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?
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.
To be brutally honest, I'm worried that you can become a midwife within a year in some states in America. I can't see how you'd get enough experience or understanding to be safe.
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,