This spring, when Hampshire Obstetrical and Gynecological Associates announced that its nurse-midwives would no longer attend births, it seemed like a straightforward business decision: birth rates are dropping, leaving the practice’s doctors and midwives essentially competing for a dwindling number of patients. Something needed to give, and it wasn’t going to be the doctors, who are, after all, the bosses.

Hampshire OB/GYN does still have nurse-midwives on staff to provide other healthcare services. But the sharp limitation on their role unintentionally placed an even sharper limitation on women in the Valley: because Hampshire OB/GYN was the only practice affiliated with Cooley Dickinson Hospital to offer midwifery birth services, the decision to end that service meant that a woman giving birth at CDH—the only hospital in Hampshire County with a childbirth center—could no longer choose to have a midwife attending her birth.

Local women’s advocates sprang into action, urging CDH to find a way to fill the void. The hospital responded with the recent announcement that it will establish its own midwifery program, staffed by hospital-employed midwives. That came as good news to activists, who say the program could be a model community-based midwifery program.

With the crisis now apparently averted, though, one niggling question remains: how did it ever develop in the first place? Midwifery is a fast-growing part of the healthcare industry; 10 percent of U.S. births are attended by midwives, up from about one percent a generation ago. Statistics say that for low-risk, normal births, midwives have better outcomes than doctors for factors like infant mortality. Midwife-assisted births are also much less likely to involve “interventions” like episiotomies, labor-inducing drugs and caesarean sections.

Finally, the midwifery model—with its assumption that birth is a natural process, rather than a medical situation, and that women are capable of having babies without a lot of interventions—has a strong feminist appeal for many women. So why isn’t its footing more secure in the progressive Valley?

Maybe it has something to do with the challenges midwifery has faced historically. “Midwifery through the ages has had more ups and downs than those uterine contraction profiles printed out from tocodynamometers beside a modern hospital bed,” journalist Tina Cassidy writes in her new book, Birth: The Surprising History of How We Are Born (Atlantic Monthly Press).

 

There’s nothing new about the midwifery model, of course. “Every culture has had a system of midwifery, usually informal, with mothers, grandmothers, neighbors or extended members of the tribe helping women through birth,” Cassidy writes. The word “midwife” comes from an Old English word that means “with woman.” In French the term is “sage-femme”: wise woman. In some cultures, midwives assume a sort of grandmother role; in African-American communities, babies were usually delivered by lay midwives called “grannies.”

In colonial America, Cassidy notes, midwives were an important and valued part of society, not just for their role “catching” babies (the preferred term of midwifery fans) but also providing pre- and post-natal care, abortions and pediatric care for newborns. Formal training for midwives only began about 100 years ago, meaning that, for countless generations, these women learned their skills informally, often as apprentices to other midwives.

For all their importance, though, midwives have also been vulnerable to attack. In the 15th century, Cassidy writes, Catholic monks likened midwives to witches—no minor matter at a time when that charge could lead to execution. The church in England began issuing licenses to midwives, apparently to vet the profession for potential witches (as well as collect a fee from the women). If a birth ended in a maternal death or a stillborn or disfigured child, the midwife might be blamed, perhaps for employing dark magic.

The real threat posed by midwives, however, has been the one they pose to the patriarchy, charges Marsden Wagner, a reformist doctor and former head of the World Health Organization’s program for women’s and children’s health, in his 2006 book, Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (University of California Press).

“[M]idwives have always been at the center of the ‘woman’s world’—that part of life and society that women have some control over, and from which men tend to be excluded, including, until recently, pregnancy and childbirth,” Marsden writes. “The profession has always attracted strong, independent women in the community, women who are difficult for men to control and whom some men come to fear. If men wish to control their women, they must find a way to control midwives.”

 

In modern times, anti-midwife sentiment in the U.S. hasn’t been based on witch-anxiety, but a decidedly more American concern: business competition. By the turn of the last century, male obstetricians, usually trained in Europe, began competing with midwives for the childbirth market, pitching themselves as a better-trained, more sanitary and more modern alternative.

The validity of those claims aside (Cassidy notes that concerns about propriety meant many male doctors never saw a pregnant female body until they attended their first birth), the campaign worked. By the early 20th century, midwives—who had enjoyed a virtual lock on the market—only attended about 50 percent of births; by the 1930s, that figure dropped to 15 percent. And midwives were mostly restricted to poor or remote areas unlikely to be served by doctors: Appalachia or immigrant or African-American communities. In many states, including Massachusetts, midwifery was made illegal, and would remain so for several decades.

Midwifery saw a resurgence during the natural childbirth movement of the 1970s. Nurse-midwifery programs—a graduate program for nurses—were established and every state offered a license to nurse-midwives. Today, there are about 6,000 nurse-midwives in the U.S., and the demand is rising. “But after all these years, despite the growing body of evidence that they provide excellent birth outcomes, midwives are still fighting the same battles for respect and market share,” Cassidy writes.

Wagner places much of the blame on a “paternalistic takeover of territory that rightly belongs to women.” Part of that takeover, he believes, involved the unnecessary “medicalization” of birth. Obstetricians, Wagner contends, are highly skilled surgeons whose presence simply isn’t required at the vast majority of births, and whose training is more likely to lead them to resort to high-tech interventions such as surgery.

“Doctors ‘deliver’ babies and believe that having a baby is something that happens to a woman. Midwives assist at birth and believe that giving birth is something that a woman does,” Wagner writes.

In Wagner’s ideal world, midwives would attend almost all births, with obstetricians reserved for riskier cases. It’s not an unrealistic model—with the exception of Canada, midwives are the norm in the rest of the Western industrialized world, with apparently good results. Twenty-eight counties have lower rates of maternal mortality rates than the U.S., according to Wagner. And 41 have lower rates of infant mortality.

The midwifery model is also markedly cheaper, both because midwives are paid less than doctors and because they’re less likely to employ costly technologies and other interventions—something the cost-obsessed healthcare industry is beginning to notice. Ultimately, it might be economic pressures that spark significant change, including increased demand from “consumers,” the women giving birth.

—mturner@valleyadvocate.com