An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.
Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant.
The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother.
The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):
Americans are more familiar with the vital work of nurse midwives than ever before, thanks in part to the PBS show “Call the Midwife.” Yet in the United States, midwifery is often seen as a fringe choice — something strange, or even perceived as “less than” when compared with OB-GYN care.
But in a country dealing with a maternal health crisis, that may all be about to change.
An increasing number of U.S. families are turning to midwives for their maternity care despite systemic, social, and cultural barriers. “The midwifery model of care emphasizes normalcy and wellness. It empowers women and gives them greater ownership of their health, their pregnancy, and the outcomes of that pregnancy based on choices that they’re able to make,” explains Dr. Timothy J. Fisher, OB-GYN residency program director at Dartmouth Hitchcock Medical Center and assistant professor of obstetrics at the Geisel School of Medicine at Dartmouth University.
“Unfortunately, the medical model of prenatal care can take some of that ownership away, in a way that can ultimately be detrimental for some people,” he says.
WHAT’S THE MIDWIFERY MODEL?
Midwifery care involves a trusting relationship between the provider and pregnant person, who share decision-making. Midwives also see pregnancy and labor as normal life processes rather than a condition to be managed.
Millennials in particular may want something different than the medical model when they decide to have a baby.
Saraswathi Vedam, FACNM, a midwife for 35 years, midwifery researcher, and professor at the University of British Columbia, tells Healthline, “We have a generation of consumers now who are socialized that they should have a voice in making decisions about their own healthcare. In previous generations it was more normative to [give] control about healthcare decisions to the provider.”
“Another increase [in midwifery services] is in people who’ve had negative experiences in birth — or have been with family or a friend and witnessed something that scared them — and they don’t want the loss of bodily autonomy,” says Colleen Donovan-Batson, CNM, the director of the Midwives Alliance of North America Division of Health Policy and Advocacy.
Kendra Smith, an editor in San Francisco, was determined to have a midwife as her care provider for her first pregnancy. Smith drove an hour and a half for every prenatal appointment so she could access her midwifery practice.
“I understood that midwives seemed to focus more on care for the whole woman during pregnancy, and felt that there was less likelihood of complications if I had a midwife,” she tells Healthline. “I thought it would be more likely that I’d be given the time to labor naturally, even in the hospital, if midwives and nurses were supporting me.”
That’s the level of assistance the midwifery model of care strives for. Midwives see pregnancy and labor as normal life processes rather than conditions fixed solely by medical professionals.
That doesn’t mean everyone who uses a midwife has to have a low-intervention birth or go without pain medications. The majority of midwives in the United States practice in hospital settings, accessible to a full range of medications and other options.
The 4 types of midwives, at a glance:
Certified nurse midwives (CNM)Certified nurse midwives or nurse midwives, have completed both nursing school and an additional graduate degree in midwifery. They’re qualified to work in all birth settings, including hospitals, homes, and birth centers. They can also write prescriptions in all 50 states. CNMs can also provide other primary and reproductive healthcare.
Certified midwives (CM)Certified midwives have the same graduate-level training and education as certified nurse midwives, except they have a background in a health field other than nursing. They take the same exam as nurse midwives through the American College of Nurse Midwives. CMs are currently only licensed to practice in Delaware, Missouri, New Jersey, New York, Maine, and Rhode Island.
Certified professional midwives (CPM)Certified professional midwives work exclusively in settings outside of hospitals, such as homes and birth centers. These midwives have completed coursework, an apprenticeship, and a national certifying exam. CPMs are licensed to practice in 33 states, though many of them work in states where they’re not recognized.
Traditional/unlicensed midwives These midwives have chosen not to pursue licensure as a midwife in the United States, but who still serve birthing families in home settings. Their training and background varies. Often, traditional/unlicensed midwives serve specific communities, such as indigenous communities or religious populations like the Amish.
Benefits of midwives:
In areas like the UK and the Netherlands, midwives are the standard providers of care for pregnancy and birth, attending over two-thirds of births. While shows like “Call the Midwife” and documentaries like “The Business of Being Born” have led some Americans to choose midwives as their care providers, they’re still vastly underutilized.
Currently, CNMs attend only about 8 percent of births in the United States. The majority of those are in hospital settings. Out-of-hospital births account for about 1.5 percent of all births. About 92 percent of these are attended by CPMs.
Midwifery care is safe — some say safer than physician care — for women and families at lower risk. People who use midwives report high levels of satisfaction with their care.
A 2018 research found that, in hospital settings, people who have midwives are less likely to have cesarean deliveries, commonly known as C-sections, or episiotomies. Other research has found that people who birth with midwives are more likely to breastfeed and less likely to experience a perineal laceration during birth.
Midwives and women of color:
Cultural competency, too, is an issue. A profound lack of midwives of color makes it even less likely that women of color will access midwifery care.
Currently, black women in the United States are three to four times more likely to die in the perinatal period than white women and, according to the March of Dimes, are 49 percent more likely to give birth prematurely.
This disparity may be because providers may underestimate the pain of black patients or dismiss their symptoms. Serena Williams is one example. She had to demand her doctors check for blood clots after the cesarean delivery of her daughter in 2017.
Midwifery care could make a difference in birth experiences for black women. Yet it can be next to impossible for black women to find midwifery providers who look like them.
Racha Tahani Lawler, a black CPM who’s been practicing for 16 years, estimates that there are less than 100 black CPMs in the entire country. As of 2009, 95.2 percent of CNMs identified as Caucasian.
Many of Lawler’s clients aren’t aware of midwifery or home birth options, she says, until they have a bad experience. “The catalyst for most black people is ‘I don’t like the way they’re treating me,’ or ‘I feel like I am being harmed in my appointments,’” she says.
Veronica Gipson, a mother in Los Angeles, chose home birth with Lawler after three birth experiences at hospitals that she felt were disappointing, disrespectful, and racialized. Although she came to Lawler with just about a month left in her fourth pregnancy, Lawler worked with her to establish care and a payment plan.
Gipson says it was more than worth it, although she was at first intimidated by the cost of home birth midwifery: “It’s so helpful to have someone who looks like you and understands you. It’s a priceless feeling, a bond and relationship. I’m not just room 31 in the hospital — I’m Veronica when I’m with Racha.” Gipson has since had Lawler attend the birth of her fifth child.
The future of midwifery in the United States:
Maternal health experts say midwifery could be a viable option to help solve a number of ills in the American maternal healthcare system, including:
Vedam believes it’ll take systems-level collaboration before midwifery is both accepted and integrated: “Healthcare administrators, health policy makers, researchers, providers, the public — everyone will need to work together.”
But consumers with resources or access to healthcare coverage can still vote by seeking midwifery care and making it known that they want midwives in their communities, adds Vedam.
Donovan-Batson of the Midwives Alliance of North America feels that when people better understand the true benefits of midwifery care, they’ll be requesting it. “Research shows us that midwife care is the safest care for a low-risk woman. We’re the experts in normal pregnancy and birth. So, if you want to have that normal experience, seek out a midwife who will work with you to get you the care that you desire.”
And if that day of full acceptance ever comes, there’s a good chance American mothers and babies may be in better care.
"I’m an Obstetrician. Giving Birth at Home Isn’t Irresponsible. To improve access to safe birth at home, nationwide standards are necessary."
By Kate A. McLean
*Dr. McLean is a board-certified obstetrician-gynecologist at the University of Washington in Seattle.*
Earlier this month, a Nebraska midwife, Angela Hock, was charged with negligent child abuse when a newborn died after complications from a breech birth at home. It’s worth noting that before this delivery, Ms. Hock, the proprietor of a business called Nebraska Birth Keeper, had performed 50 births at home without incident. Nonetheless, Ms. Hock was not certified to practice as a midwife.
It’s unfortunate that these are the stories about home birth that make headlines, because they give the practice a bad name, and contribute to a sense that home births are irresponsible, a danger to the mother and baby.
Home births can be safe — as long as they occur within a system of standards and regulations of the very sort that were missing in Nebraska. When home birth is practiced in the shadows because of fear of recrimination, patients are worse off. We can change this by acknowledging that home birth is a reasonable medical choice, and by licensing midwives for home birth in all 50 states.
I have practiced as an obstetrician in Washington State since 2006. I attend births only in the hospital, but I frequently take care of patients who intended to give birth at home and ended up transferring to me when their labor didn’t progress normally. The American College of Obstetricians and Gynecologists (ACOG) had long opposed home birth, but in 2017 issued a committee opinion acknowledging that while “hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.” By contrast, the Royal College of Obstetricians and Gynecologists in the United Kingdom encourages home birth for women with uncomplicated pregnancies.
The source of this discrepancy, as well as a great deal of controversy, is that studies on newborn outcomes have come to conflicting conclusions. Data collected by researchers in California and Oregon suggest there may be an increased risk of death in babies born at home, while research in the Netherlands found no significant difference between the risks associated with planned home and planned hospital births. There is no high-quality data from randomized controlled trials because none have been conducted. This is in part because of ethical challenges and because very large numbers of patients would be needed to definitively detect differences.
A meta-analysis of more than 24,000 births in multiple countries found lower rates of severe laceration, episiotomy and cesarean section with planned home births compared to planned hospital births. Maternal outcomes are likely better at home. What does seem clear, however, is that women undergo fewer interventions when delivering at home because the possibility of unnecessary interventions is removed, although those interventions can still be obtained efficiently through transfer to a hospital. There is also evidence from Britain that there are fewer maternal complications, like postpartum hemorrhage, when women give birth at home. Cochrane, a trusted global network of health researchers, distilled these factors to what is most important: the overall safety of home birth is comparable to that of hospital birth for healthy patients assisted by experienced midwives.
Unfortunately, giving birth at a hospital isn’t universally safe. NPR reported that the United States is the only developed nation with an increasing rate of maternal death, which has more than doubled from 1987 to 2015. According to the Institute for Health Metrics and Evaluation, it is now nearly twice as dangerous to give birth here as it is in Britain, France or Germany, despite the fact that the United States spends more on health care per capita than these countries. ACOG notes that the statistics are even more dire among minorities, with black women being three to four times more likely to die than white women.
No one is immune to this risk. In 2017, Serena Williams almost died of a pulmonary embolism after delivering her daughter when her complaints of shortness of breath weren’t taken seriously at a Florida hospital. Researchers in Alabama and Georgia found that half of maternal deaths are caused by medically preventable complications like embolism, while the other half, including those linked to rising obesity rates and poor access to health care, cannot be blamed entirely on hospitals. Nevertheless, it remains understandable that pregnant women have started to lose trust in the medical establishment.
Marginalizing home birth only endangers patients. There is a better way to handle this, starting with formal accreditation. According to ACOG, approximately 35,000 births occur at home in the United States each year. State governments regulate the education and experience needed to qualify as a birth professional through licensure. Certified Professional Midwives are the only providers required to have training in home birth, but just 33 states license CPMs to practice.
Thankfully, Texas is a state very supportive of Midwives.