In our second year of midwifery training, one of our tutors played us a video.
An American woman, running on endorphins and with a pendulous bump is pushing in a birth pool. It looks like early morning, as pale light is getting in through gaps in the curtains. It's a serene and poster perfect sight.
The baby is born and the mother catches him herself, their cord twisting back into the water.
And then she looks up, worried, as a midwife suddenly begins to suction her baby’s nose and throat with a bulb syringe. There's a collective groan in the room from my student colleagues.
Our tutor pauses the video saying:
"You’re right to groan, suctioning is not evidence based. But we should be respectful. You can get sent to prison for practising in America, and those midwives are standing up for the right to choose homebirth."
The midwives in the video had achieved highly. In a medicalised society, a mother had chosen and had a low intervention pool birth.
But there were clearly some issues with unevidence based practice.
Even if homebirth was illegal, and the midwives were aiming to avoid calling for medical intervention, routine suctioning has been shown to cause more problems, not less.
It's not something we talk about often in midwifery, but the UK has a 'special relationship' with America based on shared history and culture.
As someone who has worked alongside American midwives and obstetricians, I know we share many characteristics - passion, drive, a massive work ethic, and in every practitioner I've come across, a woman-centred attitude.
But I also wish I'd known about some of the issues around American maternity care, and some of the context of birth culture before now.
Since women having babies, and in fact midwives, learn by story telling, and America is a strong cultural influence, I think it's important all UK midwives have a clear image of what midwifery is like across the pond.
A little initial education goes a long way to giving you a framework to ask intelligent questions and take sound action to help yourself and your clients.
What’s maternity care like in the USA?
It's complex.
For starters, the caesarean rate is at roughly 1/3 of births, which is very high. The maternity mortality rate is also poor for a developed country, and is worryingly on the rise.
Obstetricians look after the majority of childbearing women, and are paid by clients directly, or by clients' insurance companies. Phrases that we'd find uncomfortable like 'patient compliance' are used, and choices are influenced by insurance premiums.
There are many different types of midwives.
It varies so much across the country - I’ll give you a few examples rather than explaining everything:
- In California, Florida and Washington, Certified Midwives do a three-year course to qualify and are state regulated
- In Texas, there are two types of midwives. Certified Nurse Midwives are trained nurses who do a conversion. Then there are Certified Practising Midwives. Their courses vary, but there is an option that is one year, start to finish
- In Alabama, only Certified Nurse-Midwives are legal. Homebirth is virtually non-existent and there have been cases of Certified Practising Midwives being sentenced for attending them
A large proportion of insurance companies will not pay for midwife-led care. So it's hard to get any kind of standard training or pay in place.
I've personally worked with and learned from some skilled and woman-centred American midwives and obstetricians. Ina May Gaskin is one of my favourite midwifery writers, I've learned so much from her, and she has had a profound and positive influence on birth.
But this doesn’t stop my belief that maternity care in America is fragmented with a worrying emphasis on medicalisation and legal proceedings.
We’re lucky in theUK that the 50 or so Universities that offer midwifery are regulated by one body only; the NMC. The way Universities and the NMC share knowledge in the UK is world class and helps to continually improve the midwifery curriculum.
I've read and heard about American midwives having blind spots in their practice. For instance one midwife reports here that she was not trained to check for the red reflex to assess babies for congenital cataracts/other issues.
I can't imagine a newborn check done with a practitioner who didn't know about the red reflex in the UK.
Please comment if you have more info, I'm stumped by that one.
There's another example of questionable American maternity practice in some official guidance about waterbirth, which you can read more about here.
I want to be very clear - this post isn’t about attacking American obstetricians or midwives, or their research. There's some wonderful things to take from American midwives, and we should respect their efforts in a difficult system.
(There's even some fascinating evidence to suggest the mortality statistics from the USA may appear worse than they actually are because of better and different reporting opposed to Europe.)
It's just I've concluded, based on the available evidence, that UK midwifery has a better record and culture of maternity care.
So if you read American research or recommendations contradicting UK ones, I suggest paying special attention to any medicalised views or blanket approaches to complex issues.
Now I'd love to hear from you.
1. What's one difference in birth culture between the US and UK that's struck you?
2. Do you think your practice has ever been influenced by US maternity care?
3. How do you think the women are impacted by USA birth culture and care here in the UK, in terms of TV, internet forums, and more general influence?
With much love and respect for midwives and obstetricians, and anyone else looking after childbearing women, in particular, those from the USA,
Ellie xxx
CPM = Certified Professional Midwife, a designation bestowed by NARM or the North American Registry of Midwives. You can see more here http://narm.org/
I am in a 1-year long didactic midwifery program, and I felt that was a good program for me because I’ve been a nurse since 2000 and a PhD scientist since 2010, so I have a considerable amount of science and medical training, and that allows me to focus intensively on the midwifery aspects of my program. There’s still no way that at the end of the 1 year program (which will most likely take me 15 months to complete not 12) that I’ll be a “midwife”. The real life birth experiences and training that is required to be a CPM will take me at least an additional year, plus testing time, if not more.
Interesting that a water birth was followed by suctioning. I live in Kansas, in the center of the USA, and I only see suctioning on either limp, unresponsive babes or EVERY single baby born in the hospital.
I’m increasingly concerned about the midwifery regulations in the USA. Outlawing homebirth after cesarean, breech births, and other choices in one state after another are increasing the number of women choosing “free” birth or unassisted birth. Which, if that’s a woman’s choice, that’s her choice, but a coerced choice isn’t really a choice. And that’s really the heart of maternity care in America. Coercion and lack of choices.
The safety of homebirth and midwifery in the UK seem to be great – and I think it’s the integration of the maternity system that allows for this quality of care. If you have a problem in your homebirth in America and need to transfer to hospital, you will most likely be separated from your midwife, you will be chastised for trying a homebirth, threatened with Child Protective Services and loss of child custody, and more! (Punitive episiotomies and cesareans are not a myth.) These abusive behaviors make women not want to seek additional care and the outcomes are tragic, and these birth experiences are what cause many of us seek maternity care in the first place.
That’s great info Melina, thanks.
Yes, that does sound like a good course for you – in the UK there are 18 months courses for people with a degree in healthcare already, or are nurses. Do you know if the year long courses are available to those without that kind of backgrounds?
The suctioning was in a video from about 7 years ago, so it may be outdated practice now. Just to get clear – does every baby at your current hospital get suctioned at birth?
Freebirth does seem to be what happens when options and support isn’t there, though some women will always choose to be alone to birth. I do believe that’s their right, though obviously there are complex ethical and support issues. It’s sad you idenity coercians and lack of choices in America, it’s not somewhere I would feel safe to have children if I’m honest, from an outsider’s perspective though I’m sure there are great options out here.
We do have an excellent homebirth attitude mostly in the UK – there have been some issues I’ve heard in terms of independent midwives being seperated from clients in theatre when a CS has been needed (unfortunate as that’s often when women most benefit from a continuous, trustworthy presence) but I think that’s improving…it’s a work in progress. Most obstetricians are very supportive of choice, even if they don’t professionally agree with homebirth, which is such a blessing and something I truly respect.
It’s interesting you say ‘these birth experiences are what cause many of us seek maternity care in the first place’ – is ‘maternity care’ synomous with ‘midwifery care’? Is obstetric care not seen as ‘maternity care’ where you are?
Thanks so much for your detailed input, fascinating and helpful x
There are three types of national certifications available in the USA: the Certified Nurse-Midwife and the Certified Midwife (both under the umbrella of the American College of Nurse-Midwives), and the Certified Professional Midwife (certified through National Association of Registered Midwives).
At the state level, CNMs are legal to practice in all states and may have hospital privileges. Depending on their regulations and collaboration agreements with physicians, they may be hospital-based, birth-center based, or (infrequently) have a home birth practice. CMs are only legally recognized in a few states. CPMs are licensed or regulated in over half the 50 states and practice only in out-of-hospital settings.
For more information please see:
http://nacpm.org/about-cpms/who-are-cpms/
http://mana.org/about-midwives/what-is-a-midwife
http://www.midwife.org/Essential-Facts-about-Midwives
http://pushformidwives.org/cpms-by-state/
Thanks so much for taking the time to write this, it’s so helpful! Very complex at least to someone so unfamiliar with US care x
North American Registry of Midwives not the National Association.
Yes every baby in the hospital is suctioned and gets a hat. Yes many transfer late because of the treatment received in hospitals for a “failed” home birth either towards the mother, midwife, or both.
Yes we live on the edge of criminal proceedings even in States that license CPM’s. Each State gives a licensed CPM different privileges. Some can suture, some can use antihemorragics, some just O2, some can use lidocaine (some are forced to suture without it, punish the women the OB’s say). I am in one of the better states, I can suture w lidocaine, use IV’s, medications, order labs, etc… However I can’t give women choices on a breech birth, or many other complications.
The 3 yr programs you mentioned are for the CPM credential through a MEAC approved school. New rules are from the first birth to the last birth must be a minimum of two years.
I have practiced in 3 different States and have never not once heard of the red eye reflex test until I read the NZ midwifery book last week. I’ll be honest, most CPM’s scare the heck out of me and even new CNM’s scare me. I have known many CNM’s who had attended 38 births total upon graduation and not one was outside the hospital.
The flaws are everywhere and vary from a State to state, from program to program, from licensing body and more. We are however fighting an uphill battle and doing our best to survive and preserve women’s rights to birth where, with whom, and how they please.
With the regulations on CMs and CPMs in the US, I have decided to go the CNM route (accelerated bachelors in nursing, then a masters in nurse-midwifery). It’s more schooling but being able to legally work in all 50 states is important to me. I don’t want to be limited to just a handful of states where I don’t have any friends or family. It’s really frustrating some of the laws I have come across. Being a very political person, once I’m an established CNM I hope to work on getting new legislation introduced.
This is exactly what I did too, Alicia. I am now about a year into practice. I graduated with a mortgage worth of college debt because I chose this path, and I don’t really make enough to cover the full payments on those loans and survive working in a small community hospital practice. I also don’t get to practice the kind of midwifery that I would like – out of hospital – because I would take a $20K per year pay cut on top of the salary that is barely enough to live on. Just some thoughts from the front lines to consider as you take your first steps. Good luck!
Ellie, I am concerned at some of your inaccurate account of midwifery here in the US. Some of the inaccuracies have been pointed out above but one thing that is important is that the one-year programs are more than full-time live in programs in a high-volume birth center where the students are eating and breathing out-of hospital midwifery. They are very rigid and thorough programs, and often much more so than traditional apprenticeships.
Most CNMs do not practice homebirth and it is often highly regulated in some states. Most of the CNM schools will not allow the students to do any sort of apprenticeships with out-of-hospital midwives, which then coming out of school if they want to practice homebirth, they don’t really have the training – only in handling things in hospital, which is a totally different situation.
In CA, the CNMs cannot legally practice at home without a supervising physician, of which there are none because they are forbidden by their own malpractice insurance. CPMs do not have to have supervision and as of 2014 we are now independent primary care providers in CA, allowing us to fully care for low-risk women.
Things are far from perfect here but MEAC and NARM are working hard to lessen the inconsistencies that vary from midwife to midwife. It is an uphill battle in many states but one that is being fought.
Thanks for your info and comment – I do want to get it right and I’m fascinated by what’s going on in the USA. Would you be interested in discussing things further via a skype chat or email? I have lots of questions, and don’t set myself up as an expert in this area.