Paper2MidwifePracticesAtUSHospitalsWinckelmann

RunningHead:THE INTEGRATION OFMIDWIFERY PRACTICESIN CLINICALSETTINGSIN THE UNITED
STATES
The integration of
midwifery practices in
clinical settings in the
United States
Kadie Winckelmann
GCHB 6410
3/19/2013

1
THE INTEGRATION OFMIDWIFERY PRACTICESIN CLINICALSETTINGSIN THE UNITED STATES
Abstract
The United States and the Netherlands are similar in several ways, but differ greatly in
cultural approach to pregnancy and birth. The Netherlands has historically viewed pregnancy and
natural and usually without the need of much medical intervention. The United States largely
views the medical model as the best way to approach pregnancy and childbirth. The Netherlands
has a much higher rate of home births and much greater reliance on midwives, while the United
States has much higher rates of deliveries in hospitals and surgical interventions. However, the
Netherlands has better health outcomes in terms of maternal and infant mortality than the United
States. This paper examines how traditional midwife and home birth practices could be
integrated into clinical care in the United States. Particularly of interest are decreasing surgical
intervention, natural techniques to reduce pain during labor, increased encouragement of
breastfeeding in hospitals, collaboration between midwives and physicians, and how these relate
to the goals of Healthy People 2020. There is some history of distrust and antagonism between
midwives and physicians, but with a collaborative partnership and the introduction of midwifery
practices in clinical settings, the United States could see better health outcomes for women and
infants.

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Introduction
In a previous review of literature, a comparison was performed to examine the relationship
between cultural attitudes about pregnancy and childbirth and birthing practices of the
Netherlands and the United States of America. Also examined, were birth outcomes and
maternal and infant mortality between the two countries. The Netherlands and the United States
are similar in terms of ethnic makeup, male to female ratio, and age, with a large percentage of
the population in each country of childbearing age. However, the United States is much larger
than the Netherlands; as of 2012, their populations were 313,847,465 and 16,730,632,
respectively (CIA, 2013). Despite the similarities between the two countries in population
composition, the two countries differ substantially regarding cultural views of childbirth.
The Dutch overwhelmingly view pregnancy as a natural and instinctive bodily process,
which the body is normally well prepared to handle, so that medical intervention is not necessary
except in high risk or emergency cases (Hingstman, 1994). Midwives are well respected and
sometimes work in collaboration with obstetricians. Home births for low risk pregnant women
are encouraged by the Dutch government. Because of these cultural attitudes, the practice of
delivering a baby at home remains a popular choice for Dutch women, with approximately one
third of women electing to deliver their babies at home or outside of a medical setting, giving the
Netherlands the highest home birth rate in Europe (Christiaens, Nieuwenhuijze & de Vries,
2013). The midwives emphasize the intrinsically beautiful aspects of pregnancy and childbirth,
while facilitating greater autonomy and comfort for the mothers in their care. This allows the
pregnant women greater control over the delivery, such as control over location, body position,

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those present for the birth, and after care, without over reliance on medical interventions, which
have historically been viewed by the Dutch as unnecessary for most deliveries
In contrast, only 1% of childbirths in the United States occur at home (Boucher, Bennett,
McFarlin & Freeze, 2009). This is largely due to the fact the American people have been
conditioned to view hospitalization and the medical community at large with the utmost respect
and reverence. Medical technology and interventions are often accepted as the safe outcome of
scientific progress, this includes intrapartum interventions such as epidurals, inductions,
episiotomies, and caesarian sections. Pregnancy is viewed as a medical condition that requires a
doctor’s supervision from beginning to end and the overwhelming majority of pregnant
American women are overseen by an obstetrician and give birth in a hospital. The United States
has a slightly higher birth rate than the Netherlands, 13.7 births per 1,000 population to 10.89
births per 1,000 population, and also higher maternal mortality and infant mortality than the
Netherlands (CIA, 2013). For the Netherlands, the maternal mortality rate per 100, 000 live
births is 6 deaths, while the infant mortality rate per 1,000 live births is 3.73 deaths . For the
U.S., the maternal mortality rate per 100, 000 live births is 21 deaths, while the infant mortality
rate per 1,000 live births is 6 deaths. Roughly one third of American women deliver by caesarian
section (Hamilton, Martin & Ventura, 2011), with elective caesarian sections and inductions
emerging as a growing trend, although studies have shown that these increase the risk of
delivering preterm and low birth weight babies, increasing the risk for infant mortality and
morbidity (Chang et al., 2013). Clearly, the use of medical interventions and the high rate of
hospital deliveries in the United States do not produce better health outcomes than the
Netherlands and its large, well-organized midwife network. This paper seeks to examine whether

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the United States could improve birth outcomes by adopting a more holistic, less medicalized
approach to child delivery. It will examine the influence of the adoption of home birth and
common midwife practices, such as water deliveries, exclusive breastfeeding encouragement,
and non-drug pain relief methods in hospitals, as well as the partnership between midwives and
obstetricians can have on birth outcomes in the United States.
Findings
The influence of midwives and doulas has influenced American hospitals to slowly, but
increasingly change how deliveries occur. Related to this is the need to meet the ever expanding
desires of an educated population with access to unlimited information at their fingertips through
the use of the internet. Women can research the practices and techniques of other cultures and
use this knowledge when approaching pregnancy and delivery. Of major importance to the need
for changes in American hospitals are the goals of Healthy People 2020, which include the need
to reduce caesarian birth for low risk women in both women who have experienced previous
caesarian delivery and in those who have not (HealthyPeople .gov, 2012). Education can be used
to disseminate information about the increased risks for preterm babies and poor health outcomes
related to elective, and possibly unnecessary surgical intervention, but it is also important to
address anxiety surrounding pain during labor, which American women have been taught to fear.
There are many other non-drug related or surgical related techniques which can be used to
reduce pain.

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Many midwives utilize and encourage non-narcotic forms of relaxation and pain relief
during labor and delivery. These techniques, used to sooth the mother and relieve pain include:
delivery during water immersion; birth balls, exercise balls which help provide support in early
stages of labor; showers; breathing exercises, most notably Lamaze breathing; freedom for the
mother to move, walk, and massage with massage oils (Vargens, Silva & Progianti, 2013). The
authors of this study note that these methods have been used successfully by nurse-midwives in
Brazil to create a more humane experience of child delivery, where the pregnant women feel
more in control and can be encouraged to appreciate their strength and power of their bodies and
find the satisfying aspect of child delivery. Instead of the fear and pain often associated with the
birth process and surgical delivery in this country, the women were shown that child delivery
does not have to be an anxiety ridden event, but a time to truly experience and connect with
one’s body . Pregnant women demonstrated greater understanding of the process and cooperated
more when they were allowed to move around and change positions. Massage oils were shown to
lessen pain during labor, as were spoken encouragement, and water tubs. The use of water tubs
during delivery is a procedure sometimes utilized during home births and at birth centers to
deliver the infant while immersed in warm water, and slowly, but increasingly being used in
hospitals that have birthing centers. This technique serves as a comfortable and relaxing location
for the mother to experience labor and delivery, while also providing pain relief without relying
on drugs. The use of drugs during delivery can affect the mother and newborn, making them
drowsy and possibly unable to breastfeed immediately. Water immersion has been shown to be
associated with spontaneous birth, lessening the need to rely on medical or surgical delivery
techniques, particularly induction, augmentation or episiotomies, and is related to lower risk of
trauma to the perineum (Cluett & Burns, 2009). In a comparison study of women who utilized

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water tubs and women who delivered without water immersion, Cluett and Burns found that the
women who utilized the tubs reported greater satisfaction with the birth process. All of these
techniques can be used to create a more relaxing and life affirming environment for childbirth,
while helping to meet the Healthy People 2020 goals of reducing surgical intervention during
low risk delivery.
Recent years have seen a growing movement to change American cultural views toward
breastfeeding and hospital practices as related to infant feeding. For many decades, breastfeeding
rates steeply declined in the U.S., particularly exclusive breastfeeding rates. Women, nurses, and
doctors were sold on the idea that formula was better because it was scientific progress and it
was more socially acceptable because women would not have to involve their breasts, which are
very sexualized in America. Babies were routinely given formula in hospitals and removed from
their mothers to sleep in the hospital nurseries. However, Healthy People 2020 has stated various
goals to increase breastfeeding, for example: to increase the percentage of babies ever breastfed
by 7.9 percentage points, to increase the percentage of babies breastfed at six months by 17.7
percentage points, to increase the percentage of babies breastfed at one year by 11.4 percentage
points, to increase the percentage of babies exclusively breastfed at three months by 12.6
percentage points, and to increase the percentage of babies exclusively breastfed at six months
by 11.4 percentage points (Healthy People.gov, 2012). Related to this hospitals across the
country have been taking steps to become Baby Friendly, which means they follow ten steps to
help promote a healthy environment for breastfeeding according to an initiative founded by
WHO and UNICEF. Included in these steps is the implementation of policy to encourage

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breastfeeding, the avoidance of pacifiers, instruction on maintaining lactation, initiating
breastfeeding within one hour of birth, giving infants nothing to eat or drink besides breast milk
unless medically necessary, and allowing the infant to room with its mother, among others
(Baby-Friendly USA, 2012). Also, encouraged is the banning of formula samples often given at
discharge to new mothers. Breastfeeding is associated with better health outcomes for women
and infants, such as better immunity and neurodevelopment for the infants and lower risk of
cancer and diabetes in mothers (Eidelman & Schanler, 2012).
The practices discussed this far can be integrated into clinical care with greater reliance on
and collaboration with midwives in clinical settings. When maternity care is structured as a
partnership between nurse-midwives and obstetricians, better birth outcomes have been
witnessed (Shaw-Battista, Fineberg, Boehler, Skubic, Woolley & Tilton, 2011). This type of
maternity care encompasses less emphasis on medical intervention and greater emphasis on the
comforting potential of touch. Decision making is shared between the nurse-midwives and the
obstetricians and use of medical interventions is limited and follows evidence-based plans. This
study found that women who were supervised by nurse-midwives in this type of practice relied
less on pain relief or operative delivery, with only 21.2% given narcotics during delivery, 23.7%
given epidural analgesia, 12.5 % delivering via caesarian section, and only 4.1% vacuum-
assisted. Stevens, Witmer, Grant & Cammarano, (2012) assert that partnership between
obstetricians and midwives, where midwives can operate independently, but have a lot of support
from clinicians if an emergency arises, can enhance birth outcomes and increase safety and
efficiency. This model allows the midwives and obstetricians to utilize their specific skills and
specialties; the obstetricians provide knowledge and skills about medical and surgical procedures

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if necessary, while the midwives can teach the pregnant women about the natural, normal, and
beautiful aspects of pregnancy, childbirth, and motherhood, with potential emphasis on practices
not always seen in standard hospital deliveries, such as exclusive breastfeeding; movement and
different birthing positions; immersion in water; bringing the newborn to the breast immediately;
and waiting to clamp the umbilical cord. The pregnant women themselves are also a vital part of
the collaboration because they bring knowledge of their bodies, their desires, their fears, and
their needs. The authors also found that this structure provided the support, guidance, and care
for women to deliver vaginally after previous caesarian delivery at a success rate of 73%.
Through collaboration, midwife practices can be used by women who choose to deliver in
hospitals, decreasing the reliance on surgical intervention.
Conclusion
Many procedures traditionally associated with midwives and home births are being
introduced to clinical settings with successful results in the United States. More and more
American women are being exposed to these practices. Traditional pain relief techniques
utilizing touch, movement, conscious breathing, and bathing in warm water can be helpful in
soothing and relaxing women during pregnancy without the use of drugs. These techniques can
also lessen the chance that the women will require surgical intervention. The integration of these
practices in hospital settings can help American hospitals reach the goals set out by Healthy
People 2020 to reduce caesarian delivery and also goals to increase breastfeeding, as
breastfeeding ability can be severely limited by drugged delivery and surgical intervention.
Breastfeeding encouragement in hospitals is important to normalize breastfeeding in this country
and to improve health outcomes for mothers and infants. Organized and formal collaboration

9
between midwives and obstetricians can facilitate this integration and improve health outcomes
for infants in the United States. With greater use of these techniques and an expanded midwife
network working independently, but with the supports of clinicians might allow the U.S. to reach
infant morbidity and mortality rates closer to those seen in the Netherlands.
Transition to a model closer to that of the Netherlands, where midwives considered the
norm, and are well respected and supported by the government and clinicians, would not be easy
in the United States. Distrust, antagonism, and opposition towards each other’s methods flourish
in the U.S. between midwives and physicians. Many doctors advocate hospital birth and
medicalization as the safest option, even when evidence points otherwise, and believe that home
births are dangerous and to be avoided and discouraged (Chervenak, McCullough, Brent, Levene
& Arabin, 2013). Doctors often instinctively turn toward surgical intervention out of concern
over malpractice suits. Doctors also worry about receiving an emergency patient, from a
midwife’s care or botched home birth, who is experiencing tremendous complications (Cheyney
& Everson, 2009). While many midwives oppose the medical interventions routinely used in
hospitals for low risk women. They view these practices as too dangerous and related to poor
outcomes, while also treating the pregnant woman as a condition that needs fixing, rather than as
a whole woman, with emotional and psychological needs, who is undergoing one of the most
natural and beautiful bodily functions the human body is capable of performing. However,
unification and collaboration between these two camps is possible as evidenced from structures
in other countries, such as the Netherlands and in recent collaborative practices in the United
States.

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References
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Boucher, D., Bennett, C., McFarlin, B. & Freeze, R. (2009). Staying home to give birth: Why
women in the United States choose home birth. Journal of Midwifery & Women’s
Health,
54(2), 119-126.
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https://www.cia.gov/library/publications/the-world-factbook/geos/nl.html#top
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https://www.cia.gov/library/publications/the-world-factbook/geos/us.html
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