After the birth of our second child and her second unnecessary Caesarian birth, my wife was semi-outraged about the way the American system of childbirth treated women. She taught herself everything she could about childbirth and completed a training program to work as a childbirth instructor. Eventually she became a doula, a professional who provides physical, emotional and informational support to the mother before, during and just after birth.
During the next 18 years she assisted more than 500 birthing couples. Those couples seemed a little better educated and a little better off than average folks and included a fair number of medical doctors and nurses as well as a smattering of generals and other high-ranking military officers from nearby Fort Leavenworth, Kan. Only one of her mothers had a stillbirth, a rate less than a fourth of the mean national rate. Eight percent wound up having a Caesarian section, also less than a fourth of the rate for the nation.
One of my wife's heroes is Ina May Gaskin. Gaskin, the author of the influential 1976 book "Spiritual Midwifery," is a licensed midwife who practices at a community called the Farm in rural Tennessee. Of the estimated 3,000 births that Gaskin and the other midwives at the Farm have attended, only 2 percent have resulted in Caesarian sections. While neither group--the women whose births were attended by my wife or by Gaskin--can be considered representative of all birthing women in the U.S., the orders of magnitude of the differences in outcomes are worth thinking about.
And we do need to think differently about childbirth in the United States. Despite spending more than any other nation on childbirth, the outcomes we get are awful relative to other countries, and they are getting worse. The United States ranks 41st in neonatal mortality and 50th in maternal mortality, and the maternal mortality rate in our country has doubled since 1987 from 7.2 per 100,000 live births to 15. So far the dominant policy response to these outcomes seems to be more medical intervention, more technology and fancier neonatal intensive-care units. That's probably precisely the wrong prescription. All those fancy tools and facilities have to be paid for, and so the pressure to use them is strong. And it's hard to turn your back on the profit motive. One of the more prominent ob-gyns in Kansas City is said to have a nice boat on the Lake of the Ozarks named Sea-Section.
It's certainly a lot more expensive to have a baby in a hospital. The average cost for a vaginal birth at a birthing center is $2,277. The cost at a hospital is $10,166, and the cost of a Caesarian delivery is $17,056, according to the Transforming Maternity Care Partnership. Not only are hospitals expensive, but they also can be dangerous places, and one reason for the better outcomes for my wife and for Gaskin is probably related to that fact. In hospital births, a doula advocates for the mother and supports the couple as they deal with the seemingly inexorable pressure for medical interventions. In Gaskin's case, the explanation is simpler: She does home births. In the Netherlands, 30 percent of all births take place in the home, and that country's rate of maternal mortality is 6 per 100,000 live births, a lower rate than has ever been achieved in the United States. Holland's neonatal mortality rate is 3.73 per 1,000 live births, compared to a U.S. rate of 6.
Things may be changing here. While home births account for less than 1 percent of all births in the United States, the number has increased by 29 percent in the last five years. And while midwives attend only about 5 percent of all U.S. births (compared to nearly half of all births in the Netherlands and similar numbers in other European countries), there is pressure to allow midwives to do more. For example, in North Carolina, which ranks 44th among the states in infant mortality and 37th for maternal deaths, three bills have been introduced in the current legislative session to ease restrictions on the practice of midwifery.
In a recent article about her in the New York Times Magazine, Gaskin says that because midwife-assisted home birth is illegal in many states and hospital birth comes with restrictions--many hospitals, for example, don't allow the woman to eat during labor in the rare event that she may need general anesthesia, and hospital protocols often include a rigid schedule for the progression of labor--many women are coerced into surgery or other interventions they don't need. With our health-care costs going through the roof and our outcomes poor and getting worse, maybe it's time for policy makers to take note of what this wise woman in Tennessee is saying and doing.
This column has been updated to correct a reference to Ina May Gaskin being an unlicensed midwife. Gaskin and the other midwives at the Farm now are certified professional midwives, licensed to practice in Tennessee.