Access to and Use of Midwifery Services: the United States and the Netherlands

ACCESS TO AND USE OF MIDWIFERY 1

Access to and use of midwifery services: the United States and the Netherlands

Ahmielleah Yeung

CaseWestern ReserveUniversity

Introduction

Despite the United State’s high level of spending on health care and ready access to the most modern technology, the country has generally failed to make the significant improvements in maternal and infant health outcomes seen in other similarly prosperous parts of the world and has a cesarean section rate more than double the 15 percent recommended by the World Health Organization as a maximum level for optimal health outcomes. Since as DeVries (2004) points out, “the quality of maternity care in both senses of that word – its nature and its outcome – often is used as a measure for the quality of an entire health care system [and] infant mortality rates have become a shorthand measure for the adequacy of a society’s health system and its overall quality of life” (pp. 15-16), this matter should be of some interest and urgency in this time of focus on American health care reform. The United States system of maternity care stands in stark contrast to that of European nations, particularly the Netherlands, in its high dependence on surgical specialists instead of midwives. In most of Europe, the number of midwives far exceeds the number of gynecologists, however in the United States that statistic is tremendously reversed, with “about 40,000 practicing obstetrician-gynecologists and approximately 8,000 practicing midwives” (DeVries, 2004, p. 41).

The United States also suffers from a lack of clear definition of the term “midwife.” Rooks (1997) identified no fewer than seven different types of birth attendants who may in certain times and settings, by various observers, be classified as “midwives.” These range widely in training, skills, and experience. Some are the old “granny” midwives, who trained primarily through apprenticeship, only attended a fairly small number of births in their own community, and are now virtually non-existent in practice and somewhat replaced by “lay” midwives. Others are Certified Nurse-Midwives with graduate degrees. There are also practitioners who hold no official medical degree but have undergone training and certification to become Certified Professional Midwives, ACC Certified Midwives, or Licensed Midwives. In addition, there are caregivers who perform all the major functions of midwives but call themselves by other terms such as doula or birth assistant, often because they live in areas where the practice of midwifery without a CNM degree is punishable by law.

What is clear is that the medicalization of birth has not improved outcomes for mothers or infants, and has potentially led to several long-term negative outcomes that are not fully seen in the research yet. Some of these include increased postpartum depression rates, poor breastfeeding success rates, and other maternal/infant bonding issues. Countries that take a less technological, more human view of the birth processes consistently achieve better outcomes than the United States in these and other family issues. This begs the question of how did we get here, and how did another place arrive at their modern birth culture, and what aspects might be transferable to American births to the improvement of our system.

History of Midwifery in the United States

Midwifery in the United States has suffered over the course of history from a lot of misinformation, both intentional and accidental. The dangers of birth have been greatly influenced by social customs and trends, from corsets creating intentional distortions of the adult female form to the unintentional distortions of the pelvis caused by the prevalence of rickets as society industrialized (Block, 2007). The political, economic, and cultural power of physicians did a very thorough job of convincing women in the first half of the 20th century that hospitals were the proper place for a modern woman to give birth, while midwives were for the uneducated and unwashed who could not afford a modern hospital birth (Block, 2007; Cassidy, 2006). There was a trickle-down effect from the upper classes to the lower in the acceptance of male birth attendants that started in the mid-18th century and rapidly accelerated in the first part of the 20th (Donnison, 1988), as having a male physician instead of a female midwife came to be seen as a sign of prestige, especially with regards to the ability to afford such services.

Midwives in the United States lacked organization that other medical professionals developed, which made them easy prey to slanderous misrepresentations of their competency by their more organized contemporaries who began publishing their trade journals nearly a century before any American midwives did. This lack of written recourse and coming together resulted in midwives being denied access to new tools of the trade and other advancements in knowledge about birth, hastening their fall into obscurity. This was furthered by well-intended organizations in the early 20th century that were deeply concerned about maternal and infant morbidity and mortality rates, and wrongly blamed the problems on midwives as primary maternity care providers as well as births occurring at home instead of in hospitals (Dye, 1986).

Furthering the move toward the medicalization of birth was the feminist movement as it grew in power. American feminists became aware of physician’s ability to put them in “twilight sleep” during birth – a practice that not only resulted in their not remembering the act of giving birth but also necessitated a large number of interventions that could only be performed in a hospital – and began demanding to be “liberated” from the pain of child birth (Block, 2007; Rothman, 1991).

Despite the general mainstream view that the move from home to hospital birth, and from midwives to physicians as attendants, was responsible for the decline in the childbirth associated death rate, this doesn’t appear to be the case in retrospect. In the twenty years that saw the majority of births shift from home to hospital, the national maternal death rate actually went up. The decline in the death rate did not occur until the late 1930s, when sanitization procedures and medication to treat infections triggered the improvement (Block, 2007; Dye, 1986). At the beginning of the 20th century, most women had a very realistic view of what giving birth was like from having been present to tend to birthing women connected to them by ties of friendship or family. By 1960, almost no American mothers knew what the experience of truly natural childbirth was like, for they had not even been consciously able to experience their own much less witness another woman go through it (Dye, 1986; Rothman, 1991).

History of Midwifery in the Netherlands

The history of midwifery in the Netherlands is significantly different than its development in other Western nations. Much of this can be attributed to the early adoption of a bourgeois culture and nuclearization of the family by the Dutch in the 16th and 17th centuries (DeVries, 2004). Also of note is the secularization of the profession of midwifery during the DutchRepublic of 1579-1895, something quite apart from the situation in the rest of Europe at the time (Rooks, 1997).

Midwives have been recognized as independent medical practitioners since 1865, allowing them to care for women with uncomplicated pregnancies without a doctor’s supervision (Von Teijilingen & van der Hulst, 1995). Unlike other parts of the world, Dutch midwives organized their profession very early, forming the organization that later became the Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV, also known as the Royal Organization of Dutch Midwives) in 1898 (DeVries, 2004). Throughout the twentieth century, their organization served to help them expand their scope of practice while elsewhere in the world midwifery work was becoming much more restrictive. Due to their early professional recognition and recognized cost-containment abilities, they were granted the status of primary maternity practitioners when the Sick Fund was established in 1941 with a rule so strict that other medical professionals could not be reimbursed for their services in attending a low-risk pregnancy if there was a midwife practicing in the region (DeVries, 2004; Rooks, 1997, Teijilingen & van der Hulst, 1995).

Characteristics of Midwifery in the United States, 1970s to present

In the last several years, midwifery, and particularly home birth, have begun to receive significant attention in mainstream American society via some well-publicized documentaries as well as frequent mentions (positive and negative) in pregnancy magazines. Television shows – both reality based and fictional – have shown home birth as an option that some women (primarily those on the social fringes) chose to attempt. All of this has increased the curiosity of pregnant women toward unmedicated childbirth as a possibility – with or without going to the extremes portrayed in the media.

This growing interest has paralleled an increase in the variety of midwives available to tend to birthing women over what was available in the middle of the 20th century. While 91 percent of births were still attended by physicians in 2006 and 99 percent of all births occurred in hospitals, the percentage of births attended by midwives (primarily Certified Nurse-Midwives, or CNMs) has steadily grown in the last few decades and now stands at nearly 8 percent. A subset of about 65 percent of the 1 percent of births occurring outside of a hospital occur in a residence, and at least 70 percent of these are reported to have been attended by a midwife, most likely a non-CNM. Underreporting is suspected in this number, particularly in areas where home birth is not legally protected (Martin, Hamilton, Sutton, Ventura, Menacker, Kirmeyer, et al, 2009).

Due to the historic hostility to home birth midwifery in the United States, much of modern non-CNM midwifery had to be reconstructed and relearned. The quality, skills, and experience of modern American midwives who are not CNMs varies greatly, from the very informal occasional birth attendant that cares for family and close friends to the highly professional, credentialed Certified Professional Midwife (CPM) who has been examined by the North American Registry of Midwives (NARM). Many non-CNMs were lead to the vocation as a result of their own birthing experiences (Rothman, 1991).

At the same time, CNMs have generally been trained more in the hospital style of birth and often act more as “physician extenders” than independent care providers, and their professional organization – the AmericanCollege of Nurse-Midwives or ACNM – has not been supportive of home birth as an option even for women with low-risk pregnancies. (Rothman, 1991). Rothman goes on to point out, “as demonstrated with lawyers, clients come and go, but the institution and the people working for the institution, be it court or hospital, D.A. or M.D., remain. For a midwife to stand firm as an advocate of the right of any given client to birth in her own way would jeopardize her relationship with physicians, nurses, and hospital administrators. Ultimately, it would cost her her job” (1991, p. 73). This professional tension experienced by midwives who practice in hospital settings (the primary location of practice of CNMs) disrupts their ability to practice midwifery-style instead of technocratic-style care with their clients and leads to their perception in some circles as “little obstetricians.”

Legal and affordable access to midwifery services, especially non-CNMs, varies drastically across the country. New Mexico is the most midwife-friendly state in the country with midwives outnumbering obstetricians and attending nearly one-third of births in 2004. New Mexico and more than twenty other states license CPMs, most of the remaining states do not legally recognize any type of midwife other than a CNM. Though Medicaid is supposed to reimburse any provider who is recognized by local law, many states do not comply. Ten states and the District of Columbia have case law or legislation that legally prohibits non-CNM midwives from attending births (Block, 2007).

Further complicating the issue are the attitudes and perceptions of American women. In a study conducted by Davis-Floyd (1992), only about 6 percent of women had conceptual frameworks that were highly compatible with out-of-hospital birth practices, while about 60 percent had conceptual frameworks that were at ease with or strongly preferred the western technocratic model of birth. The remaining 34 percent had a range of conceptual frameworks, from valuing and achieving “natural childbirth” (the definition of which varies from entirely unmedicated to any birth other than via cesarean section) in a hospital setting to embracing technology in service to the birthing woman, as well as 9 percent of women who suffered cognitive distress from their technocratic birthing experience. That final 9 percent Davis-Floyd found was highly predisposed to postpartum depression, which American women suffer from at a significantly higher rate than countries that rely more on skilled midwives for normal births.

As Davis-Floyd (1992) noted in many of the women who had out-of-hospital births in her study, Chester (1997) recognized a significant spiritual/religious influence on midwifery practice, particularly in home birth settings. Both women who chose to become home birth midwives as well as the women who seek their services are very likely to have a religious or spiritual basis for the decision. Rothman (1991) similarly points out the unlikely partnership, between feminists and those who value very traditional views of family, forged by desires to improve access to midwifery, especially for home births. The traditionalists are most often driven by devout religious convictions and social conservatism. As some of these traditionalists have realized the legal “slippery slope” similarity between restriction of birth options and restriction of abortion, a few have gone so far as to march in Pro-Choice rallies even though they are very decidedly anti-abortion (Block, 2007).

Characteristics of Midwifery in the Netherlands, 1970s to present

Modern Dutch midwives bear little resemblance to the “granny” midwife stereotype of old. Midwives today are relatively young, as the education system in place allows them to begin their four years of midwifery school immediately after completing their five years of secondary education (DeVries, 2004; Rooks, 1997). This system means that a fully-qualified midwife could start her solo practice as young as twenty-one years of age. They are considered some of the best-educated midwives in the world, even though their education is outside the university setting. Their training is not just in normal birth, but also in spotting dysfunctions and techniques of scientific research (DeVries, 2004). An estimated 80 percent of midwives are under the age of forty (interviews via email of Dutch midwife Mary C. Zwart, December, 2009) and one gets the impression from these factors that the majority of them enter the profession before the birth of their first child.

Dutch midwives are expected to carry a fairly heavy workload, attending between 90 and 150 births per year with generally at least half of these births occurring in the client’s home, which leads to a lot of midwives changing the way they have traditionally practiced – either going into group practices, short-stay hospital practices, or dropping out of attending mothers within the first twenty years of their practice (interviews via email of Dutch midwife Mary C. Zwart, December, 2009; DeVries, 2004; Rooks, 1997). The profession of midwifery, though held in high regard, is difficult to balance with the needs of the midwife’s own family at the level of professional practice currently expected.

From the birthing Dutch woman’s view of the situation, midwifery is highly accessible as it is the cultural norm. Up until the dawn of the 21st century, rules in the Sick Fund about care provider compensation for normal, low-risk pregnancies prevented payments going to health care “competitors” (primary care physicians and gynecologists) if a midwife was practicing in the region (DeVries, 2004; Rooks, 1997; Von Teijilingen & van der Hulst, 1995). Care can generally only be transferred to a gynecologist if specific need arises in the course of pregnancy or birth, unless the family wants to pay for those services out of pocket (DeVries, 2004; Rooks, 1997; Amelink-Verburg, Verloove-Vanhorick, Hakkenberg, Veldhuijzen, Bennebroek Gravenhorst, & Buitendijk, 2008). The process by which care is transferred to a specialist is very carefully detailed, which helps diminish the prevailing Western view of all births as “potentially pathological” and therefore needing monitoring by specialists (DeVries, 2004, p 59).

Today, an estimated 67 percent of pregnant women begin labor in the Netherlands with a midwife attending them (Amelink-Verburg, Verloove-Vanhorick, Hakkenberg, Veldhuijzen, Bennebroek Gravenhorst, & Buitendijk, 2008) and the number of babies born at home has held steady at over 30 percent throughout this time period. If asked why they chose to birth at home, the majority of Dutch women cite social considerations, such as the confidence of their friends and family in home birth (DeVries, 2004).

Dutch midwives also practice in short-stay hospital settings called poliklinische. This has become a popular choice for some birthing women, particularly in urban areas, as well as for immigrants from countries where home birth is not common (interviews via email of Dutch midwife Mary C. Zwart, December, 2009; DeVries, 2004). There is some evidence that outcomes, particularly in regards to lower intervention rates and referrals to gynecologists, are not as optimal in the short-stay hospitals, but the quality of care and outcomes are still remarkable, particularly in comparison to the United States (Amelink-Verburg, Verloove-Vanhorick, Hakkenberg, Veldhuijzen, Bennebroek Gravenhorst, & Buitendijk, 2008). Women who chose to birth in a short-stay hospital without medical need must cover part of the cost of the hospital room, which keeps fully reimbursed birth at home a very attractive option (DeVries, 2004).