Childbearing women, models of care, and ponderings.

 Approximately 99% of the entire population of childbearing women in the USA birth in the hospital.  The other 1 % deliver at home or at a birth center generally with a midwife present.  Also included in this 1% is a small, but growing population of freebirthers, and of course, the accidental unattended births as well.  Statistically we are the polar opposite of how women birthed a little over 100 years ago when most births were in the home. 

In this time, we have seen two different models of care for women develop:  the midwifery model of care and the medical model of care.  There is often a stark contrast between the midwifery model of care versus the medical model of care.  Even though there are important differences between those two modes of care, most women do not know enough about pregnancy, labour, birth, care provider options, and real medical risks as opposed to sensationalized risks to make an informed choice.

For the sake of understanding, below is a basic definition of both models of care:

Midwifery Model of Care

Focus on health, wellness,
Labor/birth as normal
   physiological processes
Lower rates of using
Mother gives birth
Care is individualized

Medical Model of Care

Focus on managing problems
   and complications
Labor/birth as dependent on
Higher rates of using
Doctor delivers baby
Care is routinized

According to the Cochrane Library in a review of 11 trials with over 12,000 women involved, the main benefits of midwifery care were a reduction in the use of regional analgesia and fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had gotten to know, feeling in control during labour, having a spontaneous vaginal birth, and initiating breastfeeding.  The caesarean rates were the same as under an OBGYN’s care.  This study’s conclusion stated that most women should be under the midwifery model of care.  

A key difference in the care a woman receives by a midwife is that of time and relationship building.  Appointments are often 30 minutes to an hour each.  This amount in time gives a midwife and family time to get to know each other and build a trusting relationship.  By the time the mother births, the midwife generally will know the family dynamic, detailed history, details of daily life including stresses, dietary health, the root of needs and desires.  All of this helps the midwife to partner with the expecting mother in her care.  This partnering allows for the space and growth of the woman and her family to be responsible for the care, needs, and outcomes of the pregnancy and birth.  Ultimately this results in giving a help up into the changing family dynamic and parenting confidence once baby comes.  Interestingly enough, even with all of this personalized attention, a women typically finds that being under a CNM or homebirth midwife’s care is less expensive than when being under an OB/GYN’s care.  

Of course, there are fantastic OB/GYN’s who give incredible, personalized care.  These OB/GYN’s face a great challenge in trying to offer a similar patient based care. Since they take almost 90% of the 4.3 million births each year, they have very busy practices.  Appointments throughout a pregnancy are generally only a few minutes in length and are usually split between partners. This raises an important question.  If an OB is only seeing their patient a few times throughout an entire pregnancy for perhaps for less than an hour total, how is an OB/GYN able to relationship build and get the personal details down in order to offer non-cookie cutter care?  For the most part, they literally do not have time to do so.  This situation which affects the majority of child-bearing women has been created due to the fact that medicine is a competitive business in which not only are the OB/GYN’s competing amongst themselves but they also dealing with insurance companies.  OB/GYN’s have seen malpractice insurance premiums steadily increase all the while patients’ insurance benefits are paying a fixed amount per visit.  The means needing to have a higher patient load.  It also needs to be stated that though OB/GYN’s care for most women in the US, not all or many are higher or high-risk, their training is as a surgical specialist and to handle a birth that has become a medical event.  

ACOG at last count has over 52, 000 members and the AMA states that 42,333 are OB/GYN’s.  By sharp contrast ACNM had 6519 members as of December 2008 and  NACPM states there were more than 1400 certified professional midwives as of 2008.  There are no accurate records available to indicate the amount of working direct-entry or trained and not certified midwives.  Using the available numbers, OB/GYN’s to midwives, the OB/GYN’s have a definite advantage and preponderance of approximately 5.25 OB/GYN’s to 1 midwife.  This is an interesting statistic considering  85-95% of the childbearing population falls into the normal, healthy low-risk category that midwives in the United States specialize in serving but instead serve 10% or less.   Once we look at these numbers, one can wonder: Shouldn’t the 85-95% of all childbearing women be seen by midwives? Why don’t we have more CNMs in the hospitals?  Why don’t we have a better record of direct-entry and non-certified midwives?  Why is there such a low rise in midwifery based care?  Who and what are being served by virtually all women being treated under the medical model?

How do we change this attitude? Share and speak of our own birth experiences – the good ones and the bad ones.  Women need to seek out and hire more midwives.  Women need to interview their care-providers better and demand the care that will give them the healthiest and safest outcomes.  Women need to do more research regarding pregnancy, birth, and labor so that they can make informed choices.  Women need to realize insurance is not the only way.  Women need to be the revolution of taking back their bodies and birth.  Women need to trust in their designs and the design of their babies.  Women CAN be the difference.

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