Many first-time mothers-to-be experience increasing anxiety as their due dates approach. Questions abound. What if I don’t make it to the hospital in time? Will pain meds hurt the baby? What are the chances I will need a cesarean section? Will I be induced?
In such times, women often turn to their mothers, sisters or close female friends for comfort and advice — a trusted and time-honored support system. Recent research conducted through the Women’s and Gender Studies Department at the University of South Carolina views this phenomenon through an anthropological lens, confirming the relevance of this bonded group and examining childbirth choices women typically face.
“It is pretty clear that when women stayed together, they were much more protected and valued,” says Elizabeth Collins, a WGST graduate certificate student who devised the study and is leading the data collection, collaborating with WGST graduate director Kathryn Luchok on this project. This study has received considerable interest at national and state conferences; most recently they presented Outside Voices: Homebirth Decision-Making Factors Can Inform Improvements in Maternal Health Care at the SC Public Health Association conference.
Collins sees a policy-driven information gap that inhibits women from considering all choices regarding childbirth. “We have the power to make choices, so why is that information suppressed? … It’s not the science; it’s the policy, she says, adding that 96 percent of women she interviewed had at least some college education. Options like home birth with a licensed midwife lag behind increasingly routine, institutionalized medicine, Collins asserts, which favors providers and the system, not the patient.
Medicalizing childbirth
Over the past century, the medicalization of childbirth has resulted in some 98.4 percent of births occurring in a hospital, where women risk more unwanted interventions, including C-sections and inductions, than may be medically necessary. In a clinical setting, patients feel inclined to conform to whatever providers tell them. It is widely assumed that when a woman gets pregnant, the only way she can deliver safely is at a hospital. Collins asserts it is less about where one gives birth than who is present to support the mother. It is about relationships.
Midwives have been around for centuries, yet between 1900 and 1960, they fell out of favor, and hospital births became the standard. Midwifery began to re-emerge in the 1970s and has been slowly gaining credence since. A growing acceptance of home birth has resulted in a 12 percent increase in home births nationwide from 2020 to 2021, according to Kathryn Luchok. Home births with midwives are more common in several countries such as New Zealand and The Netherlands, where they spend considerably less money on maternity care but have much better infant and maternal outcomes. In these countries, non-nurse midwives are fully integrated into their maternity health care system, while here they are not.
There are three levels of midwife: Certified Nurse Midwife (CNM), Certified Professional Midwife (CPM) and Certified Midwife (CM); only the first two operate in South Carolina. All are committed to supporting natural physiological birth, offering informed choices and advocating for their patients. Ninety-six percent of CNMs and CMs work in hospitals or birth centers, while CPMs mainly work in home settings and birth centers. CNMs have an RN degree and then do additional graduate work in midwifery. CPMs are not nurses but do midwifery training and apprenticeship. They are licensed by the state Department of Public Health. While the midwifery model is the foundation for all types of midwives, the full practice of it may be constrained in institutional settings.
"It is pretty clear that when women stayed together, they were much more protected and valued."
“When you give birth with a midwife CPM, you have her full attention,” Collins says. Midwifery-focused prenatal care affords more personal time with the caregiver to discuss topics such as nutrition, how to prepare for childbirth and breastfeeding. Midwives maintain relationships with their patients throughout pregnancy, birth and the postpartum period.
The United States has the highest maternal mortality ratio among developed countries. Part of the problem is a shortage of qualified providers, especially certified nurse midwives. According to the American College of Nurse Midwives: “Currently, the United States has approximately four midwives employed per 1,000 live births. With over 3.7 million live births a year, at least 22,000 midwives are needed in the midwifery workforce to meet the World Health Organization goal of at minimum 6 midwives per 1,000 live births. Currently, there are about 14,000 midwives in the US, including those not in clinical practice, resulting in a gap of at least 8,200 midwives.”
This fall, USC will begin offering the state’s only accredited nurse-midwifery program to help address a shortage in the maternal health care workforce. The College of Nursing further anticipates launching a Doctor of Nursing Practice program with a focus on midwifery next year.
“I’m excited about the midwifery program in nursing that begins this fall at USC,” Luchok says. She hopes that this will also build more bridges with other midwives and help garner respect for their work. Incorporating all practitioners of midwifery care into the maternity care system can help us increase services and have a stronger system. “Midwives are professionally trained people. They have a place in our birth network.”
The availability of midwives has never been more acute, as the country deals with a shortage of OBGYN physicians and a growing number of rural hospitals nationwide no longer offer obstetric services. Two rural labor-and-delivery departments close every month, on average, according to Center for Healthcare Quality & Payment Reform.
“Stopping a natural process is not good for the body or the baby. Doctors and midwives both understand it’s best to have fewer interventions.”
Convenience scheduling
Collins says that scheduled inductions, C-sections or other methods to slow or expedite labor often occur for the convenience of the health care provider.
“Stopping a natural process is not good for the body or the baby. Doctors and midwives both understand it’s best to have fewer interventions,” Luchok says.
Nonetheless, research confirms that women undergo far more medical interventions in the clinical setting. Some facilities are incentivized to provide more interventions over convenience, insurance or liability concerns. While the World Health Organization recommends a C-section rate between 10 percent and 15 percent, some 33 percent of hospital deliveries in the United States are performed via C-section. In addition, the U.S. spends more than any other nation on health care but trails other countries in positive birth outcomes.
“That is because you are taking the humans out of the process,” Luchok says, adding that hospital births are not necessarily safer, especially for low-risk women.
Collins’ study asks the core question: What are the most important factors that influence the decision to leave mainstream medical practice and seek non-institutional maternity care? From personal interviews and written surveys, the researchers found a level of mistrust toward the medical establishment based on policy-based care decisions versus purely evidence-based care.
“Control,” one respondent said. “I wanted to be the one to make decisions about my baby and care.”
Empowered choice
The choice of birth location is ultimately between a woman and her caregiver. Women who opt for home birth seek a more personal experience where they are fully empowered to have a natural delivery in a calm and familiar setting. In addition, family can be involved, and there is a lower risk of medical intervention.
Hospitals are vital for addressing certain complications in pregnancy, and respondents in the study acknowledged this. The American College of Obstetricians and Gynecologists generally recommends avoiding home birth for older or at-risk women with a baby in breech position, a multi-birth situation or who have had a C-section previously. Mothers-to-be also need to choose locations that make them feel the safest and supported. For some, that could be home, for others a birth center or a hospital.
In summary, this research suggests that women who choose home birth are generally well-educated. Respondents viewed hospital birth for low-risk patients as based predominately on policy and institutional convenience over patient care. They value the relationship and trust between patient and caregiver (midwife) and the control that allows them over their bodies.
In the memorable words of one respondent: “This will forever be one of the most beautiful, healing experiences of my life, and those ladies that held my hand while me and my baby danced in between two different worlds will always be my family.”