Distinction
Between

Midwifery
and
Medicine Care

Defining the
Physiological
Model of Care
for
 Normal Childbirth
  

Information to make an informed decision before choosing midwifery care:

As professional midwives chosen by you, we want to be sure that you understand the fundamental difference between the Midwifery Model of Care, the rights and responsibilities that are associated with midwifery care (both for family & caregiver) and the medical model of care (physician & hospital services). 

We ask that you and significant families members read the following description of the principles of Midwifery as a model of “Mother-Friendly Maternity Care”. We are happy to answer in additional questions that may arise and encourage you to also read the “Mother-Friendly Childbirth Initiative” published by the Coalition to Improve Maternity Services (CIMS) of which we are a member.

 

Principles of Mother-Friendly Maternity Care --
Mother as primary caregiver
to her unborn / newborn baby  

The childbearing woman should be respected as a self-directed individual and not viewed as a "patient" in the sense of being infirm or incompetent. Caregivers must recognize that the integrity of the mother-child relationship begins in pregnancy. Pregnancy produces a mother as well as a baby. This mutual integrity is compromised when the mother and baby are treated as if they were separate units with conflicting needs. Both statutory and case law supports the autonomy of adults, including childbearing women, to make healthcare decisions in all but "extremely rare and truly exceptional circumstances".

The autonomy of parents is acknowledged and promoted in a midwifery-based Mother-Friendly maternity care system, in which the mother is viewed as the primary caregiver of her baby. This begins with her decision to seek out some form of maternity care and continues in the daily life of the mother as she pursues a healthy life style, good nutrition, appropriate prenatal education and avoids excessive stress and toxic situations (people, places and things!). The mother has the best opportunity (even better than physicians or midwives) to monitor her own well-being and that of her fetus or newborn baby and if she detects potential problems or complications to communicate them to midwife or to medical care providers. No one is closer to or cares more about your baby’s welfare than you do. Without such astute observations and corrective interaction initiated by parents as “primary” caregivers relative to the pregnancy and the unborn baby, the role of professionals would become irrelevant, as we cannot be there 24-7, feel your pain or see in the dark.

Based on proven safety and cost-effectiveness, scientific, evidence-based practice parameters identify the midwifery-model of care for healthy women with normal pregnancies to be ideal. That ideal includes voluntary access to domiciliary (non-institutional, community-based) birth services for healthy mothers who choose to be cared for in homes or birth centers by skilled midwives or physicians. This includes easy access to hospital-based obstetrical services for complicated pregnancies and for mothers who desire medication or require anesthesia during the labor or birth. The safest form of midwifery is that which is well-articulated with obstetrical services and the safest form of obstetrical service is that which is integrated with the midwifery model of care.

World-wide maternity statistics testify to the superior outcomes for both mothers and babies of midwifery care, liberal breastfeeding, female literacy, valuing the parent-child bond and access to obstetrical medicine for complicated pregnancies. For the better part of the last two centuries these common-sense methods have been strongly associated with both good outcomes for mothers and babies and low rates of maternal-infant mortality and morbidity. They are the lynch-pin of cost-effective healthcare for childbearing families as financed by governments and other third-party payers.

Legal and Ethical Foundation for Care

The ethical foundation of the Midwifery Model of Care (MMC) rests on the autonomy of the Childbearing Family. This recognizes that each childbearing woman is the primary caregiver to her unborn and newborn baby. The proper role of a midwife is to assistant the mother in carrying out her maternal responsibilities and to help the mother in maintaining her own and her baby’s health. During the intrapartum, the midwife’s role is to provide for physiological management, to guard and guide the labor, assist the mother and function as an advocate for both mother and baby. The experienced midwife is an educated observer with emergency response capacity.

A childbearing woman has the right to expect that her midwife will act responsively to protect and promote the mother’s own physical and mental well-being and facilitate the development of a functional family unit to effectively and compassionately parent the new baby. Midwifery care is offered only at the request of and only with the permission of the mother and her family.

Informed consent is a safeguard for the mother’s best interests and is a protection from inappropriate paternalism or practitioner “preference”. Mother’s informed choice consent or informed decline of standard midwifery / medical interventions is to be honored in all but those emergent circumstances in which there is a clear and present danger of death or permanent disability to either mother or baby (the principle of health caregiver as proxy decision-maker) and for which medical, obstetrical or neonatal care offers a dependable treatment of acceptable risk to the individuals and society.

Proxy Decision-making   This refers to emergency medical decisions made for the mother (or parents) by health care professionals due to the inability of the mother (or parents) to give timely informed consent. The mother should identify someone ahead of time to act as a proxy decision maker for her or the baby in case she is unable or unavailable to do so. Most often the identified proxy is her husband (or the baby’s father) or other trusted family members. The parental-caregiver contract also contains a measure of assumption that the healthcare provider / midwife will take on a proxy decision making role in the presence of evident need. This occurs in emergent conditions requiring rapid response and specialized knowledge. This situation can occur as the result of temporary maternal illness, medication (especially narcotics) anesthesia or loss of consciousness. Examples of emergent circumstances are bleeding problems for the mother or breathing problems for the baby or neonatal emergencies that occurr when the parents are not present in the hospital.

These principles of informed consent are consistent with American College of Obstetricians and Gynecologists (ACOG) guidelines which respect the autonomy of childbearing women (ACOG Statement of Policy # 1067), principles of client autonomy as defined and promoted in obstetrical textbooks  (Gabbe's “Normal and Problem Pregnancies”, 1992 edition), the Mother-Friendly Childbirth Initiative by CIMS, Safe Motherhood Initiative as initiated by the American College of Nurse Midwives, and Maternity Center Association Statement of Right of Childbearing Women.

Mother’s right to special considerations: Relative to a history of physical, emotional or sexual abuse or other unique psychological factors, childbearing women have the right to choose obstetrician-only care, pain medications, anesthesia and/or elective surgical delivery even though medical and surgical procedures carry with them additional risks to her and her fetus / neonate. Other examples of special circumstances are considerations based on ethnic, cultural or gender-identity, a recognition of specific spiritual values and those asking for care under the religious exemption clause (California B&P Ch.5, section 2063) who for religious reason may decline standard medical protocol, testing or interventions (absent a “clear and present danger”).

Understanding the Elements of Success
for Spontaneous Labor and Birth

 Non-erotic sexual nature of childbirth: The elements of success necessary for spontaneous (natural) physiological childbearing begins with a recognition of the quasi-sexual nature of childbirth. Spontaneous biology is heavily influenced by social and psychological factors (both mental & emotional states) that are themselves an extension of normal reproductive sexuality. Acknowledgement of the non-erotic, but none-the-less sexual, aspect of childbearing is to recognize that normal labor and birth involves the same biological structures as sex and toileting.

Equally important, childbirth entails many of the same psychological principles necessary for physiological function in both sexual and excretory biology. In the natural world, childbirth usually occurs in the privacy of bathroom and bedroom in which only the closest and most trusted of friends and family members are present.

 

These principles acknowledge the mother’s physiological need for privacy and her right to voluntariness in permitting the participation of persons and procedures that transgress the boundaries of her body or sexual psyche. It also includes freedom from performance pressure and arbitrary time constraints. The childbearing woman has a right to that quality of care from her companions and her caregivers that does not disturb or interfere with normal physiology of spontaneous progress in labor & birth.

 

By creating a protected environment in which the laboring woman feels secure and yet unobserved, with emotional support by familiar people, midwifery care addresses the mother’s pain, her fears and her privacy needs so that labor can unfold naturally, without need for labor accelerating drugs, narcotic pain medications or unnatural bravery on the part of the mother-to-be. This includes an environment in which the mother feels free to make sounds of all sorts and to be unclothed if she chooses. Many women find that their labor cannot progress naturally without a supportive environment and encouraging, trusted companions.

Right Use of Gravity

It is also necessary to take into account the positive influence of gravity on the stimulation of effective labor. Maternal mobility not only helps this process along but also diminishes the mother’s perception of pain (perhaps by stimulating endorphins). Right use of gravity stimulates labor, dilates the cervix and facilitates the decent of the baby through the bony pelvis. The complex interplay of the physical and the psychological are such a biological verity of childbearing that women have an undeniable right to have the maternity care provided to them be structured to address both the gravitational influences and the quasi-sexual nature of spontaneous labor and physiological birth. [Safety of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]

   

To ignore the well-known relationship of gravity to spontaneous progress is to do so at the peril of mother and baby. Anti-gravitational maternal positions (with the mother lying on her back) means she must push the baby uphill around a 60 degree angle in the pelvis and through a partially closed door, as the pelvic outlet is reduced by up to 30% when the mother is weight-bearing on her sacrum. This non-physiological position also restricts blood flow to the uterus and placenta as the baby’s weight rests on the large blood vessels. This increases maternal pain and fetal distress by depriving both of necessary oxygen.

Medicalized Model of Care (non-physiological)

In the absence of this quality of physiological support, which is the core of the traditional midwifery model of care, laboring women frequently need narcotic medications and secondarily the use of artificial hormones to overcome the labor-retarding effects of pain meds. Pitocin-augmented labors require continuous electronic fetal monitoring, which means the mother must remain in bed except for bathroom breaks. IVs and CEFM effectively prevents the use of about 90% of the non-pharmaceutical pain relief strategies and techniques. The mother cannot move easily, walk around, get in the shower or a deep-water tub, etc. Very soon the pain of an induced or Pitocin-accelerated labor, combined with being tied to the bed by plastic tubes and electronic wires, becomes too much to tolerate. The intensified pain of an augmented labor, with its unnaturally strong, long and close together uterine contractions (every 2 ½ minutes) while unable to move freely is a set-up for epidural anesthesia. At this point a helpful doctor or nurse will ask the mother if she is ready for ‘her’ epidural yet.  Under these unnatural circumstances, it is not “if” but “when” the remainder of the typical interventions will be employed  - a condition described as “sensitive dependence on initial conditions”.

The painful anti-gravitational maternal position, which restricts blood flow to the uterus and placenta, in conjunction with equally deleterious effects of narcotic pain medications, anesthetic agents and unnaturally frequent and powerful uterine contraction due to the Pitocin (in part to off-set the labor slowing effect of the other drugs), frequently leads to signs of fetal distress on the EFM tracing. If giving the mother oxygen and rolling her over on her side does not help within a few minutes, it will be decided to delivery the baby quickly via the surgical interventions of episiotomy, forceps, vacuum extraction, or cesarean section.  This often represents the failure of the maternity care system (or individuals within it) to account for the influence of the mother’s psyche in regard to the events of labor and birth, ultimately “curing” with otherwise unnecessary surgery what started out as normal but unmet physiological needs or problems.  In regard to the physical, physiological, social or gravitational needs of childbearing women, an ounce of prevention is truly worth a pound of cure.  [Safety of Alternative Approaches to Childbirth;  P. Schlenzka, 1999