Midwifery and Childbirth in America (review)

Judith Pence Rooks. Midwifery and Childbirth in America. Philadelphia: Temple University Press, 1997. xxvii + 548 pp. Tables. $34.95 (paperbound).

Judith Rooks offers a valuable addition to the literature about the profession of midwifery at the end of the twentieth century. A certified nurse-midwife, a past president of the American College of Nurse-Midwives Foundation, and an epidemiologist with a long career in public health at the Centers for Disease Control, she regards midwifery as a means to improve public health. Supported by the Carnegie Foundation, her book addresses "an enormous, pervasive ignorance about midwifery and the kind of care needed by pregnant women" (p. xxi).

Rooks writes in the hope that more complete, accurate, and objective information will erase such ignorance--yet few ordinary women or men will read her five-hundred-page analysis. And most obstetricians, as she points out, resist evidence about their procedures' "contradictory" effects. She writes primarily for midwives, informing them in full detail about the variety of their achievements and fortifying them against obstetrics' dominance. Given the great diversity among midwives, this is a notable effort and probably the central motive for the book. She writes for policymakers as well, advancing a broad argument about midwifery's advantages for public health. She gives only cursory attention to the psycho-social background of childbearing, such as why women select midwives; the focus throughout is on the intentions and achievements of a diverse group of women who attend births. The book is comprehensive about licensing procedures, local initiatives, and governmental regulations.

After a series of short chapters on the history of obstetrics and midwifery, chapters 5 through 8 assess maternal and infant health under the dominant health-care system after 1980, lay out the differences in philosophy, experience, and objectives between midwifery and obstetrics, examine the "clientele" of midwifery, and describe the laws, education, and practice of nurse-midwifery.

In chapter 9 Rooks provides new information about entry-level midwives, those women who practice midwifery in some states with limited formal training and some certification, and who attend about twelve thousand births a year. Some have taken competency courses and have built back-up relations with physicians. They are bonded by their belief in home birth and their opposition to typical obstetric care. They are part of a larger group of independent "lay" midwives, many of whom oppose any certification or "entry" into medical practice, and who attend groups of highly motivated, middle-class women in numbers nearly impossible to assemble. The relations between the entry-level, the lay, and the nurse-midwives are very problematic. Rooks describes the troubled efforts to forge professional alliances between these different groups, such as nurse-midwives' attempts to provide education for other midwives in conferences, schools, and clinical training opportunities. She describes the care that entry-level midwives offer prenatally, for pain, and for serious complications. Her new information about this elusive group is fascinating.

Chapter 10 details nurse-midwifery's noteworthy successes in reducing rates of low birth-weight and cesarean section in hospital deliveries involving those women most at risk because of their socioeconomic status. Physicians often refer such patients to nurse-midwives; Rooks shows that nurse-midwives use fewer invasive procedures and have better outcomes than physicians. Chapter 11 reports what is known about the safety of home births involving entry-level midwives, nurse-midwives, and physicians, as well as births without attendants. Unplanned out-of-hospital deliveries have higher neonatal mortality than planned deliveries out-of-hospital; the latter have lower neonatal mortality than planned in-hospital deliveries. Rooks is cautious in making invidious comparisons between places and practitioners; everything points, however, to the safety of planned home delivery. Chapter 12 describes the cost, and the cost-effectiveness, of employing nurse-midwives. Chapter 13 compares U.S. midwifery with midwifery in Europe, Canada, Australia, New Zealand, and Japan.

Rooks provides many other insights. She clearly and fairly compares the...