The Rise of Midwives

Elizabeth Blackwell, notorious for being the first woman to obtain an MD degree in the United States in 1849, took a massive strive forward that has led to around 37% of active physicians being women in 2021 (and the number is still growing in years to come). However, while women have only recently begun taking physician career roles, they have a long history of working within a medical context through midwifery, With the earliest midwife training programs beginning in the 17th century (within the United States), throughout the 18th century, “midwives were utilized for childbirth due to a greater knowledge base [than doctors who “were not usually formally educated]” (Registered Nursing). This might be a surprising fact for those in the United States where “Only 8 percent of births in the United States are attended by midwives'' today (Healthline). This statistic becomes increasingly interesting considering in other countries, such as the UK, midwives ``attend over two-thirds of births'' (Healthline). Their role stemmed from the idea that women should assist other women in childbirth, and now their role has expanded to include aspects like reproductive care, sexual health, pre and post-natal care, and more. According to Dr. Timothy J., “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.” Especially during a time like pregnancy where one is especially vulnerable both mentally and physically, it is vital to have a professional who is willing to fight for one’s desires. Thus, it makes sense that “when midwives play a central role in the provision of maternal care, patients are more satisfied, clinical outcomes for parents and infants improve, and costs decrease. Use of midwives is also associated with fewer cesarean sections, lower preterm birth rates, lower episiotomy rates, higher breastfeeding rates, and a greater sense of respect and autonomy for the patient.” (CommonWealth Fund). If midwifery is associated with so many benefits, then why are they not the norm in the United States. The answer is that they used to be more common, are now becoming more popular, and are limited by United States laws (finalized in the mid-1990s) that prohibit midwives from practicing without physician supervision. While the popularity of midwives greatly declined in the 1920s due to people associating midwife care with the “lower class,” there was a “resurgence in midwifery sprung up in the 1970s along with the women’s movement” (Registered Nursing). According to Healthline, “An increasing number of U.S. families are turning to midwives for their maternity care despite systemic, social, and cultural barriers.” This post will attempt to question whether/how the history of the midwifery system shows an inherent mistrust in physician/hospital care, why midwives have remained separated from long-term in-hospital care (or the physician model), and why this rise in midwifery involvement might be occurring within the United States.

Most articles emphasize that compared to physician care, “Midwifery care involves a [more] 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.” (Healthline). While I think that physicians also must establish a trusting relationship between provider and patient (and that it is unfair to claim that physicians tend to be distant from their patients), I feel that the distinction between midwife care and physician care lies within the difference between more holistic care of a person versus the treatment of a condition or a disease. With midwives focusing on general women’s health and well-being, they do not make a clear distinction between the treatment of the physical versus the treatment of the mental, which is a distinction that was made very early on in the medical field. Descartes used mind-body dualism to separate the physical from the mental and assigned different denominations more-or-less a category. While the church reigned over the mind, he assigned medicine the responsibility over the body. Over time, there is increased effort to close this gap within medicine through increased focus on the mental state. This historical separation makes it very difficult for medicine to treat people holistically because there is such a focus on the body. Therefore, maybe midwives have never been fully integrated into the medical model because their focus is inherently different. To treat someone holistically, sometimes one may have to sacrifice the best treatment option in favor of something that will make someone happier mentally, which is undoubtedly a very hard call to make–especially when someone has an education that tells them what the best course of action may be. For example, a physician is more likely to advise inducing labor earlier than a midwife would. Even though inducing labor might be safer than waiting and, frankly, quicker for all the people involved, if a patient is adamant that they want a natural labor and delivery process, the midwife will fight for that until the risk of not inducing labor becomes too high.

Given the duration of time in which midwives have been around and how early their roles appeared, I think the existence of a midwife role questions what medicine includes versus what people want. Beginning with the idea that women should support women during things like childbirth, it seems natural to want someone who can understand or at least empathize with one’s pain during (as aforementioned) a considerably vulnerable time. We even see this today in medicine with around 85.2% of all OB-GYNs being women and around 90% of urologists being male. People want to be treated by someone who they feel is more likely to relate to them. While this “relatability” that began with midwives has moved into the medical model, the continued existence of midwives indicates they still have something that is different in doctors and nurses. Based on the emphasis that midwives increase autonomy and empowerment, I think some of these articles (in the sources) suggest that a focus on autonomy and empowerment is void within the current medical model. Honestly, this idea makes sense because when someone has the knowledge of what is the best course of treatment, why would they not endlessly persuade someone to follow that course of action? They understand what is physically best for that person, yet despite their advice, some people still want to do something else. The midwife focuses on what the patient wants before other factors. In Eric J. Cassel’s essay The Nature of Suffering and The Goals of Medicine, he describes what he feels is an issue within medicine: doctors treat physical suffering while not focusing enough on the mind. He states that “People can behave in ways that seem inexplicable and strange even to themselves, and the sense of powerlessness that the person may feel in the presence of such behavior can be a source of great distress.” He quite directly describes how a lack of autonomy, empowerment, and ownership in one’s medical decisions leads to suffering. Certain things are very important to certain people whether for personal, cultural, or religious reasons, and so they will fight to keep those things, even at the expense of the “best treatment option.” Maybe the existence of midwives is an indicator that this type of holistic consideration is necessary, yet not present to the full extent necessary within medicine.

In speculation about the potential reason why the use of midwives is increasing in the United States, I think the rise may be due (in part) to COVID and social media. During the COVID-19 pandemic, people were not only encouraged but mandated to stay home, especially from hospitals where there was an overflow of COVID-19 patients. This translates into people not going in for check-ups, and increased nervousness for those who must go in for checkups. Thus, if someone has an option for where and with whom they would like to give birth next to, they are not likely to choose the doctors who are potentially exposed to COVID daily. With the option for more personalized care that one could access both in and out of the hospital, maybe more people (with the means to do so) started gravitating toward midwives as a valid option or supplement. Additionally, the magnitude and the spread of digital content have changed the medical landscape. (I have another post about this topic, so I will be brief.) People now have access to content by medical professionals, sharing stories, hardships, and sometimes advice. Medical professionals and other people have access to content by patients who share the good, bad, and ugly of their experience with physicians. With more data than ever about how procedures felt and how people were treated alongside an algorithm that tends to push negative (and usually more interesting) content forward in favor of neutral content, people may have negative views of hospitals or have heard too many stories of women being ignored to go to a hospital without being uneasy about the experience. Additionally, no longer are the days where one would have to read articles to hear about people like midwives, from movies to social media posts, options and possibilities on what to do and how to do it are everywhere. Therefore, maybe more people are looking for ways to ensure that these negative experiences do not happen to them and seeing types of potential solutions online. As midwives become more popular, it is important to consider their use among various demographics. Cultural competency is vital within the medical environment, especially within labor and delivery. With black women being 3 times more likely to die during pregnancy than white women, there is concern about whether midwives can be used to help various groups of people. Just as diversity within medical professionals has increased over centuries, I would hope and expect the diversity of midwives to follow the same path. We can only hope this diversification occurs quicker due to its popularity growing during a time when cultural competence and equity are being heavily advocated for.

With “32.9 maternal deaths per 100,000 births, [which is] more than 10 times that of countries like Australia, Japan, Israel, and Spain, where rates remain between two and three per 100,000,” one can only question why this might be the case. One difference might be that “unlike other high-income countries such as Australia, Canada, the Netherlands, and the United Kingdom, the United States does not systematically incorporate midwives into essential maternity care services” (CommonWealth Fund). This interesting trend may help push the United States toward further improved healthcare and can better help even more people.

Sources:

The Rise of Midwives

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