Women have been helping other women have babies since the beginning of time. However, in the United States, dramatic changes have occurred over the last century regarding midwifery where it was nearly eradicated. In spite of this, midwifery has made a reemergence over the last 40 years. According to Davis (2004), “Midwifery is alive today for one reason only: women’s insistence on midwifery care” (p. 2). The Midwives Model of Care (MMC) is dramatically different from the Medical Model of Care, which is currently the care most pregnant women receive in the United States. The principles of the MMC are as follows (Citizens for Midwifery - Midwifery Task Force, Inc., 1996):
One of the most basic principles of the MMC is the focus on the mother as a whole; including the physical, psychological, and social well-being; and individualized care. A typical prenatal exam with a midwife is much longer than a typical prenatal exam with an obstetrician, lasting up to an hour verses less than 10 minutes. During these longer prenatal exams, the midwife develops a close relationship with the mother, and is able to assess not only the mother’s physical well being, but psychological and social well-being as well. This is extremely important as much is to be learned during this time that plays a significant role in the pregnancy, labor, and delivery of the baby. For instance, fears, which could potentially impact the mothers’ pregnancy and/or labor, can be addressed. Also, any social issues, such as issues with the mother’s partner, family, work, etc. that may be affecting her stress levels, can be discussed. The psychological and social well-being of the mother has a direct impact on the physical well-being of the mother, which significantly impacts the health of the pregnancy and the baby. Each mother’s pregnancy is treated as a unique situation where education, counseling, care, and support can be tailored specifically to meet that mother’s needs. For instance, a thorough discussion on nutrition, which significantly impacts the health of the pregnancy, can be made where the mother is educated and encouraged on wise choices.
In the Medical Model of Care, the treatment of the pregnant women can be very standardized. Birth in the U.S. has become overly industrialized with large obstetrical practices with as many as eight or nine rotating physicians seeing mothers during their pregnancy making it hard to develop a strong relationship and trust with a caregiver. In addition, in the hospital setting, it is difficult to get individualized care as hospitals must follow strict hospital protocols.
The MMC is also different during labor and delivery where the mother is given continuous hands-on assistance with a caregiver whom she has had the opportunity to form a deep and trusting relationship with, instead of an unfamiliar nurse, who is in and out of the room, and will be different upon shift change. Enkin et al. (2000) mentions a Canadian study that found that women giving birth in a hospital encountered an average of six unfamiliar professionals during labor, with some women reporting up to 14 attendants (p. 249). Additionally, several studies have shown that on average less than 10% of the labor nurse’s time was spent in supportive activities (Enkin et al., 2000, p. 249). In addition, during midwifery care women are also encouraged to move around during labor, eat and drink, and to push in whatever position the woman chooses.
Another hallmark of the MMC is minimal technological interventions. Midwives believe that childbirth is a natural physiological process that is typically safest when left alone. Just as a cat or any other mammal seeks a dark, quiet, and safe place to birth; human birth thrives under those same conditions. Imagine a cat trying to give birth in a bright hospital room, lying in bed strapped to monitors and an IV, with strangers in and out of the room, and several people yelling at the cat to “push”. Midwives respect the sacredness of birth and work to protect the birth space, only intervening when truly necessary. Midwives understand that many of the interventions that are routinely performed in the hospital contribute to many complications for mothers and babies by not allowing the natural process of birth to take place. Even after the birth, the many routine interventions done immediately at births in the hospital interfere with the critical bonding time between mothers and babies, contributing to breastfeeding issues. Midwives understand that mother and baby should be treated as a whole where they are inseparable and interdependent (MANA Statement of Ethics, 1992).
Research by Johnson and Daviss (2005) shows rates of medical interventions were much lower for planned homebirths attended by Certified Professional Midwives (CPM) than for low risk hospital births. The same study showed that CPM attended planned homebirths had comparable mortality rates during labor and delivery, similar to rates found in most studies of low risk hospital births in North America. Additionally, a higher degree of maternal satisfaction was reported. A review of 21 studies comparing births attended by certified nurse midwives and physicians found no difference in infant outcomes between the 2 groups, and less use of interventions such as labor induction, episiotomy, and epidurals by the nurse midwives (Johantgen, et al., 2011). Midwives also have much lower cesarean rates, 3-4% for out of hospital midwives compared to 32.8% for national average (Citizens for Midwifery, 2006) and (CDC, 2011). This dramatic difference in cesarean births has significant impact on outcomes for mothers and babies as maternal and neonatal mortality is tripled for cesarean births (Deneux-Tharaux, et al., 2006) and (MacDorman, et al., 2006).
Postpartum care during the MMC is much more in-depth and individualized as well. Typically, with a homebirth midwife, there are four postpartum visits as follows: one to two days, one week, three weeks, and six weeks. While under the Medical Model of Care, you typically see the obstetrician upon hospital discharge and do not see the obstetrician again until six weeks postpartum. The baby will see the pediatrician, but the mother is not giving as much follow-up during this critical time.
The final principle of the MMC is identifying and referring women who require obstetrical attention. Midwives are experts in normal pregnancy and birth, and have been trained to recognize when birth is deviating away from normal. Home birth has been proven to be safe for low risk births. Therefore, if issues arise where the mother is no longer considered low risk, these issues must be discussed and obstetrical care sought. Midwives incorporate intuition along with clinical knowledge. In addition, midwives develop a deep knowledge of each individual client during long prenatal appointments which assist midwives in recognizing issues that may be arising. Additionally, to keep home birth safe, midwives must work to develop relationships with consulting practitioners and hospitals. It is also important for midwives to develop and follow practice guidelines.
Because of the holistic, individualized, hands-on care that midwives provide, the MMC provides great outcomes for mothers and babies. Midwives attend 70 percent of all births in the six countries with the lowest perinatal mortality rates in the world (Davis, 2004, p.1). In the United States, where midwives attend only 5 percent of births, perinatal mortality is much higher, ranking twenty-sixth worldwide (Davis, 2004, p.1). According to the World Health Organization (WHO), the United States is currently ranked 41st in maternal mortality (2008). The likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece (WHO, 2008). Not only is the perinatal and maternal mortality rates worse in the United States than most other developed nations, but the cost of healthcare is much higher (Wagner, 2006, p. 243). Physicians are trained surgeons who are more expensive and their skills do not need to be utilized for most low risk births. Additionally, the cost of many of these unnecessary routine interventions and cesareans are contributing to the high cost of healthcare in this country. Increasing the number of midwife attended births in the United States would not only provide safe births with less interventions and better outcomes for mothers and babies, but also lower the cost of healthcare, and result in higher levels of satisfaction with the birth experience.
By Shannon Greika, CPM
References
Citizens for Midwifery: Midwifery Task Force. (1996). Midwives model of care. Retrieved from http://cfmidwifery.org/mmoc/define.aspx
Citizen for Midwifery. (2006). Out-of-hospital midwifery care: Much lower rates of cesarean sections for low-risk women. Retrieved from http://www.cfmidwifery.org/pdf/cesarean2x.pdf
Davis, E. (2004). Heart & hands: A midwife’s guide to pregnancy and birth. New York, NY:
Celestial Arts.
Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.H., & Breart, G. (2006). Postpartum maternal mortality and cesarean delivery. Obstetrical Gynecology, 108(3 Pt 1), 541-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16946213
Enkin, M. W., Keirse, M. J., Neilson, J. P., Crowther, C. A., Duley, L., Hodnett, E. D., & Hofmeyr, G. J. (2000). A guide to effective care in pregnancy and childbirth. New York, NY: Oxford University Press
Hamilton, B. E., Martin, J. A, & Ventura, S. J. (2010). Births: Preliminary data for 2010. Center for Disease Control: National Vital Statistics Reports. 60(2).
Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Womens Health Issues. 22(1), 73-81. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21865056
Johnson, K. C., & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330, 1416.
doi: 10.1136/bmj.330.7505.1416
MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth. 33(2), 175-82. Retrieved from
http://128.193.4.112/cla/anthropology/reproductive_lab/sites/default/files/MacDorman_2 006.pdf
Midwives of North America. (1992). Statement of values and ethics. Retrieved from: http://mana.org/valuesethics.html
Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed to put women and children first. Berkley, CA: University of California Press.
World Health Organization. (2008). Maternal Mortality Ratio [Data file]. Retrieved from
http://apps.who.int/ghodata/
- Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle.
- Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support.
- Minimizing technological interventions.
- Identify and referring women who require obstetrical attention.
One of the most basic principles of the MMC is the focus on the mother as a whole; including the physical, psychological, and social well-being; and individualized care. A typical prenatal exam with a midwife is much longer than a typical prenatal exam with an obstetrician, lasting up to an hour verses less than 10 minutes. During these longer prenatal exams, the midwife develops a close relationship with the mother, and is able to assess not only the mother’s physical well being, but psychological and social well-being as well. This is extremely important as much is to be learned during this time that plays a significant role in the pregnancy, labor, and delivery of the baby. For instance, fears, which could potentially impact the mothers’ pregnancy and/or labor, can be addressed. Also, any social issues, such as issues with the mother’s partner, family, work, etc. that may be affecting her stress levels, can be discussed. The psychological and social well-being of the mother has a direct impact on the physical well-being of the mother, which significantly impacts the health of the pregnancy and the baby. Each mother’s pregnancy is treated as a unique situation where education, counseling, care, and support can be tailored specifically to meet that mother’s needs. For instance, a thorough discussion on nutrition, which significantly impacts the health of the pregnancy, can be made where the mother is educated and encouraged on wise choices.
In the Medical Model of Care, the treatment of the pregnant women can be very standardized. Birth in the U.S. has become overly industrialized with large obstetrical practices with as many as eight or nine rotating physicians seeing mothers during their pregnancy making it hard to develop a strong relationship and trust with a caregiver. In addition, in the hospital setting, it is difficult to get individualized care as hospitals must follow strict hospital protocols.
The MMC is also different during labor and delivery where the mother is given continuous hands-on assistance with a caregiver whom she has had the opportunity to form a deep and trusting relationship with, instead of an unfamiliar nurse, who is in and out of the room, and will be different upon shift change. Enkin et al. (2000) mentions a Canadian study that found that women giving birth in a hospital encountered an average of six unfamiliar professionals during labor, with some women reporting up to 14 attendants (p. 249). Additionally, several studies have shown that on average less than 10% of the labor nurse’s time was spent in supportive activities (Enkin et al., 2000, p. 249). In addition, during midwifery care women are also encouraged to move around during labor, eat and drink, and to push in whatever position the woman chooses.
Another hallmark of the MMC is minimal technological interventions. Midwives believe that childbirth is a natural physiological process that is typically safest when left alone. Just as a cat or any other mammal seeks a dark, quiet, and safe place to birth; human birth thrives under those same conditions. Imagine a cat trying to give birth in a bright hospital room, lying in bed strapped to monitors and an IV, with strangers in and out of the room, and several people yelling at the cat to “push”. Midwives respect the sacredness of birth and work to protect the birth space, only intervening when truly necessary. Midwives understand that many of the interventions that are routinely performed in the hospital contribute to many complications for mothers and babies by not allowing the natural process of birth to take place. Even after the birth, the many routine interventions done immediately at births in the hospital interfere with the critical bonding time between mothers and babies, contributing to breastfeeding issues. Midwives understand that mother and baby should be treated as a whole where they are inseparable and interdependent (MANA Statement of Ethics, 1992).
Research by Johnson and Daviss (2005) shows rates of medical interventions were much lower for planned homebirths attended by Certified Professional Midwives (CPM) than for low risk hospital births. The same study showed that CPM attended planned homebirths had comparable mortality rates during labor and delivery, similar to rates found in most studies of low risk hospital births in North America. Additionally, a higher degree of maternal satisfaction was reported. A review of 21 studies comparing births attended by certified nurse midwives and physicians found no difference in infant outcomes between the 2 groups, and less use of interventions such as labor induction, episiotomy, and epidurals by the nurse midwives (Johantgen, et al., 2011). Midwives also have much lower cesarean rates, 3-4% for out of hospital midwives compared to 32.8% for national average (Citizens for Midwifery, 2006) and (CDC, 2011). This dramatic difference in cesarean births has significant impact on outcomes for mothers and babies as maternal and neonatal mortality is tripled for cesarean births (Deneux-Tharaux, et al., 2006) and (MacDorman, et al., 2006).
Postpartum care during the MMC is much more in-depth and individualized as well. Typically, with a homebirth midwife, there are four postpartum visits as follows: one to two days, one week, three weeks, and six weeks. While under the Medical Model of Care, you typically see the obstetrician upon hospital discharge and do not see the obstetrician again until six weeks postpartum. The baby will see the pediatrician, but the mother is not giving as much follow-up during this critical time.
The final principle of the MMC is identifying and referring women who require obstetrical attention. Midwives are experts in normal pregnancy and birth, and have been trained to recognize when birth is deviating away from normal. Home birth has been proven to be safe for low risk births. Therefore, if issues arise where the mother is no longer considered low risk, these issues must be discussed and obstetrical care sought. Midwives incorporate intuition along with clinical knowledge. In addition, midwives develop a deep knowledge of each individual client during long prenatal appointments which assist midwives in recognizing issues that may be arising. Additionally, to keep home birth safe, midwives must work to develop relationships with consulting practitioners and hospitals. It is also important for midwives to develop and follow practice guidelines.
Because of the holistic, individualized, hands-on care that midwives provide, the MMC provides great outcomes for mothers and babies. Midwives attend 70 percent of all births in the six countries with the lowest perinatal mortality rates in the world (Davis, 2004, p.1). In the United States, where midwives attend only 5 percent of births, perinatal mortality is much higher, ranking twenty-sixth worldwide (Davis, 2004, p.1). According to the World Health Organization (WHO), the United States is currently ranked 41st in maternal mortality (2008). The likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece (WHO, 2008). Not only is the perinatal and maternal mortality rates worse in the United States than most other developed nations, but the cost of healthcare is much higher (Wagner, 2006, p. 243). Physicians are trained surgeons who are more expensive and their skills do not need to be utilized for most low risk births. Additionally, the cost of many of these unnecessary routine interventions and cesareans are contributing to the high cost of healthcare in this country. Increasing the number of midwife attended births in the United States would not only provide safe births with less interventions and better outcomes for mothers and babies, but also lower the cost of healthcare, and result in higher levels of satisfaction with the birth experience.
By Shannon Greika, CPM
References
Citizens for Midwifery: Midwifery Task Force. (1996). Midwives model of care. Retrieved from http://cfmidwifery.org/mmoc/define.aspx
Citizen for Midwifery. (2006). Out-of-hospital midwifery care: Much lower rates of cesarean sections for low-risk women. Retrieved from http://www.cfmidwifery.org/pdf/cesarean2x.pdf
Davis, E. (2004). Heart & hands: A midwife’s guide to pregnancy and birth. New York, NY:
Celestial Arts.
Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.H., & Breart, G. (2006). Postpartum maternal mortality and cesarean delivery. Obstetrical Gynecology, 108(3 Pt 1), 541-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16946213
Enkin, M. W., Keirse, M. J., Neilson, J. P., Crowther, C. A., Duley, L., Hodnett, E. D., & Hofmeyr, G. J. (2000). A guide to effective care in pregnancy and childbirth. New York, NY: Oxford University Press
Hamilton, B. E., Martin, J. A, & Ventura, S. J. (2010). Births: Preliminary data for 2010. Center for Disease Control: National Vital Statistics Reports. 60(2).
Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Womens Health Issues. 22(1), 73-81. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21865056
Johnson, K. C., & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330, 1416.
doi: 10.1136/bmj.330.7505.1416
MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth. 33(2), 175-82. Retrieved from
http://128.193.4.112/cla/anthropology/reproductive_lab/sites/default/files/MacDorman_2 006.pdf
Midwives of North America. (1992). Statement of values and ethics. Retrieved from: http://mana.org/valuesethics.html
Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed to put women and children first. Berkley, CA: University of California Press.
World Health Organization. (2008). Maternal Mortality Ratio [Data file]. Retrieved from
http://apps.who.int/ghodata/
RSS Feed
