Carol Rose, a Harvard-trained lawyer from Melrose, was pregnant with her first child two years ago when her health plan pulled a switch.
She was in the exam room, waiting for her female doctor when a male doctor walked in. She’s not anti-men, or anti-doctor, but this guy was a bad match. “I had a bunch of questions,” she says. “He said, `I have limited time.’ I felt so dehumanized and medicalized that I left.”
When she turned to Leslie Ludka, a nurse-midwife who heads the midwifery program at Brigham and Women’s Hospital, she discovered “the best of both worlds” — someone with time to answer questions, yet backed by doctors at a major hospital.
When the big day came, says Rose, Ludka was great. “When the pain was at its peak, I said, `I’m not sure I can do this.’ She said, `The pain will not get worse than it is right now.’ ” It didn’t. Rose had a drug-free delivery, just as she had hoped.
Midwifery — the art of helping a woman through childbirth — is as low-tech as mother’s milk, as ancient as womankind. But until recently, it had been squeezed out of the birthing room by doctors and their gadgets, much as death has been hustled out of homes and into hospitals.
That is changing — 6.5 percent of American babies are now delivered by midwives, usually in hospitals, compared to 1 percent in 1975. And this could be good news for babies.
A study published in May by the National Center for Health Statistics found babies delivered by certified nurse-midwives were less likely to die than those delivered by doctors.
The study, by researchers Marian MacDorman and Gopal Singh, looked at all singleton babies delivered vaginally in the United States in 1991 at 35 to 43 weeks of gestation — roughly full term. (The study did not look at multiple births or Caesareans, which account for about one quarter of all births.)
Of the 2.8 million births studied, the team focused on about 1 million: a sampling of doctor-attended births (850,000) and all 153,194 births at-tended by certified nurse-midwives.
The results were striking:
– After controlling for socioeconomic and medical risk factors, the infant mortality rate — death during the first year — was 19 percent lower for certified nurse-midwives than for physicians.
– The death rate in the first 28 days — was 33 percent lower. – And the risk of low birthweight infants was 31 percent lower.
Some doctors, among them Dr. Michael Greene, director of maternal-fetal medicine at Massachusetts General Hospital, suspect that the midwives’ better track record may be due to their having patients who were “healthier to begin with.”
Dr. Fredric Frigoletto, chief of obstetrics at MGH and a past president of the American College of Obstetricians and Gynecologists, agrees. This study has “significant limitations,” he says, because it’s not clear “how patients found themselves in the midwife or doctor cohort.”
Statistician MacDorman agrees that any study like hers based on data from birth certificates can’t control for all factors, but she notes that since her study deliberately left out multiple births, preterm births and Caesarean deliveries, the women were comparable in that they all had normal deliveries.
Furthermore, her study showed that midwives were more likely than doctors to care for women at higher socioeconomic risk — black women, American Indians, teenagers, women with three or more previous births, unmarried women, those with less than a high school education and those with late or no prenatal care.
The doctors were somewhat more likely to have medically difficult cases, she says, but “the differences were small.”
So if there’s magic in midwifery, what is it? Midwives say it’s time and support — during prenatal visits and labor.
One study cited by MacDorman found certified nurse-midwives spent an average of 49.3 minutes on the first visit — versus 29.8 minutes for doctors. Subsequent visits averaged 29.3 minutes for midwives, against 14.6 minutes for doctors.
Frigoletto counters that if you add up the time the doctor, the nurse and the nurse’s assistant spend with each patient, “the total visit might be just as long.”
Unlike doctors, most midwives stay with the woman — not just nearby — for the duration. This allows quick action if the baby’s heart rate soars or plummets. If low-tech remedies such as having the woman change position or drink fluids don’t help, the midwife can then call in the doctor.
Often, the combination of massage, position changes, breathing exercises and moral support do the trick, though Frigoletto warns there’s little data linking these interventions with birth outcomes.
Midwives believe they have economics on their side, too. A 1996 study of 1,000 patients showed that hospital charges for midwife births were 21 percent lower than those for doctors, perhaps because they’re less likely to use interventions such as electronic fetal monitors and to do procedures such as episiotomies (surgical cuts to enlarge the vaginal opening).
Though midwives, like doctors, can use painkilling medications and drugs such as oxytocin (Pitocin) to induce or speed up labor, they do so sparingly lest they trigger a vicious circle: Painkillers may slow labor, which means a woman may need oxytocin, which causes more pain, which may necessitate more painkillers.
“There’s some truth to that” scenario, says Frigoletto. But usually, the need for drugs depends on the individual and how many previous births she’s had. He adds that doctors, like midwives, are cautious about using drugs too early in labor.
And midwives have some time-honored tricks up their sleeves. Instead of using forceps, midwives often ask a woman to stand and rock her hips or squat to free a stuck baby. They also may use nipple stimulation, which can help a woman’s body release its own natural oxytocin.
“What was nice,” Rose says of her son’s birth two years ago, was having “all the advantages of a midwife, yet if something went wrong, there was a doctor on call and a neonatal intensive care unit 30 seconds away.”
So nice, in fact, that Rose and her husband asked Ludka to deliver their second child, who arrived last month — with the help of another midwife at the Brigham. Ludka was fast asleep — she’d been delivering a baby the whole night before.
SIDEBAR 1:
Some nations cite lower death rates
Long a staple of medical care in other countries, midwifery is growing steadily in the United States.
In 1975, only 1 percent of American babies were delivered by midwives, according to government statistics. By 1991, it was up to 4.4 percent; by 1996, 6.5 percent.
Worldwide, the use of midwives is often associated with lower infant mortality, says Lisa Paine, head of maternal and child health at the Boston University School of Public Health.
In most countries that are “ahead of us in infant mortality rates, there is greater reliance on care provided by midwives,” she says.
But interpreting such data can be tricky, warns Dr. Fredric Frigoletto, chief of obstetrics at Massachusetts General Hospital. Neonatal mortality (deaths in the first month of life) are a big contributor toward infant mortality (deaths in the first year). The United States counts deaths of premature and low birthweight infants as neonatal deaths, but some countries might not count them at all, which skews the statistics, he says.
Still, the apparent link between reliance on midwives and low infant mortality is intriguing. In Britain, about 70 percent of births are attended by midwives and the infant mortality rate is 6.1 per 1,000 — versus 7.8 per 1,000 in the United States, says Paine. In the Netherlands, where nearly half of all births are attended by midwives, the rate is 5.2.
In Canada, midwifery is less common than in the United States, but the infant mortality rate is lower (6.0), for unclear reasons.
Japan, whose infant mortality rate is the world’s lowest (3.8 per 1,000), is facing a potential midwife shortage. Many of Japan’s midwives are over 65, and it’s not clear there will be enough younger midwives to take their place.
In the United States, there are now an estimated 5,500 certified nurse-midwives, according to the American College of Nurse-Midwives, an advocacy and lobbying group in Washington, D.C.
Certified nurse-midwives — nurses who have taken accredited midwifery training and have passed a national certification exam — are licensed in all 50 states. In addition, there are several thousand lay midwives. They are not licensed in Massachusetts and many other states. But in some cases, they have passed a different exam and may be certified by the National Association for the Registry of Midwives, in which case they’re called CPMs: certified professional midwives.
In some states, CPMs are allowed to deliver babies in hospitals, but in most states, they’re not; they deliver babies at home and in birth centers.
Despite the growth in midwifery, there are “not enough midwives to meet the demand,” says Judy Norsigian, program director of the Boston Women’s Health Book Collective, the women’s health group that wrote self-help book “Our Bodies, Ourselves.”
SIDEBAR 2:
To learn more
For more information, try:
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American College of Nurse-Midwives, 202-728-9860 or 888-643-9433 to find a midwife near you. On the web, it’s www.midwife.org
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Midwives Alliance of North America, 888-923-6262
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Massachusetts Midwives Alliance, 508-376-8201
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Massachusetts Friends of Midwives, 1 800-WITH-YOU (1 800 948 4968).
SIDEBAR 3:
A GROWING PHENOMENON
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