Obstetrics is to Hummer as Midwifery is to Toyota

by L. Janel Martin-Miranda

I've mentioned my bias about Hummers -- related to my son's deployment to Iraq. I have learned from other family members of deployed that Hummers are sort of a universal representation of and epitomize what this war is about on one level ... a society that is fearful, consumerism driven, self-centered, power hungry, and careless. And, we family members see Hummers as totally irreverant to our soldier's sacrifice, many of whom are dying in Hummers. For oil. Oil for Hummer drivers in particular. When I think of the consequence of liability avoidance, control, the cost in dollars and lives, and the harm to babies and mamas, Obstetrics is sort of right up there with Hummers, to me -- so out of proportion, gawdy, flashy, slick, irreverant, careless of others, fearful, and greedy. A sick blend of luxury and fear that leads to "too much." Meanwhile, a solid, dependable, good-lookin' Toyota -- like midwifery -- is sensible, safe, conservative, efficient, comfortable, and gets one there without all the ego, fear, and cost to the family and to society.

Last week I watched The Girl in the Cafe about four times . [About a shy civil servant (Bill Nighy, Love Actually) working for the British delegation to the 2005 Millineum Goals Summit to promote implementing plans to lower maternal and child mortality due to extreme poverty. She's an alluring young woman (Kelly McDonald, Finding Neverland) he meets at a cafe - and invites her to the Summit on a whim. Together, this unlikely couple might just change history.]And, this week I've been reading an interesting Save the Children document.
http://www.savethechildren.org/publications/mothers
/2006/SOWM_2006_final.pdf

Some alarming statistics from both have me awake wondering ..... every three seconds a child dies of extreme poverty. Every year 4 million babies die in the first month of life.

Four million babies are born in the United States every year and nearly 20,000 will die within their first month of life. Ten thousand more will die before their first birthday. BUT, did you know that four million is ALSO the very same number of babies who die within the first month of life around the world? And, ONLY 20,000 of the 4 million are in the US. Most of the four million babies are of color and born in third world countries where Tetanus, infections, diarrhea cause 36% of the deaths. Poor care during childbirth is also a factor -- most women have no access to any prenatal or medical care, but midwifery care is not given as reason for the neonatal rates. Midwives deliver babies out of hospitals because there are no doctors or hospitals, but the reasons for high death rates according to Save the Children are not because of midwives or even lack of doctors. It is generational poverty, disease, and malnourishment.

Meanwhile, ugly debating in this country about the relatively insignificant numbers of neonatal deaths in the US between home and hospital birth make me feel as ashamed this week -- as if I were to stuff myself at a huge smorgasbord while listening to my friend's slide show of her trip to Africa, and God-forbid, drive home in a Hummer.

According to Save the Children, three of the 4 million babies will die within the first week and 1/2 of those are within the first 24 hours. Prematurity complications account for 27% and asphyxia accounts for only 23%. Prenatal nutrition and lifestyle that is attributed to fewer problems in US births is a major problem around the world in third world countries. Sixty to 80% of babies weigh less than 5#. In India the death rate of poor babies is fifty-six percent higher than the rich. In Bolivia, Niger, Peru and Viet Nam the death rate of babies born in rural areas is fifty percent higher than those born in urban areas.

According to the document, 3 million of the four million neonatal deaths could be stopped by simply addressing the disease and health conditions - as have the industrialized nations. Makes me think of recent claims I have read about how obstetric medicine is responsible for the decreased neonatal mortality rates in the US, when we all know that it is antibiotics, good nutrition, clean water, and health care that addresses tetanus, infections, and diarrhea -- the real reasons for the difference in mortality rates from 100 years ago. It is not induction, narcotics, interventions, high tech gadgets (monitoring), and cesarean surgery that is saving lives. These are "bells and whistles" on the monster of a machine used unnecessarily on the majority of birthing women in the US. The Hummer of birth -- when truly, like in Europe and Japan, a Toyota does the job wihout so much consequence. Industrialized countries in Europe with low maternal and neonatal mortality rates (and small economical vehicles) have a woman-centered midwifery model of care and midwives function in partnership with physicians.

And, the disparity between rich and poor and white and non-white, and rural versus urban exist in every state in the US. What is all of this arrogance and disregard about (safety of birth in the US) when non-white women and babies are four times more likely to die than white women -- in the US in the twenty-first century? The claim about obstetrics as the savior of the women (world) doesn't hold up. Proportionately, the number of neonatal and maternal rates of women of color in the US are as alarming as in third world countries. Where is the compassion and alarm of the greatest country on the planet -- for their own babies and those of the world?? Last week I featured a story by a second year resident -- he worked in a city hospital where 95% of the women and babies were non-white and on medicaid. Yeah, a teaching hospital where doctors learn on women and babies. Who in obstetrics has the balls to gather data on the disparity between white and non-white, rich and poor, and rural and urban in the US and to look at the lack of a standard of care in obstetrics that includes midwifery? And, who will develop and implement an action plan? - - rather than focus on the 1% of women who want to birth at home and ensuring the increasing surgical rates?

Midwives and homebirth are not the problem in these third world countries, as the Save the Children project points out. The report also shows that midwives (not medwives) are the predominant caregivers in countries with low neonatal and maternal death rates. Addressing disease, health, and sanitation would cut the death rate from four million to one million -- very similar to the decline here in the US. The US lags behind European and other industrialized nations in making birth safe for women and babies.

In the US in the state of Missouri a midwife practicing as CNM, DEM, or CPM can find herself with a felony charge of practicing medicine without a license. As is the case in most rural areas, quality care -- neither obstetric or midwifery is available. Missouri women from rural areas often must travel hours to birth in the larger towns and cities -- this means higher inductions and planned csections, AND, there is an increasing prematurity rate, mortality rate, AND an ever increasing meth-amphetamine problem as the rates of children being born "under the influence" of narcotics also increases ... hmm, at the same rate as epidural's lifecycle to becoming "natural" and "normal". A reasonable, simple, doable solution exists for Missouri and every other US state and third world countries --- implement what has worked in the UK, Sweden, Denmark, and Netherlands since the thirties. And, that is, midwifery care for low risk women, decrease the environmental health concerns, and develop professional partnerships between midwives and doctors -- AND, develop a national standard of care with overseeing and accountibility from outside the medical, obstetric community. Stop letting the fox guard the chickens (and stop the drug dealers from feeding the foxes).

It's pretty clear what can be done in third world countries to save millions of lives every year -- and thousands of lives of non-white women and babies in the US. What if we were able to provide the necessary tools and supplies to support third world countries to overcome the disease and poor water and nutrition conditions and lower the neonatal death from to one million babies world wide (from 4 million) and support midwifery care, like is being done successfully in Afghanistan to lower it even more?

That leads me to another question -- What would happen to all of these babies who survived birth? Is there a natural process (of the fittest) going on or is there a racist process going on? Around the world, and in the US?

to be continued ...