Midwives: An Untapped Resource
By Ina May Gaskin
While it is axiomatic that our maternity care system is in a shambles (a good word to use, since it means a disorderly slaughterhouse), seldom do we hear a plan that isn¹t a band-aid proposed by medical associations or insurance companies to circumvent change. Now when I say ³change,² I mean a detectable difference to the people who need maternity care.
Here is a plan that could field a dedicated crew that already has a wide distribution, intelligent and knowledgeable proponents, is already working and has a training cadre in place. I am referring to the vast network of skilled direct-entry midwives who are looking for ways to come above ground and become part of the accepted system of maternity care. (³Direct-entry² means that these midwives went through midwifery training without first becoming nurses).
Direct-entry midwifery should be decriminalized in every state in which it is now illegal or where the current rules do not compel state or public health agencies to grant permits, certificates or licenses. Allowing these women to work legally and openly would mean that far more women could avail themselves of their services. With legislation to support this plan, childbirth would become safer for all women, more pleasant as a family ceremony and maternity care could be less expensive.
Several states have already legalized direct-entry midwifery, among them, Alaska, Florida, Arizona, New Mexico and Washington. In all states, even in those where direct-entry midwifery is already legal, direct-entry midwifery needs to be facilitated. Midwifery training opportunities should be opened up whether or not the United States later decides in favor of a universal health care system.
During the next ten years, we should train about 100,000 midwives to serve all over the United States. (We currently have fewer than 6,000 working, including the 3,000 certified nurse-midwives). Some midwives can be quickly trained. Since there are already thousands of foreign-trained midwives not permitted to work under the current system and as most of them are highly skilled, they would need little additional training to work as midwives in this country. Women from rural areas and inner city neighborhoods could have their training expenses paid in exchange for their pledge to work in their communities. These midwives would be able to reach and influence hundreds of thousands of mothers who are currently so alienated from the maternity care system as it exists now that they use it only when small problems have become big and expensive emergencies.
Most of these midwives would work in a fashion that is community-based, that is, their greatest loyalty would be to the mothers they serve, not to any institution. The midwives would work in groups of four or five in more highly populated areas, and in groups of two or three in regions that are more sparsely populated. They would provide sex education to young people, helping to lower the teen pregnancy rate, and they would provide complete maternity care to women of childbearing age: prenatal (including nutritional counseling), labor and birth, and postbirth care. Mothers with normal pregnancies could choose to give birth at home, in birth centers or hospital, with midwives trained to work in all settings.
The size of our nation makes a decentralized approach to maternity care all the more important. As it is now, mothers in rural areas usually have to travel out of their own county to have access to prenatal care, let alone care during labor and delivery. Poor women in the inner cities commonly wait long hours to get a very short prenatal visit. Not surprisingly, many go without.
It would be very cost-effective to train 100,000 midwives who would then stay in their communities to provide care. Midwifery care is very efficient when it comes to preventing needless premature birth, which costs an average of $25,000 per baby born prematurely. All the high technology that we have cannot keep many premature babies from going through life permanently impaired mentally and physically. We need people power, in the form of midwives, to solve this national problem. The expense of training a large number of midwives to make sure that all women have access to high quality care would be easily offset by what we would save in later medical and social costs for unhealthy mothers and babies.
The Netherlands, a country which produces far better results in maternal and child health at a far lower cost than does the United States, has had in place for many years a maternity care system much like that I have described above. The professions of midwifery and medicine are both independent, but they work together cooperatively for the benefit of all women and babies.
Prof. G. J. Kloosterman, formerly of the Department of Obstetrics and Gynecology at the University of Amsterdam Hospital was the architect of many of the more forward-looking policies in medical and midwifery education in The Netherlands. Health policy planners took him seriously when he wrote, ³Without the presence and acceptance of the midwife, obstetrics becomes aggressive, technological and inhuman,² and they sought ways to incorporate midwives into the Dutch health care system. Midwives now work with obstetricians to teach medical students, whether they intend to become obstetricians, pediatricians or family practice doctors. Medical students are also given the chance to attend homebirths and to take part in postnatal procedures, under the supervision of a trained midwife.
I believe that maternity care in the United States suffers from the very problems Dr. Kloosterman described and that these problems can only be alleviated by massive doses of independent midwifery.
Enough band-aids! Let¹s do something right in maternity care for a change.
Copyright © 1994 Ina May Gaskin
Some other works by Ina May Gaskin available on-line: