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My Favourite Planet > Blogs > Edwin Drood's Column > October 2012
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2 October 2012
Midwife crisis at the Mysterious Edwin Drood's Column
Edwin has heard the weeping and wailing of that noble profession and wonders why
the world is running out of those very special and talented pairs of safe hands.

How did you arrive? I don’t mean by bus or train. Nor is the question about identity or your historical roots, although they may have something to do with it. No, I literally mean how. Assuming your parents didn’t choose you from a mail order catalogue – in which case you may have arrived by post – then you either got here through natural genesis and natural childbirth, some kind of medically assisted conception and possibly induced birth or either of the first two coupled with a caesarean section.

Your entry into this world may have been as easy as shelling peas, as smooth and well-scheduled as a Swiss rail service or there may have been delays, difficulties, even grave dangers to your little life before you’d had a chance to get started. Your emergence may have been an emergency. It may have required surgery, forceps, suction, drip-fed anaesthetic, incubation, intensive pre- and post-natal care, or any combination of these. But if you were born in Western Europe or Scandinavia, then one person was almost certainly involved, apart from your mum, and that was the midwife.
An essential service?
If you were born elsewhere, then your chances of having a midwife to guide you in began to decrease. This does not mean that you were delivered on the kitchen table and your big sister cut your umbilical cord with the fruit knife, it may simply mean that a district nurse, medical assistant, your family doctor or other person with legitimate birthing credentials was nearby all the time. The midwifing tradition, though more or less universal, is not given the same degree of priority everywhere. In other words, this most elementary and original (in the original sense) profession is not considered essential by a large section of the medical establishment.

For example, although 99% of births in the USA are monitored by “skilled health personnel”, only about 10% of births are attended by a trained midwife. This rate varies from state to state. In Alaska, Georgia, New Hampshire, New Mexico, Oregon, and Vermont the chances of a midwife being in attendance are more than double the national average. But even if a quarter of births are accompanied by a midwife, you are left to wonder just who is looking after the other three quarters and are they really as well-trained as they should be, not only in the medical aspects of delivery, but also the psycho-social aspects?

One thing that is generally agreed about midwives is that they have a better overview of the essentially female process of gestation and birth. They have a better connection with the expectant or delivering mother, are more skilled at reading from her body language what she might find hard to express and can more easily establish trust: something that helps a great deal when proposing non-invasive or natural birthing techniques. Being, by nature of her training and inclination, more mother-and-baby-oriented, a midwife is less likely to regard her clients as patients, giving birth as a form of therapy or pregnancy as a medical condition to be resolved.
North / South divide
In North America one need have little doubt of the care quality at the medical level. Births that are not attended by a midwife in the US or Canada are probably being monitored by an obstetric gynaecologist or perinatologist. These doctors have completed four years of medical school and an additional four-year obstetric residency. The perinatologist has added a further speciality in emergency obstetrics, and the management of high-risk pregnancies, such as mothers with medical preconditions (respiratory, heart or kidney problems, diabetes, etc). If the more “motherhood-centred” and holistic approach of midwifery, coupled with medical backup where necessary, seems ideal for most future mothers in Europe, the North American woman seems to place more trust in medicine and peripheral technology. I say “seems to” because there is very little research into what women really want if they are given free choice. It may just be that a healthcare system that relies on private insurance is more likely to inflate the cost of birth with unnecessary procedures and personnel. After all, the lack of midwives in service will automatically mean that you, as a mother-to-be are less likely to be guided by your family doctor or gynaecologist toward the more natural and probably compatible option of midwife-monitored delivery. Because you can’t tell me that more than three quarters of US births are medium-risk and therefore justify the services of an obstetric gynaecologist, even in the period leading up to conception, which is when most future mums in the west decide on their pregnancy and birth choices.

Either way, our situation in the affluent West is doubtless a comfortable one at present, even though there are more midwives needed than we are currently training up for the task. Move into the southern hemisphere, whether in America, Asia or Africa and not only does the ratio of midwives to live births begin to stretch from around 28 births per “full time equivalent” midwife in the EU to 150 per midwife in, for example, Uganda (a relatively sophisticated African nation), but there is a dire lack of any other skilled personnel. However, the United Nations Population Fund estimates that up to three and a half million delivery deaths of mother, baby, or both could be avoided in 38 out of 58 developing nations surveyed, simply by raising the ratio of potential deliveries per midwife to something better than 60:1.
Missing midwives
These countries appear to be missing more than 100,000 midwives, and these are places where midwife care is traditionally and realistically the only trained pre-natal accompaniment option available. In Mogadishu or Timbuktu you’re not going to be faced with a choice between the classic medical approach of an obstetric gynaecologist or the more pre-natal-care-oriented and natural approach of a midwife. With only half a dozen obstetric gynaecologists in the entire country, such choice is not available unless you are significantly better off than most of your fellow women.

So, while the UK health services worry that many mothers do not enjoy sufficient continuity of care, because too many of the already too few midwives are working part time, and thus the chances are high that you may never see the same one twice, other nations have to deal with unqualified quacks who provide shoddy care in insalubrious surroundings and yet still make it onto the national statistics as “skilled personnel” simply because the government is too ashamed, too out of touch or too callous to admit they have a serious problem.
Lack of valid data
Because if governments routinely lie to their own people, how much easier is it to lie to international panels and agencies? Someone please fill out the forms and maybe they’ll stop bothering us! To give a clear example of what I mean. The US claims that 99% of births are “attended by skilled personnel”, and I believe them. What I find harder to believe is when that same claim (in fact, an even better one: 100%) is made by Armenia, Uzbekistan or the Peoples Republic of North Korea! Ethiopia and Somalia show more honesty by coming in at 10% and 9% respectively ... at the head of a long queue of 60 nations whose statistics are unavailable. But since these include Sweden, the Turks and Caicos Islands and the UK – none of them exactly nations on the breadline – then it’s clear that not filling out the forms is the default position of not only banana republics and petrogas dictators, but a tactic also used by welfare states and Caribbean tax havens, whenever they feel themselves to be above scrutiny and the judgement of their peers.
Noble and rewarding
What is clear from the various incomplete international surveys available is that in western nations the average age of active, full-time midwives is rising close to being pensionable, while part-timers are far from ready to take up the slack in those countries, including the UK, which are currently enjoying a mini baby boom and predicting an even bigger one. What is equally clear is that the profession (one could almost say “confession”) of midwifery is in serious crisis across the rest of the globe. And this is hard to understand when one considers how many more women are entering the workforce and pursuing studies than in previous generations and how noble and rewarding the calling of a midwife is, at least emotionally, if not financially. Ah, there’s the rub, maybe. But surely there can be few jobs that offer such a degree of, literally, hands-on engagement with the clients of your service in a more fulfilling, demanding and socially valuable situation.

Yet the bottom line seems to be: not enough trainees in developed nations, not enough places to train them in developing nations and a lack of effective budgeting in both camps. Because if one is bickering about costs, then the trained midwife is the absolute, bottom line, best option when it comes to births per dollar or babies per pound. Their rate of successful delivery is as high or higher than obstetric gynaecologists or other medical professionals (although this is possibly to be expected as they tend to handle the less risky pregnancies) and their cost to the system is a mere fraction of the serious burden of their doctoral colleagues, who cost far more to train, use more expensive apparatus, require the presence of a nursing assistant, medical orderly or anaesthetist and moreover tend to administer or prescribe peripheral medications that further inflate the health budget.

Midwife crisis? Get over it! Buy a Harley and move on ... or guide your daughters into a meaningful career.

© Edwin Drood, October 2012
Edwin Drood's Column, the blog by The Mysterious Edwin Drood,

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