Midwifery's rebirth: the government discourages midwifery despite its impressive record.

The government discourages midwifery despite its impressive record.

Mr. Brodsky, a senior research associate at Harvard Medical School's Program in Psychiatry and the Law, is a former president of Massachusetts Friends of Midwives and co-author of Home Birth: A Practitioner's Guide to Birth Outside the Hospital.

A study in the March American Journal of Public Health reported that certified nurse-midwives achieve excellent birth outcomes at a lower cost than physicians. The extensive media coverage received by the study portended a growing role for midwifery in today's cost-conscious health-care environment. Yet just a few months before the study appeared, an experienced Syracuse midwife with a loyal clientele was sentenced for the crime of helping women give birth. Arrested in a sting operation, Roberta Devers-Scott was charged with a felony: practicing midwifery without a license. To avoid prison, she pleaded guilty in November to a misdemeanor, receiving a $1,000 fine and three years' probation.

Unlike the birth attendants in the American Journal of Public Health study, Devers-Scott is an independent or "direct-entry" midwife. Like virtually all direct-entry midwives (but only 3 per cent of certified nurse-midwives) in this country, she attended births at home rather than in hospitals or birth centers. While CNMs are trained and regulated as part of the nursing profession, direct-entry midwives are trained at independent midwifery schools or through apprenticeship. Legal in some states, illegal in others, direct-entry midwives are the primary home-birth attendants in the United States.

Midwifery represents a fundamentally different model of care from obstetrics, and home birth offers the fullest realization of that nonmedical, woman-centered approach. But midwives are prevented from competing in a free market by statutory, regulatory, professional, and institutional constraints. They face the threat of prosecution for practicing illegally or exceeding the scope of their practice, a threat exacerbated by selective prosecution for clinical errors or tragic outcomes that would not be dealt with punitively in hospital obstetrics.

Study after study has demonstrated that midwives provide high-quality, cost-effective care. The study that caused such a stir last spring showed that, for comparable low-risk urban populations in the state of Washington, CNMs were less likely than either obstetricians or family physicians to resort to common obstetrical interventions, such as continuous electronic fetal monitoring, induction or augmentation of labor, epidural anaesthesia, and episiotomy. Most strikingly, the Caesarean-section rate for women attended by midwives (including those transferred to physicians' care for labor complications) was just 8.8 per cent, compared to 13.6 per cent and 15.1 per cent, respectively, for obstetricians and family physicians. As a result, nurse-midwives used 12.2 per cent fewer resources than physicians.

Noting that the midwives' approach to low-risk births "has significant advantages for patients," the researchers recommended "expanding the proportion of deliveries attended by midwives" and teaching physicians some of the skills and philosophy of midwives. The principal investigator, Dr. Roger A. Rosenblatt of the University of Washington School of Medicine, told The New York Times, "We physicians have something to learn from midwives about the approach to low-risk women."

This is old news to those familiar with the published research about midwifery over the last quarter-century. In fact, the Washington study was as remarkable for what it left out as for what it said. Because they limited their focus to births in hospitals, the researchers did not examine the equally good outcomes and even greater savings achieved by midwives in free-standing birth centers and in homes.

Recent evidence that home birth is a safe option for low-risk women comes from four studies published in the British Medical Journal last November. Conducted in the United Kingdom, the Netherlands, and Switzerland, they showed that planned, properly attended home births presented no greater risks than hospital births for appropriately screened pregnancies. Indeed, in the Dutch study, women who had given birth previously had significantly better outcomes in planned home births.

Theadvatages of home birth include fewer interventions, greater continuity of care (with the same midwife staying for the duration, even in prolonged labor), greater comfort and control for the woman and her family, less disruption of the family's usual pattern of living, and a richer, more intimate experience in a familiar environment. In one of the British studies, 85 per cent of the women who had previously given birth in a hospital preferred their home births. Of those who planned more children, 91 per cent intended to give birth at home again.

These women also placed high value on the freedom to choose the place of their children's birth, a right explicitly recognized by the British government. One woman wrote that home birth "is not for everyone, but freedom of choice is priceless." As the Dutch researchers noted, exercising choice may itself have psychological benefits, reducing anxiety and enhancing the woman's sense of well-being. These benefits of choice may then translate into improved outcomes.

In Europe midwives attend about three-quarters of all births; in the United States they attend only 5 per cent. This disparity is especially striking given midwifery's cost-cutting potential: Based on an average saving of $3,000 a midwife-attended birth, a 1995 Cato Institute report estimated that consumers and insurers could save $2.4 billion annually if 20 per cent of American women used midwives. The University of Washington researchers acknowledged that "barriers imbedded in both licensure regulations and hospital privileging processes" discourage the use of midwives. If institutionally based nurse-midwives are marginalized, home-birth midwives are even further excluded. They must practice underground in some states and, even where legal, may have difficulty obtaining medical consultation. Despite these obstacles, direct-entry midwives attending planned home births in the United States have compiled a safety record comparable to that of low-risk hospital births.

Midwives continue to engage in state-by-state legislative and judicial skirmishes, winning legal recognition or additional prerogatives in some states while suffering setbacks in others. Looming over these local developments is the prospect of a massive turf battle stemming from a move by the American College of Nurse-Midwives to claim the "direct-entry" title for its own members. The ACNM has proposed certifying "direct-entry" midwives who complete a university-based, ACNM-accredited training program. But the ACNM's insistence on institutionally based training and a bachelor's degree as requirements for all midwives has brought the organization into conflict with the Midwives' Alliance of North America (MANA), which supports multiple routes to certification and vigorously defends the tradition of apprenticeship.

The impasse with MANA may ultimately lead to greater understanding and cooperation. Until then, injustices like those now occurring in New York will continue. New York's Midwifery Practice Act of 1992 made midwifery a separate profession. But a clause requiring a written practice agreement with a physician compromised the independence the act promised. Worse, the law imposed an educational requirement that few of the direct-entry midwives practicing in the state could meet, and it classified unauthorized practice as a felony. Taking the law at face value, some long-established community midwives, including Roberta Devers-Scott, presented their qualifications and asked for licenses. Instead, they found themselves prosecuted -- poor thanks for helping to bring life into the world.