Maternity care clearly is part of "reproductive healthcare" and a key component of "maternal health", but is rarely addressed in that context. There is an unspoken assumption that U.S. maternity care is great just the way it is, with 99 percent of births in the hospital and skyrocketing rates of interventions (PDF) from induction of labor to cesarean section. However, U.S. maternity care does not compare favorably with the rest of the industrialized world. Maternal mortality is under-reported and increasing, and we have a higher infant mortality rate than many other countries. In many of the countries with better outcomes, midwives are the primary care providers for pregnant women, according to Marsden Wagner.
A recent San Francisco Chronicle article stated that the percentage of births attended by midwives in the United States has decreased in recent years (to just below 8 percent), and implied this was due to fewer women wanting the natural childbirth associated with midwives. However, less access to certified nurse midwives in hospitals and birth centers may be the reason. Many birth centers and hospital-based midwifery services across the country have been closed in recent years, not because they were not popular, but because, as one hospital administrator pointed out, "midwives are not good money-makers," or because of enormous increases in malpractice insurance rates (even though midwives are hardly ever sued). Additionally, midwives are unevenly distributed, with none in many areas. Restrictions in health insurance policies also impose barriers for women desiring midwifery care in or out of the hospital.
In the United States, certified nurse-midwives (CNMs) practice almost entirely in hospitals, a few in free-standing birth centers, while non-nurse midwives such as Certified Professional Midwives (CPMs) specialize in out-of-hospital births, mostly in homes. For a woman having a normal pregnancy (most women), and attended by a well-trained midwife, the evidence shows that a planned home birth (PDF) or birth center birth is as safe for the woman and her baby as a planned hospital birth, but with much lower rates of all interventions as well as injuries and complications. Non-nurse midwives such as CPMs are licensed in many states, where midwives and their supporters worked hard to pass legislation.
Women who have educated themselves about the evidence regarding the many practices and interventions included in standard hospital-based maternity care often want to avoid the "cascade of interventions." They seek alternatives including in-hospital midwifery care, free-standing birth centers staffed by midwives, and midwives who specialize in attending births at home.
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Today a pregnant woman can not assume that the care offered by obstetrician and in hospitals will be in her and her baby's best interests. Maternity care is "business," and women need to be well-informed and careful consumers. For one example, cesarean sections are more efficient and convenient for obstetricians and hospitals, resulting in more income. A recent Philadelphia Inquirer article points out that cesarean section rates have increased dramatically to nearly one third of all births, but there have been no changes in maternal risk factors to justify the increase, nor are any significant number of women demanding cesarean sections for no medical reason, contrary to the widely circulated myth. Other practices, such as early induction of labor, lead to more cesarean sections (PDF), and ACOG's recommendations about vaginal birth after cesarean (VBAC) have lead many hospitals to ban VBACS (PDF). Epidurals have been popularized, but based on my experience, women rarely are informed about the economic incentives for selling epidurals, the risks for themselves and their babies, or alternative and non-invasive pain-management techniques that are often sufficiently effective with virtually no risks.
For a variety of reasons, however, most women will continue to give birth in hospitals. Those who want a safe birth, even a somewhat natural vaginal birth, will need to thoroughly educate themselves about the risks and benefits of interventions, learn how to exercise their rights to informed consent and informed refusal , know their rights, and "just say no" to unwanted, unnecessary interventions. Women planning a hospital birth can help to optimize their labor and delivery as much as possible by arranging for a labor support person, such as a doula, to work with them throughout labor, and by having a nurse-midwife as their primary care provider if at all possible.
When women have the choice, many prefer the respectful, empowering, evidence-based, woman-centered care described as the Midwives Model of Care and as Mother-Friendly Childbirth. This kind of care could be the standard for all maternity care providers in all settings, but at present is most frequently found in midwife-attended out-of-hospital births.
For consumer-oriented information about maternity care and resources for bringing about change, check out the following: