The reason childbirth is over-medicalized in America has its roots in racial segregation

Healthy traditions.
Healthy traditions.
Image: AP Photo/Manuel Balce Ceneta
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Every year in the UK, more than half of babies are delivered with the guidance of a midwife. In Scandinavian countries, it’s more like three quarters (pdf), similar to the rate in France. In fact, in these and many other countries, midwives take part in almost all deliveries, as they also assist OB-GYNs in more complicated cases.

But in the US, less than 10% of deliveries are led by midwives. The rate has languished in the single digits since a century ago, when expectant mothers largely stopped using midwives to embrace doctor-led childbirth, believing that was safer. Ironically, that shift has resulted in myriad problems stemming from the over-medicalization of childbirth. Those problems are reflected in the country’s high rates of C-sections as well as in the “cascade of interventions” that comes with medically managing labor, a problem that the American College of Obstetricians and Gynecologists (ACOG) acknowledges, too.

In fact, midwife-led deliveries are as safe, and at times even safer for women as OB-GYN-led ones. A 2016 study by independent research organization Cochrane found that for low-risk pregnant women, or for those who were at risk of complications but who weren’t experiencing them yet, delivering their babies with a midwife rather than a doctor was associated with a smaller chance of premature birth or spontaneous abortion. They were also more likely to have a spontaneous vaginal delivery, and less likely to need a C-section, an epidural, or require the use of instruments such as forceps. European countries that lean more heavily on midwives also have better outcomes for babies and their mothers. Maternal mortality rates there are a fraction of America’s.

So if there’s a good chance that American women would be better off having a midwife deliver their babies, why do so few opt to do so? One needs to return to the country’s history of slavery, and its deeply embedded racial inequality and prejudice to uncover the answer.

Unfair competition

Jennie Joseph, a British-trained nurse midwife who runs Commonsense Childbirth, a birth and prenatal care center  in Orlando, Florida, had no idea midwifery was barely practiced in the US when, 26 years ago,  she “moved to Disneyland,” as she likes to say, after she met a “nice American boy.” In the UK, midwives routinely took part in deliveries: At the time over 75% deliveries were performed by midwives, and gynecologists only intervened in the case of complications.

“I knew babies were born in America,” says Joseph, who moved to the US convinced she would find a job. She was in for a rude awakening. America was no Disneyland—and there was no room for midwives. “Hospitals were horrified at the thought of a midwife,” remembers Joseph.

Indeed, the distrust between OB-GYNs and midwives runs deep in the US child-delivery business, and the feeling is mutual. American comedian Mindy Kaling weaves the rivalry into her TV show The Mindy Project. Kaling, who plays a feisty OB-GYN, regularly berates the midwives who practice upstairs from her office, in a poignant if (only slightly) exaggerated depiction of the relations between the two professions. “Midwives. It’s one thing to lose our patients to doctors but to those charlatans? It makes me sick,” says one doctor on the show.  “He left. I think he was embarrassed about being a drug dealer,” says one of the midwives, talking about a doctor writing prescriptions, adding that “prescriptions are little pieces of paper one trades in for narcotics. Making this lovely establishment no different from the hacienda of Pablo Escobar.”

This hostility dates back to the early 1900s, when doctors in the US were derided for their lack of medical education. In 1910, a report by Abraham Flexner published in the American Foundation for the Advancement in Teaching heavily criticized medical schools in the US, noting an excess of poorly trained medical professionals, and singling out childbirth practices as “the very worst showing.” (Those physicians who could afford it would return to the UK for training.)

Doctors embarked on a campaign to professionalize the field, to improve standards and to raise their earnings potential. They focused in part on better education and the use of modern technologies. For expectant mothers, physician-assisted childbirth meant using tools, like forceps, to speed up labor. Doctors also took on their main rivals: midwives. In 1912, JW Williams, a professor of gynecology, published a paper titled “Medical education and the midwife problem in the United States” in the Journal of the American Medical Association recommending that the practice of midwifery be phased out—starting with cities, and eventually in rural America, too. He, and others, blamed midwives for maternal deaths, and discouraged people from trusting their services.

As Laurie Wilkie, professor of anthropology at the University of Berkeley, writes in her book The Archaeology of Mothering, this push to medicalize childbirth wasn’t born simply out of a desire to provide better care. The American Medical Association (AMA) saw midwives as competitors for what would become the most common cause of hospitalization in America, and a reliable source of revenue. (The AMA would again show how effective it could be at protecting the financial interests of doctors some years later when it opposed socialized health care.)

The AMA’s focus on specialized health care wasn’t limited to childbirth—it was spread across all disciplines. But its expansion into childbirth was especially effective,  partly because the midwives who were, until then, running childbirth were overwhelmingly African American and Native American—both demographic groups that were easy to discredit in a country that had abolished slavery just decades before, and would enforce racial segregation for decades to come. As Barbara Ehrenreich and Deirdre English chronicle in their book, Witches, Midwives and Nurses, it wasn’t difficult to spread suspicions that midwives, who relied on traditional birth practices, were dedicated to witchcraft and sorcery, and to convince women that having a doctor—most likely white and male—deliver a child was a safer option than involving a midwife—typically black and female.

New York obstetrics professor Clifton Edgar succinctly summed up doctors’ pitch in 1911: Midwives are “dark, dirty, ignorant, untrained, incompetent women….she is evil, though a necessary evil, and must be controlled. We must save our women.”

Joseph DeLee, the country’s leading professor of obstetrics, personally took on the battle against midwives. “The midwife is a relic of barbarism.” he wrote, “In civilized countries the midwife is wrong, has always been wrong.” He spoke of the importance of rehabilitating the profession of obstetrics in the eyes of the public, taking it away from midwives in order to make its remuneration appealing: “If the public would acknowledge the dignity of his specialty it would properly remunerate him for his services. If the specialty were as remunerative as the other departments of medicine it would attract large numbers of young men.”

DeLee didn’t just work to discredit midwives. He created new processes that enshrined medical intervention in childbirth. In 1920, he introduced the prophylactic forceps operation, which became the go-to for hospital deliveries. The woman would be sedated during childbirth, and the baby would be extracted with forceps. This embodied his understanding of childbirth, which he had described in a 1915 paper (p. 23): “Obstetrics has a great pathologic dignity. Even natural deliveries damage both mothers and babies, often and much. If childbearing is destructive, it is pathogenic, and if it is pathogenic it is pathologic. If the profession would realize that parturition viewed with modern eyes is no longer a normal function, but has imposing pathologic dignity, the midwife would be impossible even of mention.”

Midwives continued to deliver the children of women who couldn’t afford medical care, but eventually they all but disappeared. “Slave women delivered America,” says Joseph, but as soon as medically managed hospital births became the preferred option for anyone who could afford it, the tradition of American midwifery, which had been passed on through generations of black women, was lost. Today, only 4% of the country’s midwives are black. “We all know each other,” says Joseph. “That’s how bad it is.”

It takes a village

A growing awareness of the tragedy of maternal mortality in the US, however, where expectant and new mothers die at a rate that’s far higher than in any other developed country, and a greater understanding of the part played by over-medicalization, has led to an easing of hostilities between doctors and midwives. ACOG now recognizes the value of midwives and encourages their involvement. As president Haywood Brown notes, “there’s enough work to go around.” This past May, for mother’s day, a March for Mothers was organized in Washington, DC, to raise awareness of the health challenges faced by new mothers; obstetricians and midwives collaborated to organize the event, and agreed that it was necessary to look at childbirth as a healthy process, not a medical emergency.

Treating obstetrics and midwifery as complementary, rather than antagonistic, could help solve another problem in the US: inadequate access to health care. Roughly half of all counties in the US do not have OB-GYNs, and even those that do may offer insufficient professional support through pregnancy, and afterwards. Midwives, whose training is shorter and less expensive than that of doctors, could fill the gap.

But first, the US would need to increase the number of midwives. Right now, 56% counties don’t have any. Moreover, those that do have midwives often deny them the right to lead the procedure or even to admit a patient without a physician taking over the case.

When Joseph started her practice, Commonsense Birth, in Orlando 15 years ago, she did it with the intention of supporting the many women who don’t have access to OB-GYNs and would go to the emergency room when in labor. To this day, she deals with the limitations on what a midwife is permitted to do by seeking to complement medically assisted birth, rather than replace it. Her clients may be women who lack insurance; others, just women who can’t find a doctor, perhaps because they moved mid-pregnancy and doctors didn’t want to take responsibility for a course of care initiated elsewhere.

Joseph works with a network of physicians, and only delivers a small percentage of the babies herself in the birthing practice. American women, she says, prefer giving birth in a hospital, and there is no need to force them to do otherwise if that’s what makes them feel safe. In most cases, she limits her involvement to education and support before and after the birth.

She decided early in her practice that it would be far more fruitful to collaborate with doctors, than compete for the same jobs, and women, she says “are thriving with the ability to choose.”

She faces challenges, however, many of them financial ones. Since she doesn’t turn any patients away, she is often left with uncovered costs. Medicaid pays for midwives, but since she doesn’t deliver the baby, she loses the bulk of the pregnancy care fee.

Nevertheless, her results are impressive. In a part of the country where C-sections account for 35% to 40% of births, only 25% of Joseph’s clients receive one—even counting the complicated pregnancies she assists.

And when it comes to maternal mortality?

In 15 years, she says, “we have never lost a mother, never had a near miss.”