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Healthcare System

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Healthcare Systems in a Diverse World

Understanding how health care systems are structured—across cultures and nations—requires an understanding of how individual societies are structured. The healthcare system that has evolved in the United States is the result of several intersecting influences: business, technology, values, historical roots, and deeply held priorities. In the U.S., the policies and practices related to pregnancy, birth, postpartum, and parenting reflect each of these influences.

While maternal and child health (MCH) status has improved over the last century in the U.S., the care and well being of mothers and their infants is not a top priority, as evidenced by the poor MCH rankings in the United States as compared to other modern countries. There are several key MCH indicators that must improve in order to deliver optimal care to families that results in optimal outcomes for women and newborns.    

The Rise of Modern Midwifery

In the early twentieth century, the midwifery profession fought to maintain a foothold amidst the special interests of the burgeoning medical professions in United States and its well-organized medical associations and lobbies. By the mid-twentieth century Grand Midwives (traditional, indigenous and Black midwives) were strategically and deliberately eliminated. Nurse-midwives struggled to find their place in the medical hierarchy of maternity care providers. Direct-entry midwives and out of hospital childbirth arose from the cultural revolution of the ‘60s and ‘70s, the civil rights and women's movement, and women’s dedication to gaining more control over their bodies and their births.

The Dominant Medical Model of Childbirth 

During the late-twentieth century, a dominant model of childbirth developed that replaced the prevailing social and public health models of childbirth. The emergence of the medical model of childbirth spawned an approach that was based on industrial and corporate models. New commercial enterprises shaped the institutions, specialties and technological strategies that defined modern medicine. 

Maternity care within a corporate model, therefore, accentuated a focus on pathology over primary care and aggressive medical management of the normal physiologic processes of pregnancy, birth, and lactation. This model also isolated individuals within a medical perspective rather than placing them within the larger public health perspective of family, culture, community and society.

Unlike other industrial nations where maternity care is provided primarily by midwives in consultation with physicians and specialists when necessary, in the United States most maternal care is provided by obstetricians who are surgical specialists best suited to high-risk patients and situations and not necessarily the vast majority of American women who enter labor at low-risk for complications. 

The U.S. Maternity Care System

The United States spends considerably more money on maternity care than any other industrialized nation in the world yet ranks significantly worse than any developed country on indicators of heath and well being for mothers and infants. And statistics are worse yet for poor and marginalized moms and babies and populations of color. 

The Midwifery Model of Care 

While the midwifery model is a safe, effective, cost-effective, and empowering model of care for women and infants, the common cultural belief is that hospital birth with an obstetrician is “best care” for moms and babies. While this is the persistent belief it is not grounded in evidence.

Research supports the fact that pregnancy care and birth with a midwife in any setting—hospital, home, birth center or clinic—is as safe and effective as care in a hospital under the management of a physician. In fact, for marginalized women—such as poor, imprisoned, homeless and vulnerable women of all races and ethnicities—individualized, compassionate, woman-centered maternity care with midwives may be the best policy.

Home Birth on the Rise

The rate of home birth in the United States has made a dramatic upturn since 2004, reversing a trend of decline throughout the 1990s. Home birth increased 29 percent between 2004 and 2009, from 0.56 percent of all births to 0.72, almost 30,000 births according to the Centers for Disease Control and Prevention (CDC.) The CDC report was not clear about why the increase is occurring. But researchers who are watching the trend suggested that the increase in home births has to do with women wanting to have control over the amount and types of maternity care procedures they experience, indicating individual preferences for lower-intervention birth, including lower cesarean section.  Lead researcher, Dr. Marian McDorman stated, “Women may prefer a home over a hospital birth for a variety of reasons including a desire for a low intervention birth in a familiar environment surrounded by family and friends,” MacDorman said. “Cultural or religious concerns, lack of transportation in rural areas and cost factors may also play a role as total costs for home births are about 1/3 those for a hospital birth.”

Key findings

  • After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.
  • For non-Hispanic white women, home births increased by 36%, from 0.80% in 2004 to 1.09% in 2009. About 1 in every 90 births for non-Hispanic white women is now a home birth. Home births are less common among women of other racial or ethnic groups.
  • Home births are more common among women aged 35 and over, and among women with several previous children.
  • Home births have a lower risk profile than hospital births, with fewer births to teenagers or unmarried women, and with fewer preterm, low birthweight, and multiple births.
  • The percentage of home births in 2009 varied from a low of 0.2% of births in Louisiana and the District of Columbia, to a high of 2.0% in Oregon and 2.6% in Montana.

References for this section

1. Perkins, Barbara Bridgman. The Medical Delivery Business: Health Reform, Childbirth, and the Economic Order. New Brunswick: Rutgers University Press, 2004.

2. Sakala, Carol and Maureen P. Corry. Evidence-based Maternity Care: What It Is and What It Can Achieve. New York: Milbank Memorial Fund, 2008. 

3. McDorman, Marian F., T.J. Mathews and Eugene Declercq. Home Births in the United States, 1990-2001. Centers for Disease Control & Prevention, NCHS Date Brief, Number 84, January 2012.