by Raymond De Vries, PhD and Eugene Declercq, PhD
The COVID crisis is shining a light on the way we organize our lives together, exposing inequalities and inefficiencies that, until now, were hiding in plain sight. Because of the changes forced on us by COVID-19, we have begun to question many aspects of our lives, including where we work, how we provide education, and how we deliver health care.
One prominent story is the plight of women anguishing over the question of where they should birth their baby. Hospitals, considered the best place for birth and the location of 98.5% percent of all US births, now seem unsafe and even unfriendly. Mothers- and fathers-to-be worry about entering a building where the sickest of those stricken with the corona virus are being cared for, they are upset with the limitations on who can be present at the birth, they are concerned that their baby may be separated from them after the birth, and they are uncomfortable being treated by caregivers hidden behind layers of PPE. On the other hand, parents-to-be wonder if it is safe to birth their baby outside of the hospital.
Even before COVID-19 struck, it was apparent that there were problems with the way we organize maternity care in the US. Maternity care professionals – midwives, obstetricians, and obstetric nurses – have long been concerned with two problems: 1) our high rate of cesarean sections – nearly one in three babies in the US is born via surgery – and 2) the number of mothers who die as a result of childbirth. The recently reported ratio of 17.4 maternal deaths per 100,000 places the US last among industrialized countries. Worse, the reported ratio for Black mothers (37.1) would rank 83rd internationally between Thailand and Argentina.
How did we get here?
Over the course of the 20th century, birth shifted from an event that took place in the home attended by midwives to a medical procedure in a hospital attended by obstetricians. By the 1990s, fewer than one percent of births were at home.
In a century that celebrated technology, these changes seemed logical. The gleaming instruments of the hospital and the highly trained specialist promised relief from the pain and danger of childbirth. But these technologies soon became ends in themselves. All pregnancies and births were seen as illnesses requiring hospitalization and care from an obstetrician. The result? A self-fulfilling prophecy, where too much surveillance, and a consequent increase in false positives, led to interventions that, in turn, justified the need for the technologies. These unnecessary interventions – doing “too much too soon” – come with a cost, measured not just in dollars but in the health of babies and mothers.
Prior studies suggest the most technological birth is not the safest birth, and that for healthy women, out of hospital births are equally safe for babies and safer for mothers (who suffer fewer unnecessary interventions, like c-sections, and hence lower rates of morbidity). Similarly, studies examining outcomes of midwife-led care find that when midwives attend healthy mothers in labor, moms and babies have fewer interventions and fewer complications
To address the worries of women birthing in the time of COVID and solve long standing problems with US maternity care, we need to rethink the organization of the maternity care workforce.
When you compare maternity care in the US with countries that have outcomes better than ours, one thing stands out: an upside-down ratio between obstetricians and midwives. In the US we have about three times as many obstetricians as we do midwives. In most other high-income countries, this ratio is reversed, with midwives outnumbering obstetricians: in the Netherlands there are 3 times as many midwives, in Australia and the UK 8 times as many. All these countries have better outcomes than the US. For example, in the Netherlands, midwives attend the majority of births ,including all of the 30% of births that occur at home and in birth centers, and nearly half of births in obstetric units. The Netherlands cesarean rate (16%) is half that of the US, while its maternal mortality rate of 1.8 per 100,000 births is one tenth that of the US (17.4).
Midwives do so well because they are more likely to be community based and offer more personalized one-to-one care. As a result of their emphasis on recognizing and supporting the physiological process of birth, they are less tempted to intervene quickly and unnecessarily. A recent study found that states where midwives are integrated into the health care system have lower rates of cesarean section, neonatal mortality, and preterm birth.
But are women in the US ready for a change in the way we provide care at birth? Are they willing to have a midwife attend their birth? Will the desire to avoid the hospital diminish when the pandemic passes? Surprisingly, recent surveys of new mothers show a remarkable openness to giving birth at home or in an out-of-hospital birth center. In a national survey of women who recently gave birth in a hospital, 29% of respondents indicated an openness to having their next birth at home, and 64% were open to having their baby in a birth center that was physically separate from a hospital. A recent California study found 54% of mothers open to having a midwife attend their next birth.
Most women in the US have grown accustomed to the idea of an obstetrician-attended birth, and that’s fine. For women with conditions that place them at higher risk, they should give birth with an obstetrician. But COVID-19 gives us the opportunity to rethink and reset US maternity care. Among all the differences that will be part of the new normal after this crisis has passed, a new and less medical approach to pregnancy and childbirth, under the care of a midwife, promises much: fewer unnecessary interventions in birth, less exposure to infection for birthing mothers, more one-to-one care with midwives and doulas (via telemedicine if not in person), lower costs, and healthier moms and babies. The enormous skills in the management of high-risk birth that obstetricians bring to care can be concentrated on those births that clearly require them.
Now is the time for the leaders in maternity care in the US to come together (via Zoom, of course) to start planning for changes that will move care for American moms and babies into the 21st century, where healthy mothers are cared for by the right caregiver, at the right time, in the right place.