Routine Midwifery Care: Why Not Here?
By Leah Hyder
In our ever-changing fast paced system of health care delivery, many women feel that they receive little personal attention, especially during pregnancy and childbirth. Into this breach step midwives, who have a long history providing women with holistic care during pregnancy and childbirth. Despite the high quality of care that midwives provide to expectant mothers, American women have few opportunities to use the services of midwives and to have those services covered by their health insurance plans. Clearly, midwifery in the United States faces more barriers than most other countries.
Midwifery is Welcomed in Europe
The United States is lagging behind other nations of the world in fully integrating midwifery into its health care system. While midwives deliver only 6% of the approximately 220,000 babies in the United States each year, midwives in other countries attend up to 80% of their countries' births.4 Barriers against and support for midwifery vary from country to country. The majority of healthy women in Europe use professionally-trained midwives. Most European countries have passed laws regulating midwives and publicly support midwifery schools and professional organizations. Most midwives in Europe work for governmental health services.7 Austria, Sweden, the United Kingdom (UK), and particularly the Netherlands possess sound systems of midwifery. In Austria, the law requires that a midwife be present at every birth.7 In Sweden, midwives provide more than 80% of prenatal care and family planning services.7 Midwives in the UK attend 70% of all births and also provide the vast majority of care to women who want home births.7 They also provide a high proportion of care between pregnancies.7 The midwives in England are independent practitioners, responsible for the full spectrum of care for healthy women.7 The Netherlands is the only industrialized country where the majority of women have home births.7
Midwifery in the Developing World
Midwifery is also prevalent in developing countries, though standards of practice are not at the same level as European nations. Developing countries often use lay midwives to complement the sparse distribution of physicians.2 Often, the only training midwives have is observation of relatives and physicians.2 In most third-world countries, the care midwives provide includes treatments which reflect cultural practices such as fasting, prayers, herbal medicines, and sacrifices to appease gods.2 Further, midwives in developing countries face unique challenges, such as lack of information about and access to proper sanitation measures, illiteracy, a scarcity of training programs and the means to attend them, and the lack of financial resources to sustain their own practice. Often, even where physicians are available, women prefer midwives because of economic and sociocultural reasons.2
Midwifery in the United States
Barriers to midwifery care in the United States are numerous and imposing. They include physician opposition, public perception of midwives as substandard, state and federal regulations, the current economic and political environment, and lack of training programs, strife between midwifery groups, lack of access to malpractice insurance, and lack of acceptance among third-party payers, including Medicaid.
Although some physicians encourage midwifery, others adamantly oppose it. While Ob-Gyns are specialists trained in interventions which are sometimes necessary in complicated or high-risk pregnancies, midwives' training emphasizes skills which help women have healthy outcomes with as little intervention as possible. A common perception is that women are safer in a hospital, with a doctor. In fact, studies show that both mothers and babies are safer with midwives. Births attended by certified Nurse-Midwives (CNMs) produce fewer cesarean sections, infant abrasions, complications, perineal lacerations, postpartum hemorrhage, and vacuumor forceps-assisted deliveries than physicians.6 CNMs also cost approximately $1000 less than physicians per birth and most develop a strong relationship with the mother.6 Is it any wonder that many physicians oppose midwives? Midwives treat normal pregnancies as the natural processes that they are. Midwives need to fight this physician opposition and medicalization, as well as the accompanying public perceptions.
Often regulations pose another barrier to midwifery care. Laws governing midwifery care vary from state to state and often do not comply with the national standards of practice set by the American College of Nurse Midwives (ACNM). Laws that require midwives to practice in hospitals or be supervised by a physician limit the midwives' scope of practice. This often means that women in rural areas who, without such restricting laws, would have convenient access to local midwives must instead travel for miles to reach a hospital or physician. In addition, the Joint Commission on Accreditation of Health Care Organizations (JCAHCO), a regulatory organization overseeing activities of most healthcare organizations in the United States, requires that physical examinations of women be done only by physicians. 5 Because eligibility requirements for health care providers to have hospital privileges often include completing physical examinations, which nonphysicians cannot do per JCAHCO standards, midwifes would not be allowed to practice in a hospital.5
Midwives face economic barriers as well. Although they do similar work, midwives are paid thousands of dollars less per year than physicians. Medicare reimburses CNMs up to 65% of the physician fee schedule which means that physicians earn over 1/3 more than nursemidwives for the same services.5 Many third-party payers adopted this payment policy, making the injustice more widespread. 5 In this session of Congress, U.S. Rep. Edolphus Towns (D-NY) is proposing The Certified Nurse-Midwives Medicare Services Act" to increase this reimbursement to 95%, which although progressive, fails to address the similar needs of midwives who are not CNMs.3 Additionally, many free-standing birth centers receive no coverage in numerous state and federal Medicaid programs at all.5 Midwives also disproportionately render care to underserved populations who often do not have insurance and can not pay out of pocket for services;
Access to Liability Insurance
Midwives often lack available and affordable malpractice insurance.7 This is a primary impediment to maternity care by midwives.7 As a result of the liability insurance crisis of the 1980s, many Ob-Gyns and midwives left practice because they could not find adequate malpractice insurance.7 Most CNMs now obtain insurance from their employers, the ACNM, or from local insurance companies.7 Some problems with obtaining malpractice insurance include its increasing costs, restrictions related to the place of birth, and medical management of pregnancy and childbirth as the accepted standard.7
Dearth of Education Programs
Access to midwife education and training is challenging. Midwifery programs across the U.S. are filled to capacity due to the demand for midwives, which is greater than the supply. One reason so few schools educate midwives is lack of funding.5. Additionally, the U.S. is still very physician oriented. But because the public demand for physicians is higher than it is for midwives, funding for the training of physicians receives more attention than that for midwives. As women increasingly use midwifery services, leverage may be created for funding of midwifery programs.
Barriers to U.S. Subpopulations
Barriers to midwifery care exist for subpopulations of the general public in the U.S. as well. Historically, poor, rural, Hispanic, African-American, and Native- American women have used midwives the most frequently.7 This prevalence was often due to the cost of care, exclusion by white hospitals, and transportation problems. Because of these factors of inequality, these women often felt that they were given inferior care when treated by a midwife. Midwives have fought this perception of the quality of their care.
Building Bridges in U.S. Midwifery
Although midwives currently face these political barriers, various groups are working for change. The American College of Nurse-Midwives (ACNM) is a professional organization for CNMs. It speaks for its membership on issues affecting education, practice, recognition, and reimbursement.5 .A second professional group, MANA (the Midwives Alliance of North America), welcomes and hopes to unite all midwives, including both lay and certified midwives. 7 While MANA focuses on directentry midwives, their agenda includes all midwives.7. Although some tension among the groups exists, different groups have taken measures to unify all midwives. The Bridge Club is an organization of nurse-midwives who want to unify the ACNM and MANA, which sometimes have conflicting views. The Midwifery Communication and Accountability Project (MCAP) of Boston, Massachusetts, has midwives work together on the community level to raise money for policy issues, hoping that working together towards a common goal would help unify the midwives. MANA welcomes all midwives and encourages dialogue among the groups. Despite their varying educational backgrounds, all midwives have much in common and many realize that working together to promote the causes of midwifery will help them all as well as the women they serve.
Future Prospects of Midwifery in the United States
While some third-party payers are apprehensive about using midwives because of liability issues, other thirdparty payers utilize midwives because of their cost-effectiveness.7 It remains to be seen whether the trend in third-party payers will be to utilize midwives in the name of cost efficiency or not to utilize them because of their liability. As more women demand midwifery services and the professional reputation of midwives grows, more third party payers may utilize midwives. The barriers to midwifery in the U.S. are substantial, but midwives constantly work to lessen them. Yet we can look to European countries for a good model and to show us areas in which we could improve to make midwifery affordable, accessible, and acceptable in the U.S.
To learn more about midwifery or its advocacy, contact the ACNM at (202) 728-9860, the Massachusetts Friends of Midwives at (508) 369-1468, or MANA at (931) 964-2589.
I would like to thank Doris Haire, Linda Holmes, and Carol Sakala for their input into this article.
Leah Hyder was a summer Network intern.
1 Byrd, T. et al. "Initiation of Prenatal Care by Low- Income Hispanic Women in Houston". Public Health Reports. 1996 November/December 111: 536-538.
2 Cobb, A. The Role of the Lay Midwife in Childbirth in Rural Portugal". Western Journal of Nursing Research. 1995 August; 17(4): 353-363.
3 Fennell, K. "An Overview of Certified Nurse- Midwifery Medicare Services". Quickening: Bimonthly Publication of the American College of Nurse-Midwives. 1998 May/June: 10.
4 http://www.metlife.com.Sb/Recaps/Docs/ midwiv.html
5 The American College of Nurse-Midwives web site: http://www.midwife.org
6 Oakley, D. et al. "Comparisons of Outcomes of Maternity Care by Obstetricians and Certified Nurse-Midwives." Obstetrics and Gynecology. 1996 November; 88(5); 82J829.
7 Rooks, J. Midwifery and Childbirth in America. Philadelphia: Temple University Press. 1997.
Certified Nurse-Midwives (CNMs)— CNMS are Registered Nurses (RNs) who complete training to become certified in nurse-midwifery by the American College of Nurse-Midwives (ACNM).7 In the US, CNMs care for 5% of all births and 95% of all births delivered by midwives.7
Certified Midwives (CMs)—CMs are not registered nurses, but are accredited by the ACNM and have graduated from an ACNM accredited midwifery school.7
Certified Professional Midwives (CPMs)—Midwives who are certified by the North American Registry of Midwives (NARM).7
Licensed Midwife—a legal term denoting state-licensed direct-entiy midwives.7
Direct-Entry Midwives—Direct-entry midwives have completed a formal midwifery education program or are licensed to practice in their state or local jurisdiction or are certified by a local or state organization.7
Birth Attendants—Birth attendants assist the primaiy birth attendant, usually a CNM or physician.7 .This term is also used by some non-CNM midwives who practice in states where midwifery is illegal unless practiced by a CNM or a physician. 7
Granny and Lay Midwives—Granny and lay midwives are other types of midwives which have existed in the US but that are virtually nonexistent today.7 Midwives historically called lay or professional midwives often call themselves traditional or independent midwives today.7