Birthing in Challenging Times

Birthing in Challenging Times A midwife can provide safe care for expectant Muslim mothers

BY ROMY SHARIEFF

The coronavirus pandemic is leading some expectant mothers and their families to consider midwifery care for an out-of-hospital birth, which would help reduce exposure to COVID-19 and other pathogens that can adversely affect the mother and the newborn’s health.

Considering the limited availability of data on the potential complications on fetal development if a healthy mother contracts the virus during pregnancy, the Royal College of Obstetricians and Gynecologists (RCOG), has strongly advised expectant mothers to practice social distancing to minimize potential risk (https://www.rcog. org.uk).

In the U.S., telehealth is quickly being adopted as an alternative to face-to-face routine care. Yet, a vulnerability exists when health care facilities provide labor and also deliver services simultaneously with care of the sick.

Even before the onset of the current pandemic, the U.S. had the worst maternal death rate of any developed nation, where non-Caucasian women are represented disproportionately among the fatality figures (https://www.npr.org, May 12, 2017). One study found that “40 percent of deaths from pregnancy-related complications were potentially preventable, mainly through improved quality of medical care” (https:// www.americashealthrankings.org). That is an alarming conclusion.

The World Health Organization (WHO), which designated 2020 as the “Year of the Nurse and Midwife,” is pushing for increased access to midwives as the first line of defense to improve birth outcomes (https://www. cdc.gov/nchs/data/vsrr/vsrr-007-508.pdf). The ability of certified nurse-midwives (CNM) and certified professional midwives (CPM) to reduce maternal morbidity and mortality around the world has finally come into focus. According to the WHO, “83% of all maternal deaths, stillbirths and newborn deaths could be averted with the full package of midwifery care” (https://www.who.int).

Even in the current health crisis, midwifery care is still poised to deliver on that statement.

THE WORLD HEALTH ORGANIZATION (WHO), WHICH DESIGNATED 2020 AS THE “YEAR OF THE NURSE AND MIDWIFE,” IS PUSHING FOR INCREASED ACCESS TO MIDWIVES AS THE FIRST LINE OF DEFENSE TO IMPROVE BIRTH OUTCOMES.

The WHO defines midwifery as “skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum throughout pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life.” A midwife is trained to handle low-risk pregnancies and various complications that may occur during birth. In a comprehensive study published in 2014, the safety of a planned home birth and freestanding birth centers of a low risk pregnancy with a midwife was indisputably documented(https://onlinelibrary.wiley. com/doi/full/10.1111/jmwh.12172). We also need obstetricians who are trained to handle high-risk pregnancies. However, in areas such as Scandinavia, where midwives are the primary birth attendants, phenomenal outcomes have been noted when compared to those in the U.S. As more American states continue to recognize midwives, more consumers can legally access the benefits that they provide.

Midwifery care also strives to provide holistic care and create an environment that empowers clients. Although there is science in childbirth, there is an even stronger element of trusting intuition, instinct and tradition, for this is perhaps one of the most life altering events a woman experiences as she transitions into motherhood. Islam recognizes and honors that journey so much so that the Arabic word for “womb” — rahm — comes from the same root as al-Rahman, one of God’s attributes.

Anecdotal accounts state that a midwife named Shifa’a bint Amr (‘alayha alrahma) attended the Prophet’s (salla Allahu ‘alayhi wa sallam) birth and that midwives also attended his children’s births.

But, what does it mean to contemporary

Muslims to have access to an out-of-hospital birth with a midwife during these uncertain times? What makes midwifery care attractive, other than minimizing risk to potentially harmful infections?

Equity. We live in a time of widespread Islamophobia. There are documented cases of discrimination against Muslims, specifically women wearing hijab. Unfortunately, health care workers are not exempt from mistreating patients. Generally, the midwifery model of care values building relationships based on mutual respect, compassion and non-maleficence.

Modesty. Preserving modesty with midwifery care may be more effortless than in a hospital. Although patients have the right to request a different attendant, such as a female obstetrician, fulfilling such a request may be difficult due to staffing constraints. In a home birth practice, families typically know who will attend the birth because they have already developed a relationship with

PHOTO © ROMY SHARIEFF

the provider and assistants during the course of prenatal care.

Honoring a Birth Plan. A midwife can offer each client an environment that better individualizes care. Midwives practicing out of hospital can usually incorporate religious values, traditions and personal preferences more easily than hospital providers. For example, some Muslims wait to announce the baby’s name until the ‘aqeeqa. However, hospital protocols may require the child’s name before discharge. Depending upon locality, midwives may have more flexibility in filing birth certificate papers.

Respecting Religious Values. Various hadiths support particular childbirth practices such as reciting the adhan in the newborn’s ear and the iqama in the left ear (“Sunan Abu Dawud,” vol. 5, p. 518); eating, drinking and mobility while in labor (19:23-26: Mary’s [‘alayha as salam] birthing of Prophet Jesus [‘alayhi as salam]). Inherently, out-of-hospital midwifery care is more flexible so integrating most special requests can happen easily.

Support. As a precaution to minimize the spread of COVID-19, some hospitals are limiting or denying women labor support during birth. While some home birth midwives are implementing similar policies, some are using discretion by limiting those who had possible exposure or are actively showing symptoms. Why is that important? A Cochrane review in 2017 noted that women who had labor and emotional support provided by doulas — a person, typically without formal obstetric training, who is employed to provide guidance and support to a pregnant woman during labor — appeared to have shorter labors, more spontaneous vaginal births and a decreased rate of interventions such as caesarean, instrumental births or use of analgesia (https://www.marchofdimes.org).

Autonomy. The term “informed choice” is used to denote an individual’s right to make his/her own health care decisions using evidence-based information on the details, risks and benefits of the options given considering his/her own situation. However, sometimes relevant information may be withheld — for instance, Cervidil, a common prostaglandin used in hospital induction, is porcine derived. Whether or not it is halal for medicinal use is important, but the larger issue is whether Muslims are informed about this fact and would they accept it if they knew? Informed choice and shared decision-making are at the core of midwifery care. Acquiring knowledge and making well-informed decisions is also a cornerstone of Islam.

As COVID-19 continues to unfold, it will take time to fully understand its implication on birth outcomes. But, the WHO contends that midwifery care is ready to make a positive difference in maternal health care, even during a crisis. For Muslims and those seeking a safe alternative to hospital care, midwives integrate skill with holistic care. Hindsight can be 20/20, but there is an opportunity now, in the present moment, to leverage midwives to simultaneously support Islamic values and improve birth outcomes. ih

Romy Sharieff, a licensed midwife and ambassador for Midwives for Haiti, has a master’s degree in engineering. She is the founding contributor of the Bryan J. Westfield Scholarship and can be reached at prenatalyoga@midwivesforhaiti.org.