Monday, September 19, 2011

Quick Hit on Midwifery Care and Disparities

Prepare yourself for the longest sentence ever:
  • In a system where truly collaborative OB-midwifery care is a relative rarity and transfers/transports from home births or birth centers can result in terrible antagonism and poor treatment,
  • and therefore many women are summarily (and possibly wisely, in this context) risked out of midwifery care in these settings,
  • then to the extent to which midwifery care is associated with better outcomes,
  • out-of-hospital midwifery care becomes a means by which the bad and worsening sociological disparities in perinatal health (by race especially, but also by insurance status and income, geography etc.) for both mother and child are exacerbated,
  • because exactly those populations who could most benefit from midwifery care are systematically excluded from accessing it,
  • due to the bigger problem of the fragmented system of maternity care.
Please, your thoughts?


  1. It's interesting, but to me it kind of sounds like you're saying that the issue with women of color (and also low-income people, those in the South, etc.) are excluded from midwifery care because they risk out. And yes, they probably are more likely to risk out, but it's not like they are beating down the doors of out-of-hospital birth options and being turned away...for most the issue is that they have no idea that the services even exist. I see this in my own communities...out-of-hospital birth is almost exclusively restricted to people who are privileged in education/social background, if not in current income, who KNOW about these options and are exposed through their friends.

  2. Hi Rebecca, Thanks for commenting! That is definitely also an issue and probably the larger one, at this point. I guess what I am trying to drive at - and thank you for helping me try to clarify my thinking - is that even if we solve the problem of differential awareness/access, the very nature of OOH midwifery care and its general suitability for low risk women has this disparity-exacerbating effect built in. So the less-healthy women who need in-hospital intrapartum care because of their risk status are less likely to receive the ancillary/morbidity-reducing benefits of midwifery care.

    I'm, urm, ignoring hospital midwives, I guess, or put another way, I've made the mistake of proxying style of care with type/place of provider. Of course, this works as a general rule but not as a hard and fast one. I guess I am saying that "medium-risk" women who "should" deliver in-hospital but may prefer and do just fine with hands-off care are a group that suffers disproportionately from the current bimodal system.

    (Thanks again for stopping by!!)

  3. This is definitely something I puzzle over quite a bit. There are some changes afoot in my home state of Oregon where Medicaid actually funds OOH birth with licensed midwife so we'll see what comes of it. Right now one has to jump through special hoops to request the sort of plan that will pay for an LDM attended home birth, so it is very much a cultural bubble of folks who seek and make that request (though overall I'd speculate that Oregon has a higher proportion of low income home birthers than other places for this reason - midwives who take the Oregon Health Plan report that to be the case.) I've often wondered what it would take to make the option more publicized to women on OHP, especially in Spanish. Perhaps bilingual mailings when a pregnancy is reported concerning options in care providers. But there's more to it than just getting the information out there. Midwifery isn't always attractive, and in fact often isn't to Latino families. I am considering trying stir up a doula program for immigrant women in my area with all of that in mind. Since Latina women largely prefer to birth in the hospital, perhaps the optimal place to bring some supportive change is in bringing in some doulas (hey Rebecca, got any ins on getting AmeriCorps to initiate a Public Health Doula program in an area without one?) I'm also brainstorming the idea of having IBCLCs who do home visits (not just for privately paying folks, so some external funding needed.) Busy, busy.

    You're talking about an issue that is a perpetual splinter under my nail. I'm REALLY interested in seeing those gaps of access bridged, and I'm totally turned off against passively participating in serving a stunted representation of my community's demographics (though I so love OOH birth). Hence, I'm marching towards public health rather than just working towards birth work exclusively. There need to be structural changes in order for the overall trends to be more well rounded and representative of who's here.