What You Need to Know About Birth Models (Birth What?!)

What You Need to Know About Birth Models (Birth What?)

Adriana Lozada: Hello, Mighty Parent or Parent-to-Be. Welcome to Birthful. I’m Adriana Lozada and we continue with our series on Models and Places of Birth. So today I have the great, enormous, immense pleasure of speaking with Robbie Davis-Floyd, who is a world-renowned medical anthropologist, international speaker, and researcher in transformational models in childbirth, midwifery, obstetrics, and reproduction.

Robbie’s here to walk us through the three most commonly-used birth models, which she labels as “technocratic,” “humanistic,” and “holistic.” Now, this conversation is a great follow-up to our previous episode with Britta Bushnell on how cultural ideals shape our approach to birth, because these ideals also shape the institutional models we create.

And Robbie does a wonderful job of explaining what you can expect from your birth team and environment, depending on the models they subscribe to, as well as how to best navigate those models. Now, in the episode, Robbie mentions that the cesarean birth rate in Brazil had reached 57% after climbing steadily, and I wanted to give you an update on that.

The good news is that, since we spoke, the cesarean birth rate in Brazil has leveled and even gone down to 55.5%. So it seems that all the advocacy efforts and policy changes have made a difference. However, we still need to put that into context because in the Year 2000, Brazil’s cesarean birth rate was 38%. So it has taken a huge effort to turn that upward trend around in Brazil, and yet it still remains one of the highest cesarean rates worldwide.

As a point of reference, the rate in the U.S. has had a similar trajectory, in that cesarean birth rates increased rapidly from 1996 to 2009, going from 20% to 33% respectively. And since then, the rate has plateaued, slowly decreasing to just under 32%, despite massive efforts to lower it over the years.

And this is a trend that can be seen in other countries as well. When left unchecked, the cesarean birth rates increase very rapidly and it then takes a huge effort to bring it down, and it never quite gets back to the levels where it was before it started increasing rapidly. We will be diving deeper into the reasons behind these rate increases and how they are linked to hospital complexities in a fascinating upcoming episode with Dr. Neel Shah as part of our Models and Places of Birth series, but I thought it really important for you to know these stats as you listen to today’s episode. So, here we go. You’re listening to Birthful, here to inform your intuition. 

Adriana: Robbie, it is such a delight to have you here!

Robbie Davis-Floyd: Thank you! I’m happy to be here.

Adriana: And I want to tell you, I’m so inspired by your work– because I feel that you are out there in the trenches, sort of observing different birth cultures around the world, and seeing some significant change happen in places where it would be easy to think that all hope was lost– even though I might be wrong, being a little bit overdramatic. So, before we get into the details of birth models, would you mind talking a little bit and walking us through the change that you’ve seen in Brazil, sort of painting us a picture through that example?

Robbie: Well, Brazil is a very interesting mixed bag. On the one hand, they have an ever-increasing cesarean rate, which has now reached 57%. The doctors are untrammeled in their use of cesareans, even though the Ministry of Health and all the birth activist groups are decrying that massive overuse of cesareans. So the contract there in Brazil is, on the one hand, you have this highly technocratic medical system that is bound and determined to do as many cesareans as possible and to stamp out homebirths.

And on the other hand, Brazil has the most active and populous and progressive social movement for the humanization of birth in probably the Americas– really, the most organized. They have an organization in Brazil called REHUNA, which in Portuguese (which I don’t speak very well) is Rede pela Humanização do Parto e Nascimento which means Network for the Humanization of Birth.

And REHUNA was officially founded in the late 1990s. They put on their very first conference in Brazil in the state– the city– of Fortaleza and the state of Ceará in the Year 2000. They chose that city because WHO had its landmark conference there in 1985, when they came out with their goal of a 15%, no higher than 15%, cesarean rate for even tertiary care centers… which of course hardly anybody meets anymore, just a few countries managed to do that. But they put on this conference in Fortaleza in November of 2000, and I was one of five international speakers invited. There was Martha Wagner and… Leslie Page, a wonderful midwife from the UK, and Ina May Gaskin and me and Jose Villar, who was at the time the head of MCH for WHO. And on the first day of the conference, we were expecting around maybe 600 people, and we were in this huge auditorium and we noticed that it kept filling up, and filling up, and filling up, until there was like standing room only and people were sitting on the stairs and it became a fire hazard!

And by the next day, we discovered that almost 2,000 people had shown up for what became… It was called the “First International Congress on the Humanization of Birth.” So that was an amazing start. And I’ll tell you a funny story about my experience there, if you’d like to hear it! 

Adriana: Absolutely! 

Robbie: So, I gave my keynote speech on Saturday morning, and it was on the three paradigms of care that I talk about so much: the technocratic, humanistic, and holistic models (or paradigms) of birth and healthcare. 

Well, anyway, I finished the talk and got this wonderful standing ovation and then I turn around to step down from the high platform and there’s this line of really good-looking guys in their 30s and 40s clutching armfuls of my books for me to sign and I said, “Who are you guys?” And they said, “Well, we’re the good guys. We’re obstetricians. We’re the good guys. We’re the ones who don’t do the cesarean. We have really low cesarean rates. And we call ourselves the Floydettes. And we compete with each other to see who can quote you most in our emails.”

Adriana: That’s the best set of groupies you could have! All doctors. That’s fantastic. It’s interesting to me how it may be because of these extremes of that cesarean rate growing and growing that created some outrage and having a lack of, you know, not so much homebirths and maybe not so many midwives that the OBs sort of… Do you think they just stepped into this role trying to go back to their instincts of why they became, you know, OBs in the first place?

Robbie: Well, that’s a very good question. I was immediately intrigued by these holistic obstetricians– as they call themselves, “the good guys” and “the holistic OBs,” where there are two labels for themselves– good guys and girls, because there are some women. And so in the subsequent years that I went to Brazil, I began interviewing them with my colleague, Mia Georges from Rice University.

We’re trying to figure out their motivations. What makes one doctor ignore scientific evidence in favor of abandoning episiotomy, and another doctor just do episiotomy right and left? And it’s really hard to get out what makes that difference. Some of them had a sort of compassion for others from childhood, some of them read the scientific evidence and actually were swayed by it. Actually, one of them– Roxana Noble from Florianópolis in Brazil’s South– she read a study that clearly demonstrated that episiotomy was a really bad idea, that all it did was increase perineal tearing, and so she quit doing episiotomies. 

Immediately all the other residents and her attending physicians jumped her case. They were all over her! “You’ve got to cut. You’ve got to cut. If you don’t cut, the perineum is going to explode.” And she said, “But look: I’m doing these births and the perineum isn’t exploding and the women are fine.” And they gave her so much grief about just stopping episiotomies that she started to wonder what else they were defending. And she started to realize that everything that she was doing was contradicting the scientific evidence in favor of a normal physiologic birth. So she was swayed by the evidence. 

Other doctors were swayed by experience. One of them, Paolo Battistuta, went to Sweden and he got a fellowship and he wanted to learn about normal birth. He didn’t know anything about it because he’d done 3,000 cesareans at that point in his life and, you know, very few normal births. And he watched Swedish midwives attending these beautiful normal births, and vertical births and he came back and said, “Okay, I’m ready. I’m gonna, you know, I’m gonna be a cool postmodern obstetrician and I’m going to do vertical births.”

And the first new client that came to him was a French woman who said she wanted a vertical birth and he said, “I’m cool with that. I can do that.” But he’d never done one before. He’d seen them done, but he’d never actually done one. And so, to give you a clue of how hard it is to change practice, she was walking around in labor and she was leaning over and she was, squatting down and standing up and, at one point, she asked him to check her and he had to get down on his hands and knees, which is a very, you know, challenging for a lot of doctors to be so low status. 

And he had to get down on his hands and knees and check her from underneath and he said, “Robbie, I honestly didn’t know what my fingers were feeling. I’ve checked thousands of women for dilation, but always standing above them. And I didn’t know. I couldn’t read the information in my fingertips, because I was coming from a completely different angle.” So he said he just guessed. He said, “Okay, four, you’re good. Everything’s coming along fine.” Fortunately, that birth turned out really well, and he began then to do more and more births like that and to abandon all the normal procedures. 

Every one of these obstetricians– we’ve interviewed 32 of them so far– has a different story. They’re all fascinating stories, but each one of them has a different tipping point, or a catalyst, or some particular event that made them realize that what they’re doing is wrong.

I’ll offer one more example. Ricardo Jones has become a good friend of mine. He runs a home and hospital practice in homebirth and hospital birth practice in Porto Alegre, in the very far south of Brazil, near Argentina. And he was an Air Force resident and he was a first-year resident, and the nurse comes running up to the room where the young residents are waiting to be called. And she said, “Doctor, Doctor, there’s a woman who’s in labor! She’s walked in off the street. She’s about to have her baby. You’ve gotta come quickly.” 

So he went down there and he pushed open the door and didn’t see anyone on the table. So he turned to the nurse to say, “Are you teasing me? Are you trying to make a fool out of me?” And she said, “No, Doctor, please open the door further.” And then he saw the woman squatting in the corner. And he went over to her and squatted down and lifted up her skirt, and he saw that the head was crowning. And he said, “Senhora, what are you doing? Get up! Get off the floor. You’ve got to get on the table to have this baby.” 

And he said, “She looked right through me, as if I were made of glass.” She was in that altered state that Michel Odent calls her “going to another planet.” I call it “going deep down inside.” But you enter a deep Delta state, you know? And she was in that state, and she just could barely even perceive him. She just looked right through him. 

And he had to catch the baby without even gloves on, which he’d never done before. So he catches the baby and he’s like, “Ew, gross!” and he hands it off to the nurse who rushes it off to the NICU, because, of course, it’s “contaminated” because it was born on the floor. And then she births the placenta and he’s yelling at her, “Look at the mess you made! All this blood all over the floor!” you know? And finally, he gets her up on the stretcher and they wheel her off to recovery. 

And later that afternoon, the birth kept bugging him all day. He kept feeling weird about it. And later that afternoon, the nurse who had called him came to him and said, “Doctor, what a good thing you were here. What would have happened if you hadn’t been here?” And he stopped dead in his tracks and he thought about it. And it hit him, “Oh my God, if I hadn’t been there, she would have reached out and caught her own baby and she would have had a perfect birth. And all I did was yell at her and do my best to disturb this intimate, innate process that she was in the middle of doing.” And “I’m an idiot!” He used a stronger word, which I won’t say on the air. He used, you know, the A-word. “I’m an a——,” you know what. 

And he just… that was his turning point. He just got it that he had to change. And of course, he didn’t know how to change, so it was a very long process. But today, half his births are homebirths and half are at hospital. He has a cesarean rate of around 15%. It’s been a long road for him, but it took him a long time to get the courage to do homebirths. But change is possible. Doctors just have to be open and willing to look at the evidence and to honor women’s requests and to understand and appreciate the normal physiology of birth. Unfortunately, their education doesn’t support them in that at all, so if they want to find out about it, they have to learn on their own. 

Adriana: And that is very interesting to me, because you can see how pervasive these birth models and these paradigms are of how culture affects us. And how hard it is when these doctors step out of their comfort zone, and have something like this happen to them and actually look at it mindfully with open eyes and realize, “Wait!” Maybe question a bit of how they are doing things. Because it’s what they’re seeing is not adding up with what they “know.” And I do want to talk more about the technocratic, humanistic, and holistic models that you mentioned, and how they affect births. So let’s do that.

Robbie: Well, back when I was doing my first book, Birth as an American Rite of Passage, I had read Barbara Katz Rothman’s work– she was a decade ahead of me– and I had read her work on the medical and midwifery models, but I was looking for terms for those models that more deeply connected them to what I saw as the core value system of the American technocracy.

I didn’t even know the word “technocracy” at the time. A colleague of mine named Nicole Saltz brought that word to my attention. I had been calling it the “technological model of birth” because it’s so focused around technology. But technocracy, I came to understand it and to develop my own definition of it. For me, a technocracy is a society developed around an ideology of progress through high technology, and the global flow of information through high technology, and also, of course, business and making money and capitalism and all of that. So, I started calling it the “technocratic model of birth,” because it’s a money-driven model, profit-oriented. It defines the body as a machine. 

If you read any obstetric textbook, it’ll say, you know, “the peritoneum is covered by cirrhosis.” It just means, you know, the birth is “the expulsion of the fetus from the uterus,” I mean, in very mechanistic terms. And so it defines the body as a machine. It separates mind from body. It focuses on the patient as an object: “the gallbladder in Room 212,” “the cesarean section in 313,” not as a human being in relationship with other human beings. It’s all about aggressive intervention with emphasis on short-term results. 

So, there’s what I call the “technological imperative”: If you can do it with technology, you will do it with technology, you must do it with technology. So, in that model, patience is not a virtue. You employ interventions as much as possible, to get the baby out as quickly as possible.

Hospitals that run entirely under this model are basically a timberline. And you don’t see that as much in the United States anymore– you see it most dramatically in developing countries that are under-resourced and they have hospitals with 11,000 women giving birth a year. I recently read an ethnography of a hospital in Mexico where doctors actually manually stretch the cervixes of the women in labor because they have such a high volume and they’ve got to get the women through, so they put the women through hell. There’s screaming in agony. The doctors are, like, ripping their cervixes to make them get to 10 centimeters as quickly as possible, to extract the baby as quickly as possible.

All that is justified under the technocratic model because the body is seen as a machine and you’re not looking at how to support or enhance normal physiology. So that’s what I call the “technocratic model of birth.” It has 12 tenets. You can go to my website, davis-floyd.com, and you’ll find the article there, The Technocratic Humanistic and Holistic Paradigms of Birth and Health Care.

The humanistic model, in contrast, defines the body as an organism, so right away we’re looking at reality– because the body is in fact an organism, it is not a machine. The metaphor of the body as a machine is a convenient metaphor because it justifies all kinds of interventions with other machines, but when you define the body as an organism, you start to look at normal physiology and try to figure out what that is and try to take an evidence-based approach to birth.

Many more American hospitals these days are humanized, much more than they used to be back in the 60s when everybody was under scopolamine and out of it. People are treated… In the humanistic model, you treat the woman as a relational subject, not as an object. She’s “Mrs. Smith with five kids, whose husband is ill.” You try to get to know her personally. It’s a relationship-centered model where relationships become important. Caregivers try to establish relationships with patients. There’s a big difference though– humanism is easily co-optable because you can paint the labor room nice colors, as Barbara Katz Rotman said, “You can hang a plant on an IV pole and call it ‘humanistic.'”

So, that’s what I call “superficial humanism,” where you paint the room all nice and you have pretty covers and the hospital is beautiful and the food is good, and people are treated kindly. And the cesarean rate at one hospital I visited that was just like that in Brazil… The cesarean rate was 100%. You know, so the women were treated with dignity and respect after they’ve had their cesarean. So that’s what I call “superficial humanism,” and then “deep humanism” is where you truly honor the deep physiology of birth, and patience is a virtue. You wait on the labor process to unfold. You don’t aggressively intervene. 

And then the other extreme is the “holistic model,” where the body is not just an organism but it’s also… but it’s more importantly an energy field in constant interaction with all other energy fields. So, in the holistic model, you talk about the oneness of mind and body and also spirit. God or Spirit comes into the equation in holism. Holistic healers believe that if spirit does exist, that it must be the most powerful force for healing in the universe. So why wouldn’t you employ it in your caregiving process?

Intuition counts in holism because it’s a form of energy, of energetic knowing. In holism, it’s a place where most obstetricians, most doctors don’t want to go, because it’s a big jump to think of the body as an energy field. The second you do that, you can understand alternative modalities, like […] homeopathy, or Reiki, or massage therapy, or Ayurveda, or Chinese medicine, all of these are holistic energy based modalities. If you don’t get the concept of the body’s energy, they won’t make any sense to you. The most important thing about understanding the body’s energy is that you start to deal with the energy around the birth, and you understand that if you intervene at the level of energy, you don’t have to intervene at the level of technology, so you can simply change the energy in a birth process. 

A great example I like to give is of a midwife friend of mine who was working as a volunteer doula in a hospital in Alaska. She was sent in to attend a young 17 year old girl, who was an unwed mother, who was terrified and all tensed up. And she was stuck at four centimeters and the hospital sent this doula in to help her and she tried to engage the woman in conversation and that the woman was too scared and she was just all balled up. And so my friend Lucia just crawled on, like, on the bed behind the mother and embraced her in her arms and let their energy fields merge and the mother was rocking back and forth and she was moaning, “Oh God! Oh God!” with each contraction in this really high tight voice.

In holism, if the body is energy, midwives postulate that there’s an energetic connection between the throat and the cervix. So, if you want the cervix to open and be loose and let the baby come, the throat must also be open and loose. So the first thing Lucia did was start rocking with her, to entrain their energy to merge their energy fields, and then she began to whisper in the woman’s ear– as the woman was screaming, “Oh God!”– Lucia would whisper in her ear in a very low guttural voice, “Oh, good! Oh, good!” And the mother began to pick that up and she kind of melted into Lucia’s arms and she began to relax. She began to naturally lower her tone of voice, “Oh, good!” she began saying as contractions came. “Oh, good! Oh, good!” And all of a sudden, she’s pushing, you know? And Lucia had to jump down and run around and catch the baby, even though she wasn’t supposed to be a doula. What had she done in that birth? She simply changed the energy. That made a massive difference in the outcome of the birth.

Adriana: That’s fantastic. That’s such a great story, and also a perfect lead to the next question I wanted to ask you: Let’s say that a pregnant person is soon going to be giving birth in a hospital with a traditional OB in a very technocratic environment. Is there a way to make that birth thing more humanistic or holistic? What are some things that could help in that situation?

Robbie: So my advice to mothers– especially first-time mothers– first of all, it’s very important to know what you want from this birth.

And it’s important to know what you’re afraid of and what you’re not afraid of. Some women are afraid of the hospital. If you’re afraid of the hospital, don’t go there to give birth! Walking in the door is going to make your body tense up in fear. If you’re afraid of not being in the hospital, then you need to be in the hospital. If you perceive the hospital as your safe place, the place where the doctors and the technology can save you and your baby, if there’s a problem, then that’s where you need to be.

So you need to know yourself in order to make the choice. You don’t choose homebirth out of some, “Oh, it sounds like it’s such a lovely idea.” You choose homebirth because it’s a firm belief that you have that homebirth is safer for you and your baby than hospital birth. And it is in many ways. Homebirth gives you less iatrogenic intervention and midwives tend not to interfere in the birth process. Statistics clearly show that homebirth outcomes are just as good as those of low-risk hospital outcomes. And so there’s no added danger or risk to homebirth. It’s just as safe as hospital birth with it planned, with a skilled midwife in attendance.

But you should only do that if you’re firmly committed to that ideology and if you truly believe in your power as a birth giver, or you want to believe in your power as a birth giver, and that’s really important to you to do it yourself. That sense of empowerment that women get when they birth completely on their own, there’s nothing like it in the world.

If you want a normal vaginal birth in a hospital, you’re very well-advised to have a doula. I mean a midwife and a doula– and in many, some areas, nurse-midwives aren’t available– but, generally, they’re much more available than they used to be. So, you want either a very humanistic obstetrician. 

How you find out if your obstetrician is humanistic or not is you look at his cesarean rates, especially for first-time births. If they’re higher than 15 or 20%, you really don’t want the guy. A lot of obstetricians have cesarean rates of 50%. If you want to schedule a cesarean, he’s your guy. But if you want a normal vaginal birth in the hospital, look for someone with a relatively low cesarean rate. And with a compassionate attitude– someone who’ll spend time with you during your prenatal visits and not shush you out the door in five minutes without answering your questions.

So, you’re well-advised to have a doula who comes to your home as soon as you go into labor. You want to establish a relationship with that doula before you go into labor and meet with her several times during the pregnancy, and then have her come to your house and the doula will know when it’s time to go to the hospital. If you go to the hospital too soon, the classic scenario is you get to the hospital at one or two centimeters and you think you’re in labor but you’re really not. You’re in what midwives call the “latent phase of labor” and that can last until five or six centimeters. It can take two or three days to get past four centimeters, you know, and that’s normal.

Then you want to stay at home with your doula (and your midwife, if you have one). You want to eat and drink as much as possible, as much as you want to, to not get exhausted. And labor is hard work! You need nourishment during labor. You want to be in and out of the tub or the shower. You want to be walking outside and then your doula will know if you really want a hospital birth, when it’s time to go, because your contractions will change. The nature of labor will change. 

And you’ll– when you enter the active phase of labor, which is at five or six centimeters and beyond– at that point, there’s not a lot they can do to you in the hospital that will slow labor down. If you go to the hospital at one or two centimeters, they’re likely to want to put you on Pitocin to speed labor up, and that produces contractions that are more painful. And so then you’re going to want the epidural. If you give the epidural too early, that slows labor. Then you need more Pitocin to speed labor up again. Then the baby goes into distress because of the added stress of the Pitocin-induced contractions. And then you end up with an emergency cesarean and you say, “Oh, Doctor, thank you for saving me and my baby,” when it was the hospital interventions that caused the problem in the first place!

So to avoid that and to have a normal vaginal birth in the hospital, you want to bring with you your doula, you want to have a nurse-midwife with you if at all possible, and or… if you want that, and then you want to go to the hospital when you’re well into active labor, well past five centimeters. Go to the hospital then. And then you want a hospital that hopefully offers labor and water, at least the option of being in showers. You want to avoid being hooked up to the monitor continuously, because the essence of a successful labor is movement. You need to be moving during labor. The monitor and the epidural hold you still, they imprison you, they tether you.

And I should say that with a caveat– there are some very savvy doulas and nurses who know how, if you have an epidural needle in your back leading to a tube, you can move a few feet away from the bed, so you can actually get out of bed, even with a monitor belt on, and you can sit on a birthing ball and rock back-and-forth, rock your pelvis. You want to move your body because the more movement during labor, the more the baby descends, the easier the descent is, and the more successful the contractions are at pushing the baby down. So you want to be moving as much as possible, you want to be… 

Don’t let anybody tell you not to eat or drink. Smuggle food in! When you’re truly, truly in active labor, you won’t be hungry. If you’re hungry, that means you’ve got some more hours to go, you want to eat to keep up your strength. Right? So take the doula, don’t go to the hospital until you’re five or six centimeters, go with your doula and make friends with the nurses, you know, be nice to them so they’ll be nice to you, and that’s the best way to achieve a normal vaginal birth in the hospital.

Adriana: So many great tips and recommendations! And it does require learning about these things beforehand. I love that the first thing is “know what you want” and “know what you fear” and “figure out where you feel the safest.” So if we step back to those months in pregnancy in preparation to get to this point, do you have reading recommendations, viewing recommendations, other suggestions to help moms sort of get to that point where they’re really believing in their power as birth givers?

Robbie: Yes, my least favorite book for pregnancy is What to Expect When You’re Expecting, mostly because they don’t give you very much information. They mostly just say “ask your doctor,” “talk to your doctor.” It’s not a very empowering book. My favorite book for pregnancy has always been Sheila Kissinger’s either The Complete Book of Pregnancy and Birth or The Complete Guide to Pregnancy and Birth, the latest edition that there is. I love that book because it gives women so much information. It’s so empowering. They help you make truly informed choices. 

And I would suggest that they watch The Business of Being Born and Orgasmic Birth– that’s a great one for getting you into the frame of mind for a normal natural birth. For people who are offended by the term “orgasmic birth,” the producer, Debra Pascali-Bonaro, made a second video called Organic Birth, which some people are, you know, more receptive to the title. But those, and yes, there’s a treasure trove of wonderful videos out there on YouTube and elsewhere. It’s very, very empowering to watch other women go through labor and to read other women’s birth stories as well. 

Adriana: Correct me if I’m wrong: I have heard that there seems to be, in the near future, we’re looking at, a possible shortage or decrease in OBs in the U.S., and that that’s going to create some change in terms of needing more midwives balancing out. What is the truth in that, and what do you see happening? (Or you can estimate…),

Robbie: I… Okay, so the World Health Organization jointly with the International Confederation of Midwives, a few years ago, issued a global call for 350,000 more midwives worldwide. What’s happening in developing countries is that the traditional midwives– or so-called “traditional birth attendants,” which is a term anthropologists don’t like because we think it disparages their role as midwives to their communities– but traditional midwives are being phased out around the world in developing countries that are trying to modernize, and they see traditional midwives as these pre-modern vestiges of the past. Even though many of them have done thousands of births and are extremely capable and competent practitioners, they carry this aura of scraggy old ladies in shawls or saris that the governments of their countries don’t like and don’t want to support. So, they’re trying to get rid of traditional midwives and replace them with skilled professional midwives. Not that traditional midwives aren’t skilled– they are!– but in the language of the health and development community, it’s all about skilled birth attendants, mostly primarily midwives who need to be trained around the world. 

Certainly in the U.S., we have a huge midwifery shortage. Midwives only attend about 12% max of all the births in the country, which is ridiculous. In Europe, midwives attend 80% of the births. In the countries with the lowest intervention rates and the best outcomes, like the Scandinavian countries and The Netherlands, midwives attend the vast majority of births. In New Zealand, you have a midwife at every birth. Even if it’s a scheduled cesarean, there’s still a midwife there beside you to hold you and hold your hand and support you. So there are some countries with fabulous midwifery systems, like The Netherlands and New Zealand, like Norway and Denmark, which have cesarean rates of 17% and 19% respectively. But then there are, you know, lots of countries where there’s a huge shortage of midwives as there is in Canada, as there is in the U.S., as there is all over Latin America and Brazil. They do have nurse midwives. They attend maybe, maybe 7% of the births in the whole country. So, yes, there’s a huge need for more midwives. Anybody who wants a marvelous profession that– okay, yes, it’s years of training and it’s a lot of hard work– but midwifery is a fantastic profession and I encourage women to go into it, women and men.

Adriana: Absolutely! No, that’s… it’s… I totally hear that we need more midwives. And part of what I was asking, though, that I’ve been hearing about is that there’s a projected future shortage of OBs in the U.S., which sort of leaves […] to me, that seems like a great opportunity to fill it with even more midwives, if that’s where it’s going.

Robbie: Yes, and that’s what I was trying to say; thank you for bringing me back to the point. Yes. We do not need as many OBs as we have, at least not for births. OBs should be attending the 15-20% of actually high-risk births that actually need skilled specialist care like that. Midwives are skilled specialists in normal births. OBs are skilled specialists in pathology. Well, most births are not pathological, but an obstetrician will turn almost any birth that he can into something pathological because he’s trained to only perceive pathology. Midwives, on the other hand, are trained in normal, and so they recognize deviations from normal because they know normal, so they know when to call in an OB because they see that it’s not normal. Whereas the OB generally sees only pathology and doesn’t know how to keep birth normal because that’s not his training. His training is in pathology. So honestly, OBs should be doing no more than 20% of the births in any given country and midwives should be the primary birth attendants. That’s how it ought to be.

So a shortage of OB doesn’t bother me the least. I just hope we get more midwives. We need more midwifery programs, more funding for them, more women entering them, all of that.

Adriana: Yes. And hopefully more of a collaborative model between the OBs working together with midwives, and then they can see less pathology and observe a little bit more normal and have this more humanized OBs and holistic OBs, like your groupies in Brazil.

Robbie: Absolutely. One of my dear friends, Richard Jennings, is one of a few male midwives. Did you know, globally, 1% of midwives are male? Like, everywhere in the world, it’s about 1%. Well, he’s part of that 1%. He’s the Director of Midwifery training and the Clinical Director at Yale. And he has helped organize– they call it their maternity, their labor and delivery ward– they call it The Center for Physiologic Birth. And they’re staffing it with midwives and they’re training the OB residents right alongside, neck to neck and shoulder to shoulder, hand to hand, with the midwifery students, so that the OBs are learning from the midwives as they go, so that they’re internalizing what we call the “midwifery model of care,” which is the combination of the humanistic and the holistic models in my language.

And so, yes, OBs need to be trained with midwives, they need to respect midwives. Most obstetricians tend to think of midwives as subordinate to them, because they’re nurse-midwives. You know, the hospital-based midwives anywhere are nurse-midwives, and that’s not how it should be. Midwives are skilled specialists in their own right– skilled specialists in normal birth. And so they should be on a collaborative level with doctors. Doctors should consult with them. Midwives should be able to refer cases to doctors when necessary, and doctors should refer those cases back to the midwife if the situation stabilizes and the pathology goes away.

Adriana: Absolutely! It’s been an absolute delight talking to you today.

Robbie: Thank you! I appreciate you having me on.

Adriana: That was medical anthropologist Robbie Davis-Floyd, who is a prolific writer, having authored over 80 journal articles, 24 encyclopedia articles, and also authored, co-authored, edited, or co-edited many, many books. Most recently, she is the co-author of the three volume anthology titled The Anthropology of Obstetrics and Obstetricians: The Practice, Maintenance, and Reproduction of a Biomedical Profession.

As a board member of the International Mother Baby Childbirth Organization, Robbie helped to wordsmith The International Childbirth Initiative 12 Steps to Safe and Respectful Mother Baby Family Maternity Care, which is available at icichildbirth.org To learn more about Robbie and read her articles, go to davis-floyd.com

And you can connect with us @birthfulpodcast on Instagram. In fact, if you’re not driving, we would love it if you would take a screenshot of this episode right now and post it to Instagram, sharing your biggest takeaway from this episode. Make sure to tag at @birthfulpodcast so we can see it and amplify it.

You can find the in depth show notes and transcript of this episode at birthful.com, where you can also learn more about my small birth prep classes and download your free postpartum preparation plan. Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.

This episode was produced in part by LWC Studios. Paulina Velasco, Virginia Lora, and Cedric Wilson. Thank you for listening to Ensuring Birthful. Be sure to follow us on Apple Podcasts, Spotify, Amazon Music, and everywhere you listen. And come back for more ways to inform your intuition.

CITATION:

Lozada, Adriana, host. “What You Need to Know About Birth Models (Birth What?)” Birthful, Birthful. September 20, 2023. Birthful.com.