Contexto Latino

A healthy baby, a happy mother, a natural birth

It is a crisp fall afternoon at Washington, D.C.'s Georgetown University Medical Center, one of the most technologically up-to-date hospitals in the United States. In a third-floor waiting room of the Department of Obstetrics and Gynecology, two expectant mothers have struck up a conversation about why they have both decided to have midwives, rather than physicians, deliver their new babies.

"I think technology has gone too far, unnecessarily," says the more experienced of the pair, already a mother of two. "I am healthy. I haven't had problem pregnancies. But my first delivery was very stressful, with so much equipment and so many problems." Then she smiles. "My second was with a midwife, and it was so wonderful I decided to have a third!"

In the United States, a growing number of women are discovering advantages in midwife- assisted childbirth over delivery with a physician. Midwives promise less technological intervention, lower costs, more intimate care, and, in general, an experience of pregnancy and childbirth as a normal, positive life process rather than as a medical emergency in the making.

In 1998, the most recent year for which data are available, nearly 300,000 U.S. births were attended by midwives, according to the National Center for Health Statistics. Ninety-three percent of these occurred in hospitals. Although midwife-assisted births account for only 7 percent of total U.S. births, they number almost twice as many as a decade ago. And while most of the increase is among more affluent, better-educated women, the trend is starting to take hold among lower-income mothers-to-be as well.

In Latin America, where midwifery has a longer history, the profile of both midwives and the patients who choose them is very different. For women in remote rural areas, lack of access to hospitals and physicians means midwives are often the only maternity care available. For higher-income and urban women, the delivery of choice is much more likely to be with an obstetrician. Indeed, in much of Latin America, the trend in childbirth seems to be toward more technology rather than less. For example, in nine countries of the region, the rate of caesarean section is higher than 20 percent (15 percent is considered reasonable). To the alarm of many public health officials, that rate is increasing.

Yet just as in North America, midwives in Latin America are at the forefront of efforts to reverse such trends. Dr. Marilia Largura, a Brazilian parteira (midwife) with a doctorate in nursing and 40 years of obstetrics experience, sees the problem as the overinstitutionalization of technology in childbirth.

"The true meaning of birth has been lost little by little in the morass of institutional rules and regulations," she complains. "As soon as a baby cries they measure its length, they take its weight, they take digital fingerprints, they give it a shot, they use strong electrical suction to clear the mucous-all in the name of science."

What gets lost, she says, is "the mother's first embrace of her baby, the parents' first glimpse of their new child, their getting to know each other-all that counts for nothing."

In the United States, midwives are fighting a similar battle. "We shouldn't be treating childbirth like it is a medical risk waiting to happen," says Dr. Carol Sakala, of the regional office of the Association of Maternity Centers of New England. She advocates building "a climate of confidence instead of a climate of doubt." She adds, "We have so much to learn from midwives, who haven't been strongly influenced by the medical approach."

For U.S. patients, midwives make sense for purely practical reasons as well. "One of these has to do with insurance and the costs of medical care," says Ms. Elisabeth Howard, a nurse-midwife at the Vanderbilt University Medical Center in Nashville, Tenn. "People are trying to reduce their health costs, and midwives have proven to be very cost-effective."

Research by the Public Citizen Health Research Group shows that in midwife-attended deliveries, the rate of caesarean section is about half the national rate. Other research has found that episiotomies are used only exceptionally in midwife-attended births, and technology is used at a minimum, hence the reduction in costs.

Proponents of midwifery insist, however, that lower cost does not mean compromising on quality of care. In the United States, the level of training of the vast majority of midwives is high. Certified nurse-midwives, who account for 95 percent of midwife-attended U.S. births, are educated in the twin disciplines of nursing and midwifery, must pass a national certification exam, and are licensed by states or state-appointed agencies.

Research on pregnancy outcomes for physician- versus midwife-assisted births puts the latter in a favorable light. A study by the National Center for Health Statistics found that in 1991, among all nonmultiple vaginal deliveries between 35 and 43 weeks of gestation, infant mortality was 19 percent lower in midwife-attended deliveries, neonatal mortality was 33 percent lower, and low birth weight was 31 percent less frequent than in deliveries attended by physicians.

One reason for these results may be that midwives typically stay with their patients throughout labor, whereas physicians tend to appear on the scene intermittently. Midwives also spend more time with patients during prenatal visits and put more emphasis on patient counseling and education. "We do not overload our schedule as physicians do to keep down costs," says Ms. Howard.

But what happens when problems arise? The vast majority of midwife-assisted births in the United States take place in hospitals, making emergency care readily available. Ms. Deanne Williams, executive director of the American College of Nurse Midwives (ACNM), says that midwives do not deny that problems of pregnancy and childbirth can require technological interventions. However, she says, mainstream obstetrics has taken such concerns too far: "We have been seduced into systems that provide high-tech care to all women and babies rather than to the small percentage who really need it. In the process, we have separated birthing women from their families, separated families from their newest member, created barriers to breast-feeding, and made the process of entering motherhood much more difficult. Without discounting the importance of technology and intervention when needed, we need to support women in the normal processes of labor and birth."

Professor Linda Walsh, of the University of San Francisco's School of Nursing, says that women who choose midwives tend to share that view. "If you look at women in the United States who actively seek midwifery care, they tend to be better educated and, as a result, they tend to question the interventive medical model of obstetrical care."

She adds, however, that lower-income women in the United States are also turning in increasing numbers to midwives. "Particularly poor women are introduced to nurse-midwifery care because the clinics they attend are often staffed by nurse-midwives," she notes. "For immigrant women, this is a good fit, since the use of midwives is consistent with their traditional beliefs." She cites studies showing that although midwives treat proportionately more poor women, their health results are nevertheless better than those of doctors.

In Latin America, where the vast majority of midwives are what public health experts call "traditional birth attendants," or TBAs, the situation is different. Traditional midwives often work in conditions of poverty, with poor access to support services and little formal training.

Such conditions, says Dr. Virginia Camacho of the Pan American Health Organization (PAHO), put the issue of midwives into a different perspective. The problem in many poor areas, she says, is that pregnant women lack access at the local level to essential, and particularly emergency, obstetrical care. Traditional midwives, she notes, are not competent to treat crises such as preeclamsia, infections, and hemorrhage.

Dr. Camacho heads PAHO's Regional Initiative for Reduction in Maternal Mortality, which is working to improve the profile of maternal and infant health in the region. In the late 1990s, infant mortality in Latin Amer-ica and the Caribbean as a whole stood at 35.5 per 1,000 live births, and maternal mortality at 190 per 100,000 live births. While these rates compare favorably with other developing regions, they are still far behind North America, where infant mortality is 7 per 1,000 live births and maternal mortality 11 per 100,000 births.

To improve this picture, PAHO, UNICEF, and others are supporting initiatives to increase patient choice of and access to medical facilities. Working with countries' ministries of health, these programs aim to increase the use of comprehensive, quality maternal health services. These include community birthing centers and maternity waiting homes where women can get care and deliver if they have no problems, but which can recognize warning signs and refer patients to more specialized care when necessary.

While emphasizing basic care and improved access, these programs are also attempting to incorporate many of the concerns that midwives and other proponents of "woman-centered birth" have brought to the fore. "The culture of birth is changing," acknowledges Dr. Camacho. "We are beginning to assess women's and their families' needs. We are finally listening to the community and learning to link culture to health services."

As for midwives as a "childbirth alternative," Dr. Camacho points out that only a handful of Latin American countries currently have professional programs in midwifery with training and licensing to provide services ranging from family planning to prenatal care, delivery, and postpartum follow-up. However, many countries offer training that approaches the U.S. nurse-midwife model, that is, university-educated nurses who receive supplemental training in obstetrics. Supporting this model, Dr. Camacho observes, "could be an alternative strategy for Latin America to improve competencies and skills in the kind of obstetric care that we know is effective in reducing maternal mortality, while also being cost effective and woman-centered."

Meanwhile, others are working to improve the skills and knowledge of traditional midwives, who outnumber professional midwives in the region. The Active Center for Human Integration (CAIS), established 10 years ago in Olinda, Pernambuco, Brazil, coordinates a National Network of Traditional Midwives from its offices in one of the poorest regions of the country. To date, the network has signed up nearly 7,000 midwives as members and has provided training to some 3,500.

"We work to provide training, legalization, and inclusion of midwives in the official health system," says CAIS's childbirth coordinator, Ms. Dayse Reis. "Midwives are important allies of community health programs and could be much better utilized in the traditional health system." Brazil's Ministry of Health estimates there are some 60,000 traditional midwives in that country, though Ms. Reis believes that may be an underestimate: "Many midwives work on the banks of rivers, at the foot of mountains, far from any system of accreditation or control."

Ms. Reis concedes that most traditional midwives are strictly empirical, have little notion of anatomy, and are often illiterate. Therefore, she says, training should be designed to fill in those gaps and to ensure that traditional midwives are capable of referring patients to emergency care when necessary. "An experienced midwife can tell if there are problems well before the birth," says Ms. Reis. "Part of CAIS's work is to train them in areas such as first aid."

Midwives' advocates say it is important that training programs such as these be conducted in the women's mother tongue and by other women, and that midwives be trained within the referral system rather than in isolation.

But while traditional midwives-and their patients-can without doubt benefit from outside training, Prof. Walsh and other nurse-midwives caution that transferring technology and obstetric practices from one culture to another can have unintended negative consequences. In the United States, Prof. Walsh says, "We have not done a good job of examining the appropriate use of technology, and as a result we have inappropriately exported obstetrical technol-ogy that even here has not proven to be effective."

She recalls the experience of a small clinic in San Lucas Tolimán, Guatemala, which received an electronic fetal monitor to use during patients' labor-despite the fact that the monitor's usefulness is being questioned in the United States. "We simply don't know when it makes sense," agrees another nurse-midwife, "and to send our standards to other countries is misguided."

Prof. Walsh sees a more serious problem. "Where we often run into trouble is when we assume that providing skills training will improve care provision, when in fact, it may increase problems with morbidity and mortality." As an example, she points to the promotion of cervical examination as a way of assessing the progress of labor. "Traditional midwives don't have access to sterile gloves and so may increase the incidence of infection by using this practice," she observes.

For Ms. Williams of the American College of Nurse Midwives, what should be promoted across cultures is a "model of care that seeks to empower women and results in a childbirth experience that re-inforces a woman's ability to mother and a family's identity." Dr. Kenneth Bell, of Kaiser Permanente, has called it "gentling the art of obstetrics."