I see many pregnant women in our society akin to a man who keeps driving his little Chevy truck that breaks down frequently, and is convinced that his truck is the best that can be had, because all of his friends say so. Even books about buying a good truck say so. The man who sold it to him told him that it was the best kind of truck he could drive. Sure, he doesn't like the breakdowns, but he's been told that his truck is the best, so he does his best to live with the aspects he doesn't like and pride himself that he is driving the best truck anyone could buy.

How many women are taken by the marketing that occurs in this country? We tell them that if they would only come to the hospital, they might experience a few breakdowns and inconveniences, but their experience will be the best they will find anywhere - safe and comfortable.

That's what we say.
But is it true, or is our modern maternity care system not all its cracked up to be?

Research on the Stillbirth-Cesarean connection

From the Lancet 2003; 362: 1779-84:

Stillbirth linked to cesarean section

Investigating the relationship between previous cesarean delivery and subsequent stillbirth.

Cesarean section can increase the risk of stillbirth in subsequent pregnancies, claim researchers, in findings that add to the growing debate over the acceptability of elective cesareans.

Professor Gordon Smith (University of Cambridge, UK) and colleagues studied data on 120,633 births in Scotland between 1992 and 1998. They found that the proportion of stillbirths was greater in women who had previously delivered by cesarean section (2.4 per 10,000 women) than among women who had only delivered vaginally (1.4 per 10,000 women).

The increased risk of stillbirths with unknown causes began at around week 34 of the pregnancy in women who had undergone a cesarean for a previous birth, regardless of the reason for the procedure.

The association is "biologically plausible," the team comments, reasoning that previous cesarean delivery may influence uterine blood flow and mechanisms of placentation in future pregnancies.

An OB's opinion on C-section

From www.obgyn.net

There are many benefits of vaginal delivery, for both mother and baby. During a vaginal delivery the amniotic fluid is squeezed from the baby's lungs, making it easier for him or her to breathe. This does not happen as much during c-section.

Furthermore, it is a misconception that c-section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c-section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c-sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c-section versus vaginally.

Contrary to popular belief, a c-section is a major operation, not unlike a hysterectomy in it's complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs.

These complications are usually much more common with c-sections than vaginal deliveries, although as with all medical issues the patient's individual situation will dictate which complications are more, or less, likely.

An unfortunate side effect of our legal system is that many women are led to believe by malpractice lawyers that a c-section will prevent any and all problems for their baby. This is simply untrue and is a very unsophisticated way of looking at this major operation and pregnancy in general.

D. Ashley Hill, M.D.
Associate Director Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency Orlando, Florida

Cesarean section - the way to go?

More and more women are choosing to go the "cesarean route." After all, most plan to have only one or two babies, and they'd rather put up with recovery after major surgery once or twice than "ruin a perfectly good vagina" as one woman put it.

But does cesarean really preserve a woman's body more than vaginal birth?
Is it really less painful?
Are the risks the same?
If I had all the information on risks and benefits, would I choose a C-section for myself?

A doctor friend of mine whose wife recently gave birth by cesarean to her only child, remarked over dinner the other day (as I was discussing natural birth with someone else), "There's nothing quite like a c-section. Slit it open. Take the baby out. Sew it back up and you're done. No sweating, and moaning, and hours of misery. No natural birth for me. I don't find it compelling!"

Is a c-section really akin to just "unzipping," pulling the baby out and sewing the uterus shut again?

Well, not exactly, according to some nursing students who I was visiting with a couple of weeks ago. They were just finishing their eight weeks of Labor and Delivery in their RN training. One of them was lamenting that she had only seen c-sections, during her clinical days, and never witnessed a vaginal birth in the hospital. (She had seen vaginal births in South America, totally unmedicated, and unassisted by any "professional.")

"So," I said, "What do you think of C-sections? Would it scare you to have one, or does it look better than vaginal birth?"

"Oh, my goodness!" she replied. "If women only got a ten second 'behind the scenes' look at c-sections, they would never opt for one. They look awful! The whole uterus, tugged out of the body, lifted up and set on top of the abdomen for repair. The blood loss... it just looks like you tipped over a cup of water and it's pouring out. And then they stuff a rag inside the uterus and..." she shuddered. "I've helped people with severed limbs and stuff, but a c-section was just really gross."

My friend, Jason, and his wife just had an elective cesarean this week. He called to tell me the baby's weight and all the "proud father" news. I asked him if his wife was into recovery yet.
"Oh, yeah, C-sections don't take long. It only took about 10 minutes and we had a baby!" he exclaimed.
"Except that the c-section looked really awful. She didn't feel a thing. But it took the doctor pulling on the baby's head for all he was worth and three people holding her down on the table to get the little six pound guy out! Afterwards, it all looked... uh, just gross. I tried not to hurl, and couldn't watch the rest of it."

Dr. Deirde Lyell, assistant professor of Maternal-Fetal Medicine at Stanford University in California, has this to say:
"Unless a woman has a compelling reason for needing a C-section, vaginal delivery is still the way to go. A C-section is major abdominal surgery and carries a greater risk of severe bleeding, infection, re-hospitalization and blood clots."

Why Do Women Put Up With Birth the Way We Serve It?

The question deserves raising: Why do women put up with [the options they are offered for childbirth]?
"Americans trust doctors and they trust hospitals, and they equate the two with health. And people want what's best for their babies. They assume that you decrease your risk by going to a hospital and having a top-flight doctor. What they don't understand is that obstetricians are surgeons, and they know pathology, but they really suck at wellness." (-Judith Lothian) They are trained to sew up a tear, but not to prevent one.

- Excerpted from "Pushed: The Painful Truth About Childbirth
and Modern Maternity Care,"
by Jennifer Block

Photo Credit: photographer Lindsey Woessner, copyright Molly Remer

Physician Liability

I heard Dr. Marsden Wagner, a perinatologist and former director of Women's and Childrens' Health for the World Health Organization (WHO) talk about liability risks for obstetricians who are finding themselves getting sued every time someone doesn't end up with a perfect baby.

Dr. Wagner made a statement that I will never forget. He said,

"If you're going to play God in the delivery room, you're going to get blamed for natural disasters."

Herein I believe, lies the biggest solution to our liability crisis. Doctors have led people to believe that they are "God" and if their patients will only come to the hospital where things are "safe" and where the "best medicine in the world" can take care of them, they can sit back and relax and wait for the doctor to produce a pink, squalling baby.

People are no longer being good healthcare consumers. It is implied at their very first visit that the doctor is in completely in control of everything that could happen and has a drug for every problem at his/her disposal and the eventual outcome will be secured if the doctor is allowed to "work their magic."

"So, honey, hop right up here on the exam table and put this paper gown on... We'll take a peek and tell you exactly what is happening inside you..."

Of course, people are angry and disillusioned when they obeyed all the rules, and did things the "safe" way - only to end up with this - a damaged or dead baby.

What is the solution?

The solution is better informed consumers. It's partly the health care system's fault and it's partly our own fault as consumers if we don't "read the labels" on what we're ordering.

The C-section Epidemic - Jennifer Block

A fabulous op-ed piece, published in the LA Times, written by Jennifer Block, author of "Pushed: The Painful Truth about Childbirth and Modern Maternity Care."

More women are dying in childbirth thanks to the high numbers of doctors and mothers who opt out of normal delivery.

By Jennifer Block
September 24, 2007

Pre-term births are on the rise. Nearly one-third of women have major abdominal surgery to give birth. And compared with other industrialized countries, the United States ranks second-to-last in infant survival. For years, these numbers have suggested something is terribly amiss in delivery wards. Now there is even more compelling evidence that the U.S. maternity care system is failing: For the first time in decades, the number of women dying in childbirth has increased.

The Centers for Disease Control and Prevention last month released 2004 data showing a rate of 13.1 maternal deaths per 100,000 live births. For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.

These high rates aren't a surprise to anyone who's been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.

What's to blame for the poor U.S. showing? True, we are the only industrialized country without universal healthcare. But when it comes to childbirth, we basically have it. Ninety-nine percent of women give birth in a hospital with access to all the bells and whistles -- high-tech machines that continuously monitor the baby's heart rate, drugs that can control the speed of contractions like the volume on a stereo, instruments that can coax a reluctant head out of the birth canal, and surgeons at the ready to perform the mother of all interventions, the caesarean section.

The C-section, now used to deliver 30% of American babies, is such a norm these days that, in some places, doctors and women have taken to calling it "C-birth" or even just "having a 'C.'" Pet names aside, the procedure is major surgery, and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here's why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.

Placenta accreta is one of them. The placenta embeds into the uterine scar from a previous surgery, causing a catastrophic hemorrhage at the time of delivery. Most women with placenta accreta lose their uteri; as many as 1 in 15 bleed to death. In 1970, accretas were so rare that most obstetricians never encountered one in their career. Today, according to a University of Chicago study, the incidence may be as high as 1 in 500 births. And that is all because of caesareans and repeat caesareans.

Obesity plays a part as well because obese women are more likely to have health problems that make a caesarean more likely, and more likely to suffer surgical complications. Still, it all comes back to the "C," which could easily stand for "culprit."

According to a sweeping 2006 study by the World Health Organization, published last year in the medical journal Lancet, a hospital's caesarean rate should not exceed 15%. When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die.

Too many caesareans are literally medical overkill. Yet some U.S. hospitals are now delivering half of all babies surgically. Across the nation, 1 in 4 low-risk first-time mothers will give birth via caesarean, and if they have more children, 95% will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability.

American maternity wards are fast becoming surgical suites. We've become dangerously cavalier about it, but the caesarean rate should be a major public health concern. Universal care alone won't solve the problem; what pregnant women need is entirely different care. They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.

http://www.latimes.com/news/opinion/la-oe-block24sep24,0,6378847.story?coll=la-opinion-center

Case Study Reveals Economic and Political Forces that Hinder Access to Midwifery Care

Piercing the veil: The marginalization of midwives in the United States.

Social Science & Medicine, 65(3), 610-621. [Abstract]

Goodman, S. (2007).

Summary: This qualitative case study analysis illuminates the forces behind the underutilization of midwives in the U.S. maternity care system and the process of their professional marginalization. The researcher identified two prominent midwifery services that had good outcomes and were connected with prestigious and influential institutions. One was a university-affiliated hospital practice that had provided uninterrupted midwifery service to the community for nearly five decades. The other was a birth center in continuous operation for nearly 30 years and hospital-owned for the final seven. Both practices were threatened with closure in 2003. In the case of the university-affiliated practice, the midwives ultimately maintained their ability to practice but the hospital imposed restricted clinical practice guidelines resulting in an 84% decrease in the number of midwife-attended births and a number of midwives leaving the service. The birth center practice closed abruptly in a decision handed down by the hospital without the involvement of the center's Board of Directors. In order to understand the circumstances behind the closures, the researcher conducted 52 in-depth interviews with midwives, nurses, service administrators, childbirth educators, policymakers, and physicians and reviewed archival data such as email correspondence, policy statements and memos.

In both cases, the publicly articulated reason for the attempted or actual closure of the midwifery services appeared to be reasonable. In the university-affiliated practice, the hospital claimed that too many of the women in the neighborhoods served by the hospital were high-risk and midwifery care was therefore unsafe. In the case of the birth center, the hospital reported that the decision to close was prompted by a 400% increase in malpractice insurance premiums. In neither case did the hospital provide any documentation or other evidence to support these rationales for closure. Interviews and analysis of archival data revealed that the midwifery services represented competition to the hospital, local physicians, or both. The case of the university-affiliated midwifery practice was particularly overt: the hospital had recently paid a multi-million dollar fine for double-billing the Medicaid program for births attended by midwives - once for the midwife and again for the consulting physician. When this fraudulent practice was discovered and the hospital was censured, midwives became a source of competition rather than income. In the case of the birth center, five-fold growth in the number of birth center births over the time the hospital had ownership may have appeared to be siphoning business away from the hospital's labor and delivery unit. Despite these potentially powerful economic and political motives for closing the midwifery services, the public were led to believe that the decisions were driven by rational concerns about safety and liability. The author concluded, "In the cases studied, institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. In fact, the elimination of midwives seemed to be a rational decision when framed in the context of patient safety and the rising cost of medical malpractice" (p. 9).

The author explored aspects of the U.S. health care system that facilitate professional marginalization of midwives. The most problematic is the way the U.S. medical education system is funded. Hospitals essentially get paid twice for care provided by medical residents because they can bill directly for the care and also receive large subsidies from the federal Medicare program in exchange for providing residency opportunities. The more residents a hospital employs, the more federal money they get, so there is a government-imposed disincentive for hospitals to employ midwives. Furthermore, in many states midwives must have formal practice agreements with physicians in order to obtain licenses, liability insurance, reimbursement, or hospital privileges. This requirement makes midwives dependent on their competition in order to gain access to employment. Finally, midwives' reliance on low-tech care practices result in lower utilization of medical devices and services that may be separately billable.

Significance for Normal Birth: Advocates for improvements in maternity care are often at a loss to explain why childbearing women cannot access care providers who support normal birth. Normal, physiologic birth, it would seem, must be less costly than technology-intensive birth. Solving this paradox requires an understanding of the political and economic forces that foster dependency on high-cost obstetrics to the detriment of women and babies. While this study is small and focused on two specific examples of midwifery service closures, it provides important insight into the systemic forces that hinder women's access to midwifery care despite a large body of evidence that midwives provide equal or better care than physicians with lower reliance on costly technical interventions. The study documents how our market-based health care system safeguards the interests of the medical profession which can often be at odds with those of women, babies, and society.

Radical, systemic reforms are needed if the United States hopes to achieve a high-functioning maternity care system, characterized by effective, high-quality care, universal access, and cost containment. Evidence from countries with excellent maternity care outcomes suggest that eliminating barriers to midwifery care must be a priority. Birth advocates can begin by calling for accountability and transparency from hospitals and maternity care providers.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17475381&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum