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).
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.
of Mother-Friendly Maternity Care --
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
ethical foundation of the Midwifery Model of Care (MMC) rests on the autonomy
of the Childbearing Family. This recognizes that each
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.
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.
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”).
the Elements of Success
for Spontaneous Labor and Birth
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
|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.
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
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 ˝ 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
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