Tuesday, March 21, 2017

The rural health landscape (Part II): Rural midwifery—Origins

Recently, during a dinnertime discussion punctuated by a phone call from my mother—“Call the Midwife is airing on April 2nd! What is the Netflix password?”—my boyfriend raised a bemused eyebrow and commented, “Aren’t midwives like witch doctors?”

No, no they are not—but surprisingly, my boyfriend is apparently not alone in his misconception. According to a 2015 article published by NPR, many people continue to imagine midwives as, at worst, “old ladies with potions and herbs,” and, at best, as “untrained labour coach[es]” averse to modern medicine. Indeed, the prevailing myths about midwifery (see below) seem to position midwives as anti-establishment, anti-western and anti-modernity. It is possible these misconceptions are rooted in the profession’s historical underpinnings.

The midwifery origins story is steeped in rurality. In the late 19th century, two concerns preoccupied physicians: overcrowding and competition. An influx of practitioners into the medical market in the 1820s and 1830s prompted a new professional self-consciousness and a desire on the part of “learned gentlemen” to distinguish themselves from the “quacks.” In the Age of Reform that followed, qualified practitioners increasingly relied on “appeals to science as the justification for professional prerogative”—though, it must be noted, such appeals “took place well before medicine could demonstrate the efficacy of its science.” In obstetrics, especially, the effects of medical professionalization were severe. Before 1900, midwives and physicians attended births in roughly equal proportions, and less than five percent of women gave birth in hospitals. Then, in the first decades of the new century, Dr. Joseph DeLee, now considered the father of modern obstetrics, published a series of influential articles and textbooks on the practice of obstetrics. In The Prophylactic Forceps Operation, Dr. DeLee described labor as “a painful and terrifying experience,” resulting in “much morbidity that leaves permanent invalidism.” He concluded that professional medical intervention was the means by which to protect mothers from Nature’s pathogenic process. In 1915, Dr. DeLee spoke at the Sixth Annual Meeting of the American Association for the Study and Prevention of Infant Mortality. According to Volume 88 of the Medical Record:
Dr. Joseph B. DeLee of Chicago asserted his opposition to every movement to perpetuate the midwife, declaring her to be a relic of barbarism . . . He regarded her as a drag upon the progress of the science and art of obstetrics, her existence stunting the one and degrading the other. . . . In educating the midwife he felt that the profession assumed the responsibility for her, lowered the standards and compromised with wrong, and personally he refused to be particeps criminis.
Dr. DeLee was not alone in his opinion; even those “who had favored the midwife now admitted that she must be eliminated,” and that “she should never be regarded as a practitioner.” Notably, even amidst these avowed renunciations of midwifery as a professional practice, numerous physicians acknowledged that “in rural districts there was no demand for obstetric hospitals and dispensaries, but that there was a demand for good midwives.” Dr. J. Whitridge Williams of Baltimore voiced his belief that absent midwives, the “farmer’s wife” would have only the “neighboring farmer’s wife to look after her confinement.”

The obstetrical restructuring sought by Dr. DeLee and his contemporaries had a disparate impact. “For example, as physicians became the provider of choice for the affluent woman, midwives cared for an increasing number of poor women. These midwifery clients usually lived in either rural areas of the country, or in immigrant areas of large urban cities[.]

By 1935, midwives attended less than 15 percent of births. By 1939, over 50 percent of all women and 75 percent of all urban women gave birth in hospitals; by 1950, the percentage was 88; by 1960, it was 97. By the 1960s, fewer than 70 midwives were practicing in the United States, and the infant mortality rate had increased by 41 percent.

Today, many of the myths perpetuated during the period of medical professionalization remain entrenched in the popular imagination. Many Americans continue to believe that delivering with an obstetrician is safer than delivering with a midwife. In reality, studies show that “mothers whose care was led by a nurse-midwife had lower rates of episiotomies, drug-induced labor, and vaginal tearing during delivery.” Many Americans think that opting for midwifery care precludes a woman from giving birth in a hospital. In reality, “[m]ost births with midwives occur in hospitals, with relatively small percentages at free-standing birth centers or at home.” Many Americans continue to typecast midwives as naturopathic providers who lack formal training. In reality, “[t]he vast majority of midwives in the United States are certified nurse-midwives (CNMs) and certified midwives (CMs).” Typically, CNMs have earned at least a master’s degree from an accredited college, in addition to clinical training and certification from a national board. They have prescriptive authority in every state. Perhaps the most common myth is that midwives provide only maternal care. In fact, “CNMs and CMs provide health care services to women in all stages of life, from the teenage years through menopause, including general health check-ups, screenings and vaccinations; pregnancy, birth, and postpartum care; well woman gynecologic care; treatment of sexually transmitted infections; and prescribing medications, including all forms of pain control medications and birth control.

That said, some of the midwifery stereotypes ring true. Historically, midwifery shared a special affinity with rural America. Around the same time obstetrical medicine was organizing, Mary Breckinridge founded the Frontier Nursing Service (FNS) in Kentucky’s Appalachian Mountains. According to the National Museum of American History:
Serving families in a 700-mile area extending into four southeastern Kentucky counties, FNS had, by 1930, six outpost centers, with two nurse-midwives at each responsible for both the general health of all of the families as well as prenatal, labor and delivery, and postnatal care for women in their district.

The narrow winding roads of Appalachia meant that nurse-midwives might have to ride for up to an hour on horseback to help a woman in labor. Though supervised by physicians, the isolated nature of rural Kentucky meant that these midwives often worked independently, carrying supplies with them.
Today, FNS remains a bastion of midwifery. Today, many educational programs continue to emphasize rural outreach. For example, the stated mission of Frontier Nursing University (FNU), originally established as a part of FNS' demonstration project, is "to educate nurses to become competent, entrepreneurial, ethical and compassionate nurse-midwives and nurse practitioners who are leaders in the primary care of women and families with an emphasis on underserved and rural populations.” Over 80 percent of FNU graduates work in areas HRSA has designated as rural or underserved, and the program currently has nearly 2000 students enrolled across the United States.

Part I of this series provided a snapshot of women's health in rural areas.  In the interview that follows in Part III, a recent graduate of Columbia University’s Nurse Midwifery Program gives us a glimpse of modern midwifery and its intersection with rural populations.


K. Harrington said...

Great post (my mother also loves Call of the Midwife). I agree that many Americans still have misconceptions about midwives and their training. When I starting seeing a midwife for my maternity care, one member of my family was concerned that the midwife would not have the medical training to intervene if something went wrong.

It seems like there is a movement towards using midwives for maternity care and away from obstetrics. I have met quite a few women who are receiving their care from a midwife instead of a physician. But I worry that this trend of using midwifery services is starting to be viewed as a luxury or a choice – for home births in particular. I know that midwives are providing much needed care in some rural areas of the country, but I would be interested to know the general demographics of women accessing midwifery services in the United States. Although a home birth might be cheaper if you do not have health insurance, some insurances – like Medi-Cal – will not cover a home birth. For low-income women in rural areas, they will need to drive long distances to have a hospital birth, as opposed to having a midwife come to them.

ofilbrandt said...

I echo and appreciate K. Harrington's comments to this article. My experience certainly shows that using a midwife is a privilege for the upper class and/or urban and not so much of a choice for rural mothers. I can comment on the first but would like to point out that, unless I'm much mistaken, midwives do not have hospital admitting privileges in the case that something goes wrong in the birth. infant and maternal death rates are going down in general. Babies have safely been born for millennia. Maternal health prospects are improving. Despite this, even in the US today, about 20 in 100,000 mothers die in childbirth. Obesity, increase in Cesarian births, and older mothers are partially to blame. http://time.com/4508369/why-u-s-women-still-die-during-childbirth/ http://www.csmonitor.com/USA/2017/0322/US-infant-mortality-rate-declines-but-disparities-remain

I went to school at UC Berkeley. This gave me unique access to an alternative upper class urban center. Babysitting to make ends meet, I met a number of mothers who worked with midwives and doulas throughout their pregnancies. A doula, per google, is more of a birthing coach, which a midwife is a healthcare provider. It was not lack of access to an OB/GYN practice, lack of health care coverage, or lack of funds but simply a personal choice to go this route for their pregnancies. This supports the author's assertion that

Note that Call the Midwife is about a midwife that takes a post in a church serving a local urban population. A follow-up to this article may benefit from mentioning the role of religion in bringing these services to rural populations.

Mollie M said...

Love this post, sorry I am a little late on joining the conversation. I love talking about midwives! My mother has been a nurse practitioner-midwife for over 30 years in a small town. I remember that she had been present at the births of many of the new friends that I brought home from school, which I found embarrassing at the time. My mother, whom I adore and respect immensely, used to always tell me that she chose to be a nurse practitioner midwife specifically because the nursing world presented a different philosophy of care, one that is different than what you'd find in medical school. She pointed out that the origins of the word "midwife" means "with the wife" or with women; she saw herself as a support and companion to women in labor in addition to a nurse practitioner with medical training she had. I know that for her, being a midwife in a small town always meant that she had a very intimate connection with the community; and going to work with her always meant staring through the glass panels at all the sweet little babies!

I do think that the word 'midwife' is colloquially used in multiple contexts, and due to the history you laid out so well in your post, not everyone means to refer to a certified midwife who works in a hospital under MDs. The term is sometimes still used to indicate something more traditional and informal, which can make the conversation confusing and add to myths and stereotypes about the profession.