In nearly every industrialized country outside
North America, midwives provide primary maternity
care, and obstetricians, generally, are hospital-based
specialists providing tertiary maternity care.
In Scandinavia, the Netherlands, New Zealand
and other countries, all prenatal, intrapartum
and post-partum care for at least 70 percent
of women is provided solely by midwives. These
countries have much lower obstetrical intervention
rates than Canada and have maternal and perinatal
mortality rates equal to and, in some cases,
better than Canada.
An autonomous midwifery profession in equal
standing with the medical profession is a key
component of an optimal modern maternity care
system.
Introduction
Recently during a panel discussion on one of
the most popular American television talk shows,
a practicing Obstetrician said: "Midwives
are obstetricians' assistants." As a fellow
panel member, I tried to correct his misperception.
Through no fault of their own, the people of
Canada and the United States, including health
professionals, have little understanding today
of midwifery. In the early years of the twentieth
century, midwifery
in these two countries was eliminated as a legitimate
health profession. As a consequence, people
have had no personal experience with midwives
and, in addition, have received considerable
misinformation about midwifery.
When I left the United States after many years
of clinical practice as well as teaching and
research in perinatal epidemiology at the University
of California at Los Angeles, I suffered from
the same ignorance about midwifery. Fifteen
years as the responsible officer for Women's
and Children's Health for the European Regional
Office of the World Health Organization have
given me the opportunity to observe midwives
first hand in many industrialized countries,
and to learn how midwifery plays an essential
role in a modern maternity care system. Frequent
consultation during these years on maternity
care in Canada and the United States has allowed
me to observe the stark contrast to maternity
care in all other industrialized countries.
The History of Midwifery
Midwives have always been with us- women in
the community to whom other women can turn for
support with women's problems. ‘Midwife'
is early English for ‘with woman'. The
French word for midwife, ‘sage femme' (wise
woman) goes back thousands of years as does
‘]ordmor' (earth mother) the Danish word
for midwife. Hypocrates started a midwifery
training program in the fifth century BC. In
the Bible, the Book of Exodus already recognized
the strength and independence of midwives who
defied the Pharaoh's command to kill all sons
born to Hebrew women. Before North America was
‘discovered,' the first law to regulate
European midwifery was passed in Germany in
1452.[1] Since then and without interruption
to the present, every little girl in Europe
grows up with the understanding that if she
ever has a baby, she will have her midwife.
As Europeans migrated to the New World, midwives
were among them. In the mid-1600's, the King
of France commissioned midwives working in New
France, and the British government paid for
the services of midwives in Nova Scotia.[2]
Indeed, midwives were a valued part of the developing
health care system in Eastern Canada, participating
in the teaching of medical students at McGill
University in the mid-1880's.[3]
As the number of physicians increased in Canada,
they attempted to monopolize health care through
medical practice acts. By the end of the nineteenth
century, midwives were beginning to disappear.
The successful attempt to dismantle midwifery
happened nowhere in the world outside North
America. Nurses in Canada and the US supported
the medical domination of maternity care and,
in 1910, an attempt to open a school of midwifery
in Canada was defeated by opposition from both
nurses and physicians.[4] Almost eighty years
passed before a midwifery school finally opened
in Canada. With the present renaissance of midwifery
in Canada, a century of ignorance and confusion
about midwives must be overcome.
The Midwifery Model of Care
That midwifery disappeared from Canada and
the US, except for underground midwives and
midwives in the most isolated areas, reinforced
the now prevalent Canadian and American myth
that midwifery is second-class obstetrics for
those who cannot get a doctor. It is essential
for North Americans to understand that Canada
and the United States are the only two countries
in the industrialized world where today well-established, well-
respected health profession, midwives fare outnumber
obstetricians, and midwifery and medicine are
distinct professions, inherently complementary,
and based on overlapping but distinct bodies
of knowledge.
Midwifery is primary health care for women.
While often limited to primary maternity are,
it may include such other aspects of women's
reproductive health as family planning and reproductive
tract infections. A midwife is analogous to
a family physician in providing primary care
and referring to specialist care as needed.
A midwife who transfers a labouring woman to
an obstetrician is no more incompetent than
a family physician who refers a patient with
a heart problem to a cardiologist. Obstetricians
do not impose standards of practice or practice
protocols on midwives any more than midwives
impose the same on obstetricians. It is active
collaboration based on mutual respect between
health professionals of equal standing. The
midwifery approach to care is well summarized
in a recent book, recommended to anyone interested
in learning more about midwifery in North America:
The key elements in the midwifery model, then,
are normality, facilitation of natural processes
with the minimal amount of evidence-based interventions,
and the empowerment of the woman and the family.
By contrast, for a highly trained, highly skilled
surgeon (an obstetrician) to give primary maternity
care, including routine prenatal care to healthy
women, and assist at uncomplicated births is
analogous to asking a paediatric surgeon to
baby sit healthy two year olds. Such a baby
sitter will come with a very high fee, and the
costs will be even higher when the healthy baby
gets tired and fussy and the surgeon turns to
medication to calm things down.
Advantages of Midfwifery Care
Are midwives safe? While some doctors suggest
they are not as safe as doctors, it is essential
to look at what the scientific evidence has
to say.
Earlier research is summarized in a review of
publications between 1925 and 1984.[5] The studies
were consistent in finding similar or better
maternal and infant morbidity and mortality
rates when midwife care was compared with care
provided by physicians. These were not randomized
controlled trials (RCT's) and were often before
and after studies. However, in all the studies
reported in this review and in all studies cited
in this paper, procedures or outcomes that occurred
to clients of midwives who were transferred
to physician care were counted as having occurred
to a midwife's client.
As one example of earlier research, in the
1960's in Madera County, California, midwives
were brought in by the Health Authorities to
provide maternity care in an area where there
had never before been midwives, and maternity
care was previously provided by doctors. A statistically
significant drop in the rates of prematurity
and neonatal mortality followed. However, after
several years, backlash from local doctors resulted
in the firing of all midwives. There followed
a rebound of prematurity and neonatal mortality
rates to the level prior to the introduction
of midwives.[6]
In the mid-1980's, the Office of Technology
Assessment (OTA) of the US Congress conducted
its own review of the scientific literature
on the safety and effectiveness of midwifery
care. The OTA concluded that midwives manage
low-risk pregnant and birthing women as well
as, if not better than, physicians.[7]
A meta-analysis search of reports in which
the research method satisfied stringent scientific
criteria, published in 1995, yielded 15 papers
comparing outcomes of midwifery care and physician
care.[8] No significant differences in outcome
measure, including fetal distress or Apgar scores,
were noted, with one exception. There was a
statistically significant reduction in
low birth weight rates when prenatal care was
provided by midwives.
A study in Canada compared the quality of prenatal
care provided by midwives and physicians.[9]
Using the recommendations for prenatal care
from the Society of Obstetricians and Gynaecologists
of Canada (SOGC) and the American College
of Obstetricians and Gynecologists (ACOG), independent
assessors found 84 percent of midwives provided
superior or adequate prenatal care compared
to 40 percent of family physicians.
More recently, two RCT's, both in Scotland,
compared midwife care with care involving physicians.
One RCT, comparing a midwife-managed delivery
unity with a consultant-led labour ward, found
no difference in neonatal mortality, while Apgar
scores at one and five minutes and cord pH were
identical in both groups.[10] The other RCT
compared "midwife-managed care," in
which all prenatal, intrapartum and post-partum
care was provided by a particular midwife, with
"shared care" in which women received
care from a variety of physicians and midwives.[11]
The maternal, fetal and newborn outcomes with
midwife-managed care were as good (as safe)
as with "shared care".
Most recently, a study carried out by the United
States National Center for Health Statistics,
published in 1998, used the entire United States
birth cohort for 1991 of approximately four
million live births, and compared 100 percent
of certified nurse midwife-delivered births
(n=153,194) with a 25 percent random sample
of physician-delivered births (n=686,644).[12]
To limit patient population differences between
the two groups, only singleton, vaginal births
at 35 to 43 weeks gestation were included. The
authors summarize the results: "After controlling
for social and medical risk factors, the risk
of experiencing an infant death was 19 percent
lower for certified nurse midwife attended than
for physician attended births, the risk of neonatal
mortality was 33 percent lower, and the risk
of delivering a low birth-weight infant 31 percent
lower. Mean birth weight was 37 grams heavier
for the certified nurse midwife attended than
for physician attended births."[12]
In summary, a search of the scientific literature
fails to uncover a single study demonstrating
poorer outcomes with midwives than with physicians
for low-risk women. An advantage to midwifery
care is that evidence shows primary care by
midwives to be as safe or safer than care by
physicians.
Another major advantage of using midwives routinely
for primary maternity care is a marked reduction
in the unnecessary use of obstetrical interventions.
Here a large literature applies which can be
only briefly summarized. The meta-analysis cited
above found midwifery care to be associated
with greatly decreased rates of anaesthesia
and IV fluid use, moderate decreases in narcotics
use, use of forceps, electronic fetal monitoring
(EFM) and analgesia, and greatly increased rates
of spontaneous vaginal births.[8]
Six studies published since 1992, comparing
midwifery care with physician care, all found
statistically significant differences in the
rates of obstetrical interventions.[13-18] These
studies found midwifery care to have significantly
lower rates of EFM, analgesia including epidural
block, episiotomies, oxytocin use, forceps and
vacuum extraction. One Scottish RCT found the
midwife-managed delivery unit to have statistically
significant less use of electronic fetal monitoring
and analgesia and more freedom of mobility.[10]
the other Scottish RCT found midwife-managed
care to have significantly less use of:
electronic fetal monitoring; induction; episiotomy
(no increase in perineal tears).[11]
Many studies, including some cited above, also
found lower Caesarean section rates with midwifery
care. A survey of 419 hospital midwifery practices
and 41 free standing birth center midwifery
practices in the US found an overall Caesarean
section rate for all midwives of 11.6 percent,
about half the national rate at the time.[19]
A study in Western Canada found a four percent
Caesarean section rate among midwives compared
to 15.1 percent among physicians, a statistically
significant difference in spite of a small sample
size.[20]
An important reason that midwifery care leads
to far fewer Caesarean sections is the far higher
rates of successful vaginal birth after Caesarean
section (VBAC) with midwifery care. The survey
of midwives cited above found an attempted VBAC
rate of 88 percent and a successful VBAC rate
of 78 percent among midwives compared with a
national rate at that time of 21 percent successful
VBACs.[19] Several studies found the physicians
more frequent use of epidural block to control
labour pain as another reason for the higher
Caesarean section rates among physicians.
recent book evaluates the serious overuse of
obstetrical interventions, including the role
of midwifery in the reduction of such overuse.[21]
A maternity care system in which midwives provide
primary care and obstetricians provide tertiary
care has been proven scientifically to have
less unnecessary interventions and, thus, be
safer.
Another advantage of midwifery care is cost
savings. As no data can be found comparing costs
of midwifery services with physician services
in Canada, it is necessary to turn data from
the United States and the United Kingdom. Although
data about costs are difficult to apply across
health care systems, it is reasonable for the
moment to assume that costs will be in the same
direction in Canada as in these other countries.
Not only do midwives have lower salaries and
incomes than physicians, in addition, their
proven lower intervention rates produce great
cost savings. Only in a few examples from the
large literature on maternity costs can be included.
A study at the University of Michigan showed
the average total cost for care of obstetrician's
was $548 higher than average total costs of
midwives' clients.[22] Another study reported
a 13 percent reduction in payroll costs in the
obstetrics and gynecology department of a large
US health maintenance organization by using
midwives.[23] A recent study found
12.2 percent greater use of resources by obstetric
patients than by midwifery clients in another
university hospital.[18]
Obstetrician intensive care is expensive. Canada,
with a population of around 30 million, has
approximately 3000 obstetricians while the United
Kingdom, with a population of around 57 million,
has approximately 1000 obstetricians. Canada
has three time the number of obstetricians for
half as many people because, unlike the United
Kingdom, Canada does not have a full complement
of midwives.
A Professor at Johns Hopkins University has
calculated the annual health care cost saving
in the United States, by using midwifery for
75 percent of births instead of the present
five percent, to be 8.5 billion dollars, the
annual savings by eliminating routine EFM to
be 675 million dollars, the annual savings by
lowering the Caesarean section rate to 15 percent
to be 1.5 billion dollars, for a total savings
by developing midwifery care and demedicalizing
birth in the US to be 13 to 20 billion dollars
a year.[24] Whether paid for by private parties,
insurance companies, health maintenance organizations
or a national health care system, this much
higher cost of obstetrician intensive maternity
care is borne by the public.
An important advantage of midwifery care which
receives too little attention is the ability
of ‘user friendly' midwives successfully
to reach the hard to reach, underserved, socially
disadvantaged groups. A case in point is the
success of midwives in serving Inuit women in
the Canadian North.[4] The Institute of Medicine
in the United States, in a report on ways to
improve utilization of prenatal care and thereby
reduce low birth weight, pointed out the special
ability of midwives to reach low-income women,
adolescents, minority groups, inner city and
rural groups.[25]
A final advantage of midwifery care, often
disparaged by those following the medical model,
is the woman's degree of personal satisfaction
with her care. The midwifery model emphasizes
the importance of women's satisfaction. The
evidence in the literature is overwhelming:
midwifery care is statistically significantly
more satisfying to the woman and her family.[11]
Midwifery in Industrialized Countries Outside
North America
In Western Euorpe and other industrialized
countries, midwifery is seen as a separate profession,
and there is no confusion, as in North America,
as to whether midwifery is the practice of medicine.
In nearly all countries, midwifery is regulated
by a board of midwives. A handful of countries
have, in the past, required students to train
first as nurses before coming to midwifery training.
This is changing, as fewer countries maintain
this policy. In some countries, for example
Germany, being trained as a nurse makes it far
more difficult to enter midwifery training.
This trend is a result of the growing appreciation
that nursing and midwifery are two separate
professions with different methods and goals,
and a different relationship to physicians.
In every highly developed country outside North
America, midwives provide primary maternity
care and obstetricians, generally, are hospital-based
specialists providing tertiary maternity care.
In Scandinavia, after an initial screening examination
by the family physician at the time of the diagnosis
of pregnancy, over 75 percent of pregnant women
have all subsequent prenatal care, come to the
hospital in labour, are assisted at birth, are
cared for post-partum and are discharged home,
never again having laid eyes on a doctor since
the initial screening visit. The national Caesarean
sections rate in Sweden is 11 percent.[26] These
countries have the lowest maternal and perinatal
mortality rates in the world.[26]
In the mid-1980's in Germany, the National
Society of Obstetricians and Gynaecologists
asked the national government to repeal a law,
on the books for a long time, stipulating that
there must be a midwife present at every birth.
Women's groups and midwifery groups immediately
descended on Bonn, defending the law. As a result,
the law was not changed but midwifery changed.
In Germany, the last decade has seen an explosion
of independent midwifery practice, with more
and more midwives attending planned home births,
and the number of free-standing birth centers
staffed by midwives increasing from less than
10 to over 50.[27]
In the Netherlands, over a third of all births
are planned home births with a midwife in attendance,
and the number of planned home births is slowly
rising.[28] Another third of births are midwife-attended
hospital births. Maternal and perinatal mortality
rates are equal to or better than rates in other
industrialized countries.[26] The national Caesarean
section rate is nine percent.[28] Nearly every
Dutch obstetrician supports the present system,
and in 1997, the National Government gave the
Dutch Midwifery Association 10 million gilders
(30 million Canadian dollars) for the further
promotion of midwifery and planned home birth.
Following a series of parliamentary hearings,
the British parliament in 1993 issued a report
"Changing Childbirth" which strengthens
midwives as the principle primary maternity
care providers and urges that women be given
choices for maternity care[29] In 1990, a new
law in New Zealand has given midwives powers
similar to family physicians, including autonomous
private practice, prescription writing and hospital
privileges. Women can choose their maternity
care provider and 80 percent choose a midwife,
who is their provider throughout pregnancy and
their home or hospital birth attendant.[30]
Midwives, family physicians and obstetricians
all receive the same flat fee for assisting
at birth. The national Caesarean section rate
in New Zealand is 11 percent and for women in
the care of midwives the rate is eight percent.[30]
Since the midwifery law of 1990, the perinatal
mortality rate continues to decline and compares
favorably with other highly developed countries.[26]
Slowly but surely, midwifery is moving towards
full autonomy. Nowhere outside North America
are midwives required to identify obstetrical
supervision or backup. In those places in the
world where autonomous midwives have equal standing
with doctors, the combining of the midwifery
model with the medical model results in the
most modern, optimal maternity care system and
the best outcomes for women and babies.
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