It was 1960 and public-health officials in Madera, Calif., in the fertile San Joaquin Valley between Fresno and Stockton, has a problem.
Doctors and nurses were in short supply at the county hospital where indigent black and Mexican-American women -- many of them under 20 and part of the migrant stream that harvested the cotton, grape and citrus crops -- came to have their babies. The soaring infant-mortality rate reflected the shortage. For every hundred babies being born, three did not live to be a year old and four-fifths of these died in the first month.
Then two certified murse-midwives, paid by the State Halth Department, arrived at the hospital. Thereafter, all its maternity patients were examined by a physician, but the nurse-midwives took charge of most of the expectant mothers from prenatal care through labor and delivery.
Soon, more women began to come in early in pregnancy for regular prenatal care and fewer of their babies were premature. At the same time, the rate of infants dying in the first month dropped from 23.9 to 10.3 per 1,000 lived births -- only to climb to 32.1 per 1,000 live births three years later when, because of opposition from the California Medical Association, the nurse-midwives left.
This sort of experience is familiar not only to the two physicians and one public-health specialist who reported it in the Jan. 1, 1971 issue of "The American Journal of Obstetrics and Gynecology." It is also an old story to those who know the histories of a number of other U.S. projects where nurse-midwives have done themselves proud.
These include the Frontier Nursing Association in Kentucky, Su Casa Maternidad in Texas, the Maternity Center Association in New York City, the now defunct Chicago Maternity Center and the Booth Maternity Center in Philadelphia, to name just a few. Moreover, in several European countries with lower rates of infant death and birth trauma than our own, highly trained professional midwives provide most of the obstetrical care, turning their patients over to physicians only when complications arise.
If the performance of midwives has compared favorably for normal pregnancies with that of obstetricians in these rural and urban settings -- and it has -- a greater reliance on midwivew in the District of Columbia, whose infant death rate has been called a "public embarrassment," might also pay dividends.
Doubtless, many obstetricians in this city might object. They are already discomfited by the presence here, at Georgetown University, of one of the 24 programs in the nation that prepares registered nurses for the certification examination of the American College of Nurse-Midwives. And they do not like it either that three of the Georgetown graduates have formed a group practice in Bethesda, that has delivered more than 600 infants to middle-class metropolitan area couples at home in the last three years with no maternal deaths and the loss of only a single infant.
With the trend toward smaller families, the business of obstetrics has become highly competitive. Yet the facts are that most of these same obstetricians do not accept Medicaid patients and that, in any case, their offices are in parts of the city far from where the poor patients who need their services live.
Nor does it seem likely that Mayor Barry's Department of Human Resources (DHR) can recruit enough obstetricians to practice at its neighborhood clinics. With the average obstetrician in this country said to be earning $90,000 a year and few (according to DHR Director Albert Russo) willing to come to work for much less than half of that, there is a limit to the number the city can attract.
Certified nurse-midwives are content with more modest incomes, as is attested to by the salaries of those employed by the Group Health Association and by D.C. General Hospital.
But it is not a matter of money alone. It is also a question oforientation and attitude. In contrast to obstetricians, who are biased toward treating pregnancy and childbirth as an illness, nurse-midwives are educated to regard them as essentially normal processes that require the encouragement of good health habits. In the nurse-midwives' view technological intervention -- with its risks as well as benefits -- is called for only if nature somehow falls down on the job.
The upshot is that murse-midwives often have far more rapport with pregnant women than do obstetricians -- and not just because patient and professional are of the same sex. (Some nurse-midwives, in fact, are males.) And they alsos have more of that commodity -- time -- which is particularly precious when an expectant mother is young, economically disadvantaged and put off by the impersonality of our system of health care.
It is, of course, precisely that sort of young woman who has brought to the District of Columbia the dubious distinction of having the highest infant-death rate in the nation for a city of its size. While no one would suggest that Washington forego the skills of obstetricians and neonatologists as it attempts to solve this problem, why not give midwives a bigger role and enlist them as frontline troops?