The Midwife Divide

The birth of children is at once both an entirely everyday occurrence and a miracle in its own right. With few exceptions, for every child born, there was someone there to catch them. This task has fallen to midwives, both trained and untrained, for most of recorded history. One of the earliest textual mentions of midwifery comes from the Bible, where we learn that two women, Puah and Shifra, delivered the babies of the Israelites and, against the wishes of the Pharaoh, refused to kill each newborn Hebrew male. Their bravery, so the story goes, gave us Moses.

Modern midwifery, particularly in the United States, is at something of a crossroads. While there is steady evidence that births attended by certified nurse-midwives (CNM) produce better health outcomes than standard obstetric care for non-complicated pregnancies and deliveries, the lack of qualification standardization across state lines has made it difficult for some pregnant women to have access to a midwife. This is especially true for vulnerable populations.

A joint research effort of NPR and ProPublica, released in 2017, revealed that the United States has the highest rate of maternal death in the developed world and the highest rate of death from pregnancy-related complications. The numbers worsen dependent on the demographic: an explosive investigation by the New York Times in April 2018 reported that children born to black mothers in the U.S. are twice as likely to die in the first year of life than white infants. Black mothers are also far more likely to suffer from conditions that can be traced to socioeconomic divisions. “For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions…that lead directly to higher rates of infant and maternal death,” Linda Villarosa wrote for the Times, “And that societal racism is further expressed in a pervasive, longstanding racial bias in health care—including the dismissal of legitimate concerns and symptoms—that can help explain poor birth outcomes even in the case of black women with the most advantages.”

Midwifery is not a perfect solution to these disparities, most so deeply entrenched in the American healthcare system that it is difficult to parse cause and effect. What midwifery does offer is an opportunity for all women to approach birth from a place of wellness, rather than sickness. Midwife-assisted births are associated with fewer interventions (from I.V. fluids all the way to caesarean sections), which, in routine pregnancies and deliveries, means less possibility of adverse postnatal complications. There is emotional advantage, too—the value of which cannot be assigned a percentage or a number.

Of all the sins of the United States’ complex, overburdened, and comparatively ineffective healthcare system, one of the most dehumanizing is the sense that doctors are so overworked that there’s little time to form relationships between patient and caregiver. To provide personalized and informed medical assistance in the world of birth, it takes consideration of general wellness, preexisting conditions, and emotional status—all areas of personhood that can be inadvertently rushed or overlooked by physicians buried under hundreds of patients. This is not to dismiss the role of obstetricians and specialists, nor the advancements of medical science that have given us the ability to handle high-risk pregnancies and deliveries that would certainly have ended in death in times past. But the medicalization of birth, with such consistently poor outcomes, has left many soon-to-be mothers searching for alternative modes of care. Emerging research resoundingly considers their work to be vital in the transformation of maternal care in the United States. 

A Fad? Or an Actual Medical Advantage?

When Tamar Prager became pregnant with her first child and needed to decide what kind of care she wanted to receive for her pregnancy, she knew she wanted, as much as was possible, a natural experience. Having studied to be a nurse practitioner, she was familiar with all manner of possible medical scenarios once delivering: “I had learned in my O.B. rotations about all of the interventions for standard practice of care—Pitocin, antibiotics via I.V., all of it. If there was a way to reasonably avoid it, I wanted to do that. I had the desire to have a natural birth, and I had to figure out who would provide that care, and it seemed to be a midwife.” She chose a highly reputable practice, headed by an obstetrician, that enabled her to create a relationship between herself as a patient and midwives as her birthing team. “The idea behind the practice was that you saw all of the midwives, so you could have a relationship with each one,” she explained in a phone interview. “You couldn’t be sure which midwife you would deliver with, so you met with them all. It was pretty hands-off: they of course did ultrasounds at specific markers, but the point was that you weren’t receiving anything excessive.” When it came time to deliver, she was able to do so in a birthing center just 20 minutes from her home. “The room felt like a nice hotel room—really spacious and calm, unlike a standard hospital room and bed. The midwife I ended up delivering with was excellent. It was uncomplicated—and yet still required an immense amount of knowledge. After I delivered, we rested for a few hours. It was so lovely. No one was taking blood excessively or checking in every 15 minutes. Obviously, the fortunate part of this is that nothing needed excessive monitoring. But the whole time I felt like I was on the trajectory that I wanted to be on, and my midwife allowed that to happen for me.

“I didn’t want to be seen as just ‘the patient’, or a clinical specimen at the time of delivery. I was looking to be seen as a whole person, from my first appointment through the birthing of our child. The midwifery practice approached me not just through a medical lens, but through all the lenses pertinent to the process. I was an individual with strengths and challenges, questions, and goals. This was my first pregnancy, so I was keenly aware of wanting a provider who could guide me through the long hours of labor up through the final stage in a manner that was suitable to me. I was so fortunate to have found that. Six years later, I think back to my birthing story and feel awe and gratitude.”

Prager was an ideal candidate for the use of a midwife—low-risk, and well-informed of her options. She also delivered in New York City, which has far different medical offerings than more rural parts of the country. This presents a significant challenge for the potential nationwide adoption of midwifery as standard care for routine deliveries. Beyond geographic distribution of practicing midwives, there is also the question of knowledge—the growth of midwifery as a viable alternative to large-scale obstetric practices and hospitals will not succeed if midwives are not well-known as medically competent and reflective of modern medicine. Part of this responsibility falls to the larger healthcare community.

There is currently not even a standardized definition of midwife in the United States. This means that in some states no medical licensing is required to use the term. Published research on the efficacy of midwifery in the context of maternal health almost always refers to certified nurse-midwives, a medical license and term recognized by medical boards and colleges. Lack of standardization perpetuates misconceptions about modern midwifery—a phenomenon documented in The Atlantic in a 2015 article in which author Jamie Santa Cruz detailed the consequences when laws differ among states. “Certified nurse-midwives, who complete an extensive nursing education culminating in a graduate degree, can practice legally in all 50 states. But 28 states also allow “direct-entry” midwives, who may enter the profession through an apprenticeship to a more experienced midwife. As a result, the term “midwife” has no standardized meaning in the U.S. … Since 2010, the International Confederation of Midwives, which represents midwife organizations in approximately 100 countries, has advocated for a standardized minimum level of training for all midwives, not just in the U.S. but globally.”

Will Jewish Women Jump on the Bandwagon?

Emerging and shifting attitudes toward midwifery offer a unique chance to reflect on the role of supported birth in American Jewish communities. While there is little data on what percentage of women nationwide using midwives for delivery are Jewish, there are many established Jewish groups in which midwifery has played a consistent role. In 2014, Tablet magazine profiled Orthodox Jewish women who deliver with midwives and doulas—and have been doing so for decades. (A doula is a trained, non-medical support person on the birth team.) “Orthodox women seek out doulas in part because they would rather have natural birth,” writes author Kylie Ora Lobell, “Since they’re often planning to give birth more than once or twice or even three times, they want to avoid C-sections.” Jewish CNM Shadman Habibi told Tablet, “If a woman is Orthodox, and she comes from this tradition, she really does not want intervention, even during prenatal care.”

Doulas trained in the Orthodox tradition understand rules and customs relating to modesty, another advantage. They can help support a laboring mother and ensure that all required headscarves and blankets stay in place—and that the birthing room remains a space (mostly) separate from male healthcare providers and husbands. Multiple midwives working in Conservative and Orthodox populations cited a book called B’Sha’ah Tovah, still in circulation, as a hallmark text for some Jewish American families. Described as a guide to “clinical and halachic pregnancy and childbirth,” the book seeks to ground expectant and observant parents in both rabbinic wisdom and a sense of strength. Written by a rabbi and his wife, a practicing nurse-midwife, the book blends general medical knowledge with questions of faith (like whether an expectant mother is expected to fast for Yom Kippur). Material like this may not be mainstream, but illustrates the clear possibility for connection between traditional Jewish practice and the ongoing service of midwifery.

In a 2017 Hadassah magazine article, a Pittsburgh-based midwife summed up what she sees as the link between low-intervention care and the Jewish tradition: “As Jews… how we eat, how we calculate time, everything we do is infused with purpose.” She sees Western medicine as having turned every pregnancy and birth into an overanalyzed medical event. Her goal, like that of many other Jewish midwives, is to restructure how patients see the process—finding the spiritual in the ordinary.

Shira Moss, a practicing CNM in New York State, echoed similar sentiments in an interview. “I was actually born into the hands of a midwife, as were all of my cousins, so I grew up hearing the word ‘midwife’ as a very positive word, and I really got the sense of how powerful they were and what a positive impact they’d had on my mother and my aunts.” To that end, she says, she felt fully supported when she decided to enter the field herself, and considers her work to be a natural outgrowth of the types of values—Jewish or otherwise—she was raised with: “At Passover, when we talk about Shifra and Puah, the amazing midwives in the story, I feel exceptional pride to be a part of such a radical and righteous historical Jewish tradition.”

Everyone Deserves a Doula

The integration of midwifery as a standard form of practice for maternal healthcare depends, of course, on a fundamental shift in cultural and social perceptions of what birth should look like. According to the most recent data available, in 2014 midwives attended about 12% of births nationwide. The vast majority of these occurred in hospitals, with certified nurse-midwives. As a point of comparison, in the United Kingdom, the most recent data show that almost half of babies born in the last year were delivered by midwives (including the Duchess of Cambridge’s third child). Britain’s rate of maternal death, incidentally, is almost three times lower than that of that United States. Britain’s numbers are considered conservative by worldwide standards: in Israel today, for example, over 80% of uncomplicated births are attended by midwives. 

Shira Moss highlighted this ongoing disparity when she spoke to Lilith, and offered a vision of an integrated healthcare model for the United States. “In many countries worldwide, all low-risk pregnant people go to midwives for their prenatal care and for their births, because it is widely understood and accepted that midwives are unique specialists in taking care of low-risk pregnant people over the course of their reproductive lifespan.” She noted, “If a pregnant person becomes high risk, they are taken out of midwifery care and are smoothly transferred to M.D. care. This allows for an integrated healthcare system in which each different provider’s role is valued and even cherished, and in which patients receive exactly the care that they need from the correctly identified provider, which leads to better neonatal and maternal outcomes across the board.”

Change is slow, but steady. This past April, Governor Cuomo of New York proposed an initiative to address the ongoing crisis of racially divided maternal mortality, particularly in New York City. Under his directive, doulas would be medically reimbursed under Medicaid, along with an expanded effort to change post-birth practices in hospitals in the hopes of curbing deaths from preventable complications such as a hemorrhage. Moss sent a letter to Cuomo directly in response to that announcement, both in support of the policy and to communicate knowledge she has accrued in her years of practice. “I wrote how midwives are uniquely positioned to address this and many other issues affecting neonatal and maternal outcomes, and how unfortunate it is that we are not one of the central players in addressing the needs of pregnant people in this country… relatedly, I believe another major challenge is the lack of understanding of who midwives are, what we do, what our scope of practice is, how we are licensed, who our patients/clients are, where we work (at home, in birth centers, and the majority of us work in hospitals), if our patients can work with us and still get an epidural (they can, as long as they’re in the hospital!), and how skilled we are as clinicians.” 

Overall, Moss is confident that using midwives will become more common.“I love the word midwife,” she said, “and that it sounds witchy and old timey…but I get that it means that some people don’t understand that our minds are sharp and we are tracking everything doctors would track as we provide excellent medical, holistic, individualized and comprehensive care. It also means people don’t know that we are trained in institutions of higher learning, and often times practice in huge medical institutions, and that we practice using evidence-based research. We’re not just sitting in a corner in our grass skirts and Birkenstocks, beating our drums, lighting incense and chanting a baby out with our eyes closed while a mother labors and births, without assistance, down by a river.”

Justine Orlovsky-Schnitzler is a writer on the move, currently based in Arizona. She graduated in 2017 from UNC-Chapel Hill and is a regular contributor to the Jewish Women’s Archive.