North Ottawa Community Hospital (NOCH) recently announced that they were eliminating their midwifery program. Public outcry ensued. Without producing any evidence, the administration blamed patients choosing obstetricians over midwives and economics as driving factors. The situation at NOCH is a continuation of the medical industry historically dominating obstetrics at the expense of midwives and patient care.
In order to get my women’s studies degree in 1998, I completed an internship at Elizabeth Seton Childbearing Center in Manhattan. I was interested in learning more about how race and class impacted childbearing decisions. In my paper for class, I wrote about how, historically, traditional birth attendants were systematically ousted from the hierarchy of male obstetrics. As historians Barbara Ehrenreich and Deidre English wrote in their pamphlet, “Witches, Midwives and Nurses” in 1973
“[T]he sexism of the health system is not incidental […]. It is historically older than medical science itself; it is deep-rooted institutional sexism [that] is sustained by a class system which supports male power (41 – 42).”
I was shocked to find out that 20 years later in some of NYC’s public hospitals serving the city’s poorest women, obstetric care was dominated by midwives (Baquet & Fritsch). Far from representing a reversal of power, the economically-driven shift was linked to substandard care when doctors were not available and midwives were forced to care for women with high-risk pregnancies and medical emergencies.
In Grand Haven, the loss of midwifery care affects primarily Ottawa County women who enjoy a higher socioeconomic status than in the rest of the state. In 2012, the median household income for Ottawa County was $55,158 compared to the state average of $46,793 (United States Census Bureau). Ottawa County moms are also more likely to be married and older than statewide (2012 Michigan Resident Geocoded Birth Files). Finally, Ottawa County is one of the whitest counties in the state, 93.1% of their residents are white compared with 80.1% statewide (United States Census Bureau).
Is there a national trend toward women, particularly higher-income white women choosing doctors over midwives, resulting in midwives being pushed out of obstetric and hospital practices? Not hardly. In 2009, births attended by midwives reached an all-time high of 8.1% (Declercq, E.).
When Time Magazine and the New York Times reported on this trend, both cited the greater acceptance among white women as a driving factor. Time pointed out that, in 1990, more nonwhite mothers used midwives whereas in 2009, they gave birth with midwives at the same rate as women of color (Rochman, B.). The New York Times reported that midwives were becoming a status symbol among Manhattan’s elite, with some popular practices booked solid. “It sounds bizarre,” they quoted Ms. Sylvie Blaustein, the Founder of Midwifery of Manhattan as saying, “but midwifery has become quote-unquote trendy” (Pergament, D.).
While I could find no basis for a trend toward less midwifery preference among white, middle-class women as NOCH administrators suggest, evidence for an economic motivation abounds. Obstetricians only compete for low-risk patients with midwives when reimbursement rates are high and birth rates are low. At NOCH, both of these criteria exist: only 32% of births to Ottawa County moms were publically funded in 2012 compared to 44% statewide (Kids Count Data Center) and birth rates (the number of lives births per 1,000 women) have declined during the last decade for which data is available, from 14.1 in 2002 to 12.3 in 2012 (2002 – 2012 Michigan Residents Birth Files). When you look north to Muskegon County, birth rates have also declined, but less dramatically and a whopping 62.7% of births are covered by Medicaid (Kids Count Data Center).
Unlike in Grand Haven, where midwifery hospital care has now become extinct, Muskegon County supports two busy midwifery clinics that almost exclusively serve women on Medicaid – Hackley Community Care and Muskegon Family Care. While any woman can seek care at a federally qualified health center, as NOCH administrator Barbara Nyblade, Director of Physician Practices at NOCH, pointed out, few from Grand Haven will cross the bridge to do so.
In this twist of fate, we find childbearing choices favoring the poor. In the meantime, NOCH has hired three new obstetricians to replace the midwives who have been moved to other positions. While natural childbirth advocates continue to make their voices heard on the streets and in the media, we can all find comfort in the one thing that hasn’t changed when it comes to obstetrical choices in the U.S. in recent decades: the former NOCH midwives can always find work serving the poor.
2002 – 2012 Michigan Residents Birth Files, Division for Vital Records & Health Statistics, Michigan Department of Community Health; Population Estimate (latest update 9/2012), National Center for Health Statistics, U.S. Census Populations With Bridged Race Categories. Accessed online @ http://www.mdch.state.mi.us/pha/osr/Natality/BirthRateTrends.asp on 10/20/14.
2012 Michigan Geocoded Resident Birth files, Division for Vital Records & Health Statistics, Michigan Department of Community Health. Accessed online @ http://www.mdch.state.mi.us/pha/osr/chi/births/Birthchar/BxChar.asp?DxId=1&CoCode=70&CoName=Ottawa on 10/20/14.
Baquet, D. & J. Fritsch. “Lack of Oversight Takes Delivery-Room Toll.” New York Times. March 6, 1995.
Declercq, Eugene. “Trends in Midwife‐Attended Births in the United States, 1989‐2009.” Journal of Midwifery & Women’s Health 57.4 (2012): 321-326.
Ehrenreich, Barbara, and Deirdre English. Witches, Midwives, and Nurses: A History of Women Healers (Contemporary Classics). Feminist Press at CUNY, 2010.
Kids Count Data Center. Medicaid Paid Births – Single Year. Accessed online @ http://datacenter.kidscount.org/data/tables/1716-medicaid-paid-births–single-year?loc=24&loct=2#detailed/5/3804,3813/true/868,867,133,38,35/any/3639,13078 on 10-20-14.
Pergament, Danielle. “The Midwife as Status Symbol.” New York Times. June 15th, 2012. Accessed online @ http://www.nytimes.com/2012/06/17/fashion/the-midwife-becomes-a-status-symbol-for-the-hip.html?_r=1& on 10/20/14.
Rochman, Bonnie. “Midwife Mania? More U.S. Babies than Ever Are Delivered by Midwives.” Time. June 25th, 2012. Accessed online @ http://healthland.time.com/2012/06/25/midwife-mania-more-u-s-babies-than-ever-are-delivered-by-midwives/ on 10/20/14.
United States Census Bureau. State & County Quick Facts. Ottawa County, Michigan Accessed online @ http://quickfacts.census.gov/qfd/states/26/26139.html on 10/20/14.