The 20th Century was a golden age for maternity care. With the advent of modern obstetrics, childbirth went from a routinely deadly event to a rarely deadly advent. A myriad of interventions, from antibiotics to blood banking, from safer anethestia to safer C-sections, from neonatal ventilators to surfactant led to a 99% drop in maternal mortality and a 90% drop in neonatal mortality. The medico-technocratic model of maternity care has been a stunning success.
But the medico-technocratic model of care placed the the convenience of physicians ahead of maternal autonomy, and the midwifery model of care was advanced as a corrective. The midwife model of care put the focus back on women’s experience. Once childbirth was routinely safe, it made sense to focus on more than whether the mother and baby survived the experience. The midwife model of care acknowledged that many practices existed merely for physician convenience and offered no benefit for women and perhaps harmed them, or at the very least was cold and impersonal. Making sure that mothers are awake and aware for the birth of their children, inviting partners and other family members in for the birth, and rigorous investigation of routine maternity practice dramatically improved women’s experience.
Although the midwife model of care has brought improvements, it suffers from a similar problem as the medico-technocratic model of care. It still puts the provider at the center of care. The midwife model takes the core beliefs of midwives as incontrovertible fact, specifically the idea that there is a “best” way to give birth and that best way involves as little technology as can possibly be used. Midwives start with the bedrock assumption that unmedicated vaginal birth is the ideal and anything else represents a deviation from ideal. It uses midwives beliefs as its starting point, and that’s the wrong place to start.
I propose a new model of childbirth care for the 21st Century: a materna-centric model of care. A materna-centric model would take the best features of the two previous models, the dramatic improvement in safety wrought by the medico-technocratic model, and the focus on experience provided by the midwife model, but it would locate mothers at the heart of maternity care, their views, their values, their desires. The materna-centric model of care would have as its fundamental premise the idea that birth experiences are contingent on maternal culture, values and personal experiences. When you place the mothers values at the center, it is obvious that there is no best way to give birth; there is only what the mother prefers.
There is no need to glorify vaginal birth, and no reason to valorize refusing pain relief. The model is both culturally sensitive and personally sensitive. What constitutes a good birth is going to be different for a woman from Southeast Asia than for a woman from the US Southeast. What constitutes a good birth for a woman from a fundamentalist religious sect is going to be different from a good birth for a woman who works in the tech industry. Nobody is wrong. And, most importantly, no one’s birth choices make her superior to anyone else.
It may be helpful (albeit imperfect) to draw an analogy between maternity providers and interior decorators. Obstetricians can be understood as decorators who limit their designs to spare and functional choices. They decorate houses with every piece of furniture you need, but much of it is drab, and some of it is not comfortable. Midwives go beyond obstetricians in that their designs are colorful and comfortable. There’s just one problem; they only decorate in their preferred style, shabby chic. The equivalent of the new maternity provider (doctor or midwife) would be a decorator who decorates in the style that the client prefers, not the style that is most convenient for the decorator or most pleasing to the decorator.
The midwife model of care is outdated because it places the midwife at the heart of maternity care. As a result, it serves the needs of midwives, but leads to unnecessary suffering and tremendous guilt on the part of mothers. We need a model of maternity care that places mothers squarely at the center of care, and uses their values as the touchstone for decisions, not the provider’s values.
In other words, we need a materna-centered model of care.
