Last week in Part I, I reviewed the history of birth practices in the United State from 1940 to 2016. This week, let’s project forward to 2040. Currently 99% of all births in the U.S. occur in hospitals, one third of them by Caesarian section. Utilization of the expensive space, equipment, supplies, and personnel from the hospital setting makes birth a very expensive event in the U.S. Despite the significant expenditures and the use of advanced medical technologies, the United States is one of only a handful of countries across the globe with an increasing rate of maternal mortality. Currently 17.8 of every 100,000 mothers die in childbirth or in its aftermath, putting the U.S. in 33rd place worldwide. Key factors driving this increase include poor pre-natal care, complications from C-sections, and an increasing number of hospital-acquired infections. Surely we can do better than this.
My inspiration to investigate how we might improve these disappointing results came from reading an announcement from Britain late last year. After conducting a careful study, the British National Health Service published new guidelines that suggested that women with straightforward pregnancies consider giving birth at home. This suggestion might seem a bit outlandish at first, until you learn a bit more about how healthcare works in Britain. As soon as a woman becomes pregnant, she is matched up with a nurse midwife who will work with her all the way through pregnancy, delivery, and getting established at home. While the occupation of midwife might sound unfamiliar and perhaps dated to you, is it important to understand that certified nurse midwifes, both in Britain and the U.S., are highly educated medical professionals with full university degrees.
In order to develop a better understanding of what motivated the British National Health System to embark on this initiative and whether we could consider similar changes here, I arranged to meet with Jane Gledhill. Jane is a Certified Nurse Midwife, the Nurse Manager at the Women’s Birth and Wellness Center in Chapel Hill, NC and, as I will discuss later, Secretary of the Legislative Committee for the North Carolina Chapter of the American College of Nurse Midwives. Jane’s interest in midwifery began in the early 1980s during her first pregnancy. Her research on birth settings – hospital, birth center, or home – and their various risks and benefits convinced her to have her own children at home and, some years hence, enter nursing school in 2003. From 2009 to 2012, Jane worked with a home-birth, midwife practice and since then at the Birth and Wellness Center. Birth centers provide a sort of middle-ground hybrid between home and the hospital.
There were several factors that helped to drive the transition from home to hospital births in the U.S. in the decades following World War II. These included:
- a cultural trend towards using modern science and technology whenever possible;
- maternal deaths during home birth from excessive bleeding;
- a reduction in infections for both mother and child due to improved sanitization; and
- infant deaths from complications arising during home birth deliveries.
I had a long conversation with Jane regarding how changes in scientific knowledge and the field of medicine that had occurred since the 1940s and how these changes could impact the way we manage birth and delivery today.
I think it is safe to assume that our primary collective concern about home birth is the possibility of the mother bleeding to death at some location remote from the hospital. Prior to the 1940s, this was the leading cause of maternal mortality. So this is a certainly a legitimate concern. However, in 2016 we have a far better understanding of the causes of bleeding during birth than we did during the Great Depression and we have the tools and knowledge to deal with these problems. As a result maternal deaths from excessive bleeding in the U.S. are very rare in any location and, if issues arise, a hospital setting is not usually required for nurse midwives to address them.
Jane and I discussed the issue of infections at some length. During most of human history, maternal infections during home births were a common occurrence. This is not the case in 2016 when trained midwives are present. Today, giving birth at home or birth center with a midwife, an environment far removed from pathogenic bacteria often encountered in hospitals, has a lower rate of infection than hospital births. This dynamic is also supported by the approach taken by midwifes who perform fewer manual, pre-birth inspections of the mother’s cervix compared to obstetricians; thereby reducing the number of opportunities for an infection to take hold. A home birth does offer one scientifically interesting advantage with regard to infection. The people and bacteria living in a house exist in equilibrium such that all people living in the house will develop similar population distributions of resident bacteria, their microbiome. As a result, a woman giving birth at home, within her familiar equilibrium, enjoys and additional layer of protection from infection since the bacteria living both within her and within the home will attempt to crowd out any unfamiliar and possibly pathogenic species. (Please read the endnote on this topic for some further musing on this subject.)
That leaves us with the issue of unexpected complications for the either the mother or infant during delivery that could require emergency care. These situations can and do occur. However, they are not common in uncomplicated pregnancies, especially if the mother has given birth before. When they do occur, nurse midwives are trained to recognize, react, treat or transfer to the hospital as necessary.
As Jane and I discussed the various options for birth settings and approaches, it became increasingly clear to me how important, logical, and efficient it would be to make all birth options, hospital, birth center, or home, available to all women. However, there are a variety of administrative and regulatory barriers here in the U.S. that limit the availability of the out-of-hospital options. One of these barriers stands above the rest. Nurse midwifes in North Carolina are not allowed to practice without the signature of a supervising physician. Given the dynamics of liability law in the U.S., a relatively small number of North Carolina doctors are providing signatures. Jane and all certified nurse midwives greatly value strong relationships with doctors and rely on them when their expertise is needed. However, the practice of utilizing providers who are trained to care for complicated pregnancies and deliveries on in all circumstances is not an economically optimal approach.
North Carolina is only one of six states that still require a supervising physician for nurse midwives. In the other 44, nurse midwives regulate themselves like other professions do. You don’t have to listen to hard to hear the echoes of patriarchy here, with the male-dominated doctors’ associations exerting control over the female-dominated practice of midwifery. In her role as Secretary of the Legislative Committee for the North Carolina Chapter of the American College of Nurse Midwives, Jane is lobbying the General Assembly to try to change this and have us catch up with the rest of the nation. Legislation which would remove the requirement of a physician’s signature and generally modernize the practice of nursing, midwifery and otherwise, will be considered during the next legislative session in Raleigh.
As we look forward to 2040, one hundred years after my mother was born at home, I am convinced that home birth, albeit with midwives, and will be common again and the number of deliveries in birth centers will have grown dramatically. Our current hospital-only model is neither economically efficient nor is it providing optimum outcomes for either mothers or babies. As I view the long-term trends through the lens of my engineering eyes, what I see is an overcorrection in Post-War America in which we decided to use our new hospital facilities and medical knowledge in all possible situations. Like all overcorrections, this one should, and I believe already is beginning to, shift back toward a more rational equilibrium with some births at home, some in birth centers, and some in the hospital. If we want to catch a glimpse of what that equilibrium might look like, a quick flight to the Netherlands where 30% of children are born at home, might do the trick. The Dutch are always ahead of us.
Jeff Danner and Jane Gledhill discussed this week’s column with Aaron Keck on WCHL.
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Long-time readers will have certainly noted my particular fascination with the microbiome. Much of the current discussion of the microbiome, my columns included, describes a fascinating journey of co-evolution between humans and bacteria. As I keep delving into the human-bacteria interrelationship, it seems increasingly clear to me that this relationship is not one of co-equals but one directed primarily by the bacteria. It will take me more time and research to refine my thoughts on this, but I look forward to writing about it in Common Science ® in the future.
As bit of foreshadowing, consider the following. Our resident bacteria need humans to interact with one another, so that we swap bacteria back and forth and the microbiome with a constant flow of bacteria genes. The reason why our microbiome needs a steady supply of these genes is too complex to describe in an endnote. So please just accept it for the moment. Bacteria are intimately involved in many functions that promote human interaction. They produce odors that make us attractive to one another. They release chemicals to the brain that make us feel happy when we have skin-to-skin contact with another human. As a result of these and other actions, bacteria help to make sure that humans continue to make more humans and generate more and more of the bacterial nirvanas known as the human large intestine. More on this topic at a later date.