Should the US Call the Midwives?

Most of the deliveries that occur on the show are done in the home, and you watch as the midwives prepare home delivery packets including necessities like rubber sheets for the bed. In the US, it is entirely the opposite.

I am a huge fan of BBC Television programs.   I realize that admission fully qualifies me to receive a status of “Nerd” or “Snob”, depending on your familiarity with their programs, but I wear the badge proudly.  There is nothing better than curling up with a mug of tea (made in the British fashion with a splash of milk) and watching a program like Sherlock.  Or if you are like me and love the dry/witty/cutting style of humor that is distinctly British, you can’t miss Blackadder, Are You Being Served? or Vicar of Dibley.  Then of course there is the pinnacle of human comedy achievement in the form of Monty Python’s Flying Circus, who have a comedy repertoire that will have you rolling on the floor at their antics as they ramp up the satire/observational humor dial to a factor of 11 to create a truly unique comedy experience.

One recent BBC program which airs on PBS in the United States I have recently begun to appreciate is a program called Call the Midwife.  The show’s popularity seems to suffer because of the popularity of another British period drama on the same network, the famous Downton Abbey (which is in and of itself a re-telling of an older British program called Upstairs, Downstairs, but I digress…).  Call the Midwife is currently in its fourth season, and follows the story of midwife and nurse Jenny Lee, who arrives at an Anglican convent called Nonnatus House to work as a midwife as part of the houses’ charitable outreach.  She joins the sisters of the house and fellow nurse midwives Cynthia, Trixie and later Camilla “Chummy” Browne as they preside over the pre-natal care,delivery and ante-natal (the British term for post-natal) care of women living in the poverty rife East End of London in the 1950’s and 1960’s.  It is based on the memoirs of real-life midwife and nurse Jennifer Worth.

Call the Midwife - Ep 4The program deals with far more than the drama of labor/delivery itself and all of the possible post-delivery complications like post-delivery psychosis or babies with complications like cystic fibrosis or spina bifida.  It examines issues related to spousal abuse (Season 2 Episode 1), inter-racial relations and mixed race children (Season 1 Episode 4 and Season 2 Episode 3), and how poverty can influence a pregnancy…in one episode following the story of a woman who, upon finding herself pregnant again even though her family is already on the brink of starvation, turns to back alley abortion services that nearly end her life.  Because it is based on real memoirs, you get an authentic look at poverty, family life and motherhood in London, where the ghost of World War II still haunts the people.  Is there fabrication?  Sure…it is a television show and needs to be interesting for the audience or they won’t watch it.  But it does stay fairly true-to-life as women in poverty go through this life changing experience.

As an American watching the show, it requires a bit of a mental adjustment, and not just switching back and forth from our grandparent’s time to the modern day.  Most of the deliveries that occur on the show are done in the home, and you watch as the midwives prepare home delivery packets including necessities like rubber sheets for the bed.  You see the midwives inspecting the homes to see if they are appropriate for home delivery, and get an up-close and personal look at the quality of poor housing blocks in the post World War II damaged city, including apartment buildings with one shared toilet for the building, lack of decent sewer services and all manner of insect infestation.  Very few of the births on the show are done “in hospital” as they refer to it.

Labor in the USIn the US, it is entirely the opposite.  Women in labor give birth in hospitals as a matter of accepted fact; eyebrows are raised when someone tells you that they are opting for a home birth because it is so unusual.  While the idea of giving birth with a midwife is an idea you may hear about (and normally only in more affluent or hipster-inspired areas), for most women the established norm is the frantic drive to the hospital, praying that you don’t hit traffic on the way and are forced to have your baby in the car or on the side of the highway.  The idea that midwives and home deliveries are standard practice in the UK, and are even encouraged by government programs, is an almost completely alien concept.

But the truth is that in the US a majority of the deliveries that occur are rather routine. Though I have not experienced pregnancy or labor myself, I was present for the birth of my oldest nephew and while it was a comforting thought to know that a doctor was present and that the hospital could accommodate any medical emergencies that might arise, I found myself wondering later whether or not all of the expense and expertise was necessary in the majority of cases where the pregnancies are low-risk.  There are exceptions where delivery in a hospital is absolutely vital, such as when a mother is expecting twins or when she has conditions like pre-eclampsia, but these situations are relatively rare and with proper medical supervision throughout the pregnancy can be identified early.  Jenny Lee and the other midwives in the show are fully qualified nurses who bring plenty of experience and knowledge about when a doctor or an ambulance need to be sent for…such as when Camilla’s placenta ruptures during her early labor.  Midwives in the United States who are certified and/or licensed have similar levels of medical expertise and far superior medical equipment to that used in the show.  In fact, a 2005 study in the British Medical Journal found that for low-risk home births in the US and Canada which were attended by a qualified midwife, the infant mortality rate was 1.7%, which is equivalent to hospital births.  In a May 2009 Time Magazine article covering this very question, assistant professor of anthropology Melissa Cheyney pointed out that there is a large bias among OB/GYN’s to midwifery which undoubtedly plays a role in professional organization’s reluctance to look into it.  Part of the bias, Cheyney explained, comes from the fact that OB/GYN’s only deal with midwives and their patients when something goes wrong and there are complications leading them to go to the hospital for treatment.  While this is exactly as it should be, this does mean that many OB/GYN’s are only seeing the bad cases where something has gone wrong, and not the hundreds of safe and routine deliveries the same midwife might preside over, which leads them to assume that all midwives and their delivery are poorly handled and unsafe for the patients.

nprI ran across this article from NPR recently which asks the same questions.  Should More Women Give Birth Outside the Hospital? begins by featuring a recent statement from the British National Health Service, which states that women with straightforward pregnancies are better off delivering at home rather than in hospital.  Of course if a pregnancy is complex (like multiple babies) or if the mother suffers from medical conditions which complicate the pregnancy or labor/delivery she should deliver at a hospital.  The statement raised eyebrows in the US, but Dr. Neel Shah of Harvard Medical School responded in a New England Journal of Medicine editorial that as long as the right pregnancies are chosen and the midwives have links to medical centers they can call should something go wrong during labor and delivery, it can be safer for both mother and child to deliver at home.  Dr. Jeffrey Ecker of the American College of Obstetricians and Gynecologists frowns on planned home births, but noted that it is difficult to compare the British and US systems for midwifery and planned home deliveries, pointing out that the UK has support systems in place to accommodate midwives and planned home deliveries, while no such system exists in the United States.

That system is what Call the Midwife features, and aside from the show being well written and well cast, it is enlightening to see it in practice.  Of course risk cannot be completely mitigated; things can go from normal to very wrong with surprising speed during labor/delivery, which the show does a good job of demonstrating on numerous occasions.  But it does make me wonder if, with the emphasis in the US healthcare system going towards reducing the exploding costs, developing a similar support system for midwives in the US would be beneficial.  To my mind, it at least merits further study.  This is a complicated issue and there are major differences between risks faced by American mothers vs. British ones.  But just because the issue is complex doesn’t mean we shouldn’t look into it.  After all, we might just be able to learn a thing or two from our British friends.

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