Science & Safety of
and the Physiological Foundation of Evidenced-based Midwifery Care
faith gibson, LM, CPM
Part I ~ Science, Safety and Medical Interface
Who & What: The historic definition of midwifery is “The care of healthy childbearing women and their babies during the normal events of physiological childbearing". Midwife-attended home birth is a planned (non-emergency) event occurring to a healthy mother experiencing a normal pregnancy who self-selects to remain at home and does not plan on using labor stimulants, pain medication or anesthesia. Mothers who are appropriate candidates for community-based midwifery must experience a spontaneous onset of labor at term, progress unaided by drugs and in a timely fashion through the stages and phases of labor and must give birth while both she and her baby are adequately hydrated.
Those women who desire or require medical assistance in any of these areas are transferred to hospital-based obstetrical management. However, it should be noted that a search of over a million California birth registrations to determine retrospectively how many women actually fall into this category of “normal” (no maternal or fetal complications antepartum or intrapartum and no need to employ “artificial, mechanical or forcible means” to bring about the birth of a healthy live baby) revealed that approximately 70% of labors were normal. This large cohort of childbearing women would not have necessitated referral or transfer of care from midwifery to medical management unless the mother desired pharmaceutical pain management [“Safety in Alternative Childbirth”, P. Schlenzka, 1999]. Among the subset of women who self-select for home based care the figure for normal birth is even higher, depending on the parity of the parturient ~ 98% for multips, 80-90% for primips.
Protective Benefits of Midwifery and Appropriate Access to Medical Services: Less than 1 % of childbearing women are interested in community-based midwifery care, as it precludes any form of pain medication or anesthesia, something most women do not wish to do. While the numbers of women choosing community-based midwifery is very small, it is still important that they and their babies receive the protective benefits of professional care. According to a study of OOH births in North Carolina by Bennett et al, unattended home births have a perinatal mortality rate of 30-60 per 1,000 where as the rate drops to 3 per 1,000 (less than the state average of 7:1000) when mothers are attended by a skilled midwife. Good midwifery care results in a timely recognition of complications and appropriate transfer of care. This greatly increases good outcomes. This principle clearly demonstrates that midwifery care and appropriate access to medical services is protective. Availability of midwifery services an issue of public safety and creates a responsibility on the part of the medical profession to see that road blocks to medical and hospital services are not erected.
Obstetrical Care Remains the Popular Majority Choice: Please note that while a high proportion of childbearing women technically qualify for midwifery care (healthy with normal pregnancies), only a tiny percentage actually are interested in it or would even consider utilizing it. In hospital settings only about 6% of mothers are attended by professional nurse midwives. For the last 30 years the domiciliary birth rate has held steady at about 1% ~ an already small number divided further between free-standing birth centers (1/2% attended by CNMs) and client homes (1/2% attended by LMs and CPMs). ACOG can find comfort in the obvious – 94% of pregnant women prefer physician providers, 99% hospital-base birth services while only ˝% will utilize a licensed community midwife for home-based care.
Safety & Science-based Evidence: At present more than a 100 scientific studies published in peer-reviewed professional journal articles, state and national sources of vital statistics and reports from the World Health Organization all support the efficacy of domiciliary midwifery services. As measured by perinatal mortality and morbidity, medical interventions and the rate of obstetrical complications, maternity care for low and moderate risk women as provided by professionally trained midwives in conjunction with access to appropriate medical services normal is equal to or better than hospital-based obstetrical care. For this cohort of healthy childbearing women, the care of a skilled midwife is safer than either a physician-attended or unattended birth [“Safety in Alternative Childbirth”, P. Schlenzka, 1999].
Historical Background: For the last 100 years a credible body of scientific literature has consistently documented the relative safety of midwife-attended birth for healthy women while also revealing a negative association between routine physician care and maternal-infant health. In 1910 an influential report on medical schools by the Rockefeller Foundation (the Flexner Report) was highly critical of medical education in the US because it lack hands-on experience in obstetrics, as was the custom in Europe. A large and dependable supply of “teaching cases” was necessary to develop obstetrics into a new surgical specialty.
However, the majority of normal births were attended by midwives at the time, a fact interpreted by most doctors as “depriving” medical students of valuable “clinical material” and graduate physicians of economic opportunity. In order to elevate the status of obstetricians organized medicine embarked on a campaign to eliminate the independent practice of midwives and subsume their clients into the professional agenda of obstetrical medicine. When midwives were replaced by physicians between 1910 and 1920 as providers of normal maternity care, it resulted in an increase in maternal deaths of 15% per year for more than a decade and an increase in neonatal birth injuries by 44% over the same ten years [Annual Transactions of the American Society for the Prevention and Study of Infant Mortality, 1910-1915].
Historically the problem was that physicians took over the care of midwifery patients without any idea of the philosophy, principles or techniques of midwifery. Doctors related to the care of healthy childbearing women primarily as an opportunity to develop skills in interventive & surgical obstetrics. This resulted in the routine use of chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. Anesthetic deaths, hemorrhage, infection, brain injury to newborns and long-term gyn complications for mothers followed in the wake of this ill-conceived idea to use healthy women as source of “teaching material” for doctors.
Unfortunately the large number of bad outcomes under the care of physicians led both doctors and the lay public to erroneously conclude that childbirth itself was intrinsically dangerous when in fact it was the inappropriate application of emergency interventions to normal circumstances that was the culprit. This false association fueled the campaign to further medicalize childbirth and resulted in the wholesale replacement of midwifery by obstetrics and a hospital-based system of maternity care. It was not until the generally improved economic status of the US population (starting in 1935) and the resulting improved health of the general public, combined with the medical discoveries surrounding WWII (safer anesthesia, antibiotics and safer blood transfusions through blood typing) that this negative association between medicine and perinatal mortality was neutralized, in part by permitting successful treatment of the complications associated with routine hospitalization and interventive obstetrics. [Neal DeVitt, ].
Obstetrical Hospitalization Not Safer for Healthy Women: Not a single scientific study has ever proven hospitals to be a safer place to give birth or establishing obstetricians to be safer caregivers for healthy women. In fact, scientific literature identifies professional midwives to be the safest and most cost effective category of caregiver for healthy women with normal pregnancies [W.H.O Safe Motherhood series “Normal Birth ~ A Practical Guide”, 1994].
Malpractice Prevention equates with Practitioner Presence During Active Labor: Physicians have nothing but negative things to say about mothers laboring at home under the direct care of a skilled midwife but choose not to acknowledge the irony of the current system in which mothers labor in the hospital while their doctors are at home or across town at the office. A physician lawyer (David Rubsamen) conducted a study of 63 lawsuits against obstetricians subsequent to neurologically damaged babies.
Dr. Rubsamen identified the absence of an awake physician (or other authorized practitioner) from the immediate area of the laboring women and lack of (or disruption in) continuity of care as a major factor in the events leading to litigation. In approximately 60% of these cases mis-communication occurred between the physician who typically was not present (or not awake) and the L&D nurse, making absence of the practitioner the most frequently preventable factor relative to brain damaged babies, expensive litigation and multimillion dollar judgments against doctors and hospitals. This is described by Dr Rubsamen as one of several “malpractice traps” that makes “obstetrics a loss leader for professional liability insurance carriers throughout the US”. [The Obstetricians’ Professional Liability ~ Awareness and Prevention”, Dr. Rubsamen, 19-- ]
Unfortunately, this problem continues. The April 2000 issue of Contemporary Ob/Gyn reported a recent malpractice case in which the physician blamed the nurse for not notifying him of late decels and poor fetal heart rate variability over a four hour period of progressive deterioration. The nurse insisted that the physician (who was not in the hospital) had been telephoned and appropriately informed. Situations of this type would be prevented under the midwifery model of care in which the full time presence of the practitioner is routine.
A Plan for the 21st Century ~ Workable Midwifery Laws
Midwives and home birth families would like to see the energy currently expended by organized medicine to fight against home birth midwifery be redirected into more beneficial pursuits. For the last 30 years a steady 1% of childbearing women have chosen to give birth in a non-medical setting, usually their own homes. Of particular note is the greatly increased safety of having a skilled midwife attendant with a perinatal mortality of 1-3 per 1000 live births (current national rate is 7 per 1000) versus infant death of 30 to 60 per1000 for unattended or “do it yourself” deliveries. Mothers that seek out midwifery care have already declined conventional obstetrical services -- it is the presence of a trained attendant that makes this a safe choice. The best option, given these realities, is for the American College of Obstetricians and Gynecologists to support workable midwifery laws, ones that adequately protect all parties (including mothers and babies) and which include a “hold blameless for care not rendered” clause for obstetricians and other medical careproviders.
ACOG officially supports freedom of choice for childbearing women in its abortion policy statement (page1067 of ACOG Compendium 2000) regarding informed consent which notes “informed consent is an expression of respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities and to support of the patient’s freedom within caring relationships”. We are suggesting in the strongest terms that ACOG not restrict its official respect for informed consent and its organizational support of the “patient’s freedom within caring relationships” only to women choosing a doctor to abort a pregnancy while denying it to those who choose to maintain their pregnancies while receiving care from a community-based midwife. It sends the wrong message; one, which I am sure, is not intended.
Single Standard of Care, Internally-Consistent Practices
The idea may seem shocking at first but I suggest that a great burden would be lifted from obstetricians and midwives both to have a single standard of care relevant to the physical, psychological and social needs of childbearing women, rather than our current system that depends instead on the category of caregiver for its standards of practice. At present the “right” care for a healthy laboring women is defined differently if that care is being rendered by a board-certified obstetrician than by a family physician, a CNM or a community-based midwife. The real issue should not be the routine of a particular discipline but what is best for that particular mother under the individual circumstances of her specific labor. The category of caregiver and the duties required of professionals should reflect the best of evidence-based practice parameters as related to the woman’s situation and her informed consent decisions.
In an integrated system the provision of maternity care would occur along a coordinated spectrum, with midwifery and obstetrics at opposite ends of a continuum, one spanning the most simple to the most complex. Respective expertise of all caregivers would overlap in the middle of the spectrum but would not be identical. Both disciplines would continue to benefit from the abilities of the other. At one end would be a small number of community midwives caring for healthy mothers in the domiciliary setting of their choice. At the other end of the continuum would be the increasing complexity of medical treatments, hospitalization and a modest number of obstetricians, perinatologists and other medical specialists caring for highest risk pregnancies and sick neonates. In the middle, caring for lots of health women and babies, would be lots happy hospital-based professional midwives and family practice physicians.
In this configuration, everyone would be singing from the same hymnal for the first time in a 100 years. Many areas of practice among the four major categories would be essentially the same regardless of type of caregiver. This would give midwives and physicians a chance to learn from each other, develop internally consistent practices and give rise to an elevated standard of care that spans the full spectrum of modern-day maternity care.
Bringing Midwives and Physicians Back Together
I would imagine that ACOG is familiar with one of the largest consumer groups -- Citizens For Midwifery founded by Susan Hodges. This national organization promotes the midwifery model of care as the most appropriate form for healthy women with normal pregnancies who do not plan on using pharmaceutical pain management during labor or anesthesia for delivery. It identifies the Midwifery Model of Care as monitoring the physical, psychological and social well-being of the mother, providing her with individual education, counseling, prenatal care and continuous hands-on care through out labor and birth, minimizing technological interventions, identifying and referring women to physicians who require obstetrical attention and providing individualized postpartum support in the weeks following the birth. This traditional model of maternity care is statistically associated with a reduced incidence of birth injury, trauma and cesarean section. Obviously, physicians as well as midwives can provide care under the principles of midwifery management, either personally or by employing professional midwives to provide care to healthy women.
Many other consumer advocate and Internet groups have been formed in the US to bring about a fundamental change so that America can join that large group of nations in Western Europe, Japan and elsewhere with excellent perinatal outcomes and affordable maternity services directly attributed to their policy of supporting and promoting the midwifery model of care. Changes being pursued by these groups include the recommendation that primary staffing for all hospital L&D rooms be by nurse-midwives. The full-time presence of a practitioner (either physician or professional midwife) should be routinely required at the bedside while the woman is in active labor. We need a national campaign to raise consciousness of the problem of unnecessary episiotomies and defining the routine use of episiotomy as a form of genital mutilation. Improvements in medical education so that hospital midwives instruct medical students in the principles of normal birth before students are exposed to obstetrical pathology would be an enormous help. Re-defining the normal “standard of care” for healthy women to be the physiological management (the midwifery model) and establishing the legal theory that standard midwifery methods be employed first and foremost before it would be considered appropriate to utilize obstetrical interventions (for example, use of non-pharmaceutical pain relief measures before offering epidural anesthesia; utilizing upright and mobile maternal postures during the pushing stage prior to recommending operative delivery for failure to progress, etc).
Futures Market ~ “Off-Site Birth Technology”
I often wonder why obstetricians don’t seem interested in being part of this active dialogue so that the membership of ACOG can have a voice and vote in how these changes come about. The midwifery model of care is the next frontier of the public health movement. Hospital-acquired infections and medical errors kill more than 80,000 patients annually which means that well-run domiciliary services spare healthy childbearing women from unnecessary risks and save the public from the added expense of paying for these complications.
If I were an investor looking for a futures growth market, I’d buy stock in companies that made increasingly affordable miniaturized birth technology (such as the Baby Dopplex 3000, a fully-functional laptop-sized EFM from Huntleigh in the UK or their brand new “Fetal Assist”, a 6” x 10” x 2” battery-operated 2# computerized electronic fetal monitor which analyzes the FHT pattern, allows one to chart in “real time”, store records on multiple patients, has a modem connection and other wonderful features; the affordable Palco pulse oximetry or portable ultrasound like the 5 # hand-carried SonoSite 180). This would permit any couple planning to labor at home to rent an “off-site birth technology kit” from their local hospital (paid for by health insurance) that would include the same modest number of medical surveillance devices routinely available in any community hospital. These would be utilized by a well-trained community midwife to monitor the mother and baby as appropriate.
I’d also encourage hospital administrators to look at the physical building as merely the hub of a wheel, with little satellite “labor rooms” all over their catchment district as healthy low risk moms are cared for at home in their own bedroom (with suitable technology) by a professional midwife who can, if indicated, transfer the mother in to the hub/hospital to take advantage of more sophisticated technologies and physician services. If I were a professional educator I’d start designing curriculums to formalize the cross pollenizations between physicians and midwives, providing opportunities for each to learn from the expertise of the other.
Keeping place of birth from becoming an issue of safety
It is mutually advantageous that midwives and physicians stop trolling each other’s problematic outcomes looking for fodder for gossip columnists. Lets just stick to evidence-based practice parameters and a realistic assessment of the literature on place of birth as a safety issue, as the only relevant conversation is how to work together to keep place of birth from becoming an issue of safety.
An exchange of expertise is long overdue. It is as much the responsibility of physicians to be familiar with the time-honored philosophy, principles, techniques and skills of midwifery as it is the duty of midwives to know the principles of anatomy, asepsis and how to recognize complications. Midwives universally agree that modern obstetrics has much to teach and much to contribute to the well being of the families it serves. As midwives we have already availed ourselves of both formal and informal study of obstetrical science. Likewise, the honorable but unassuming traditions and unique abilities of midwifery -- the art of being "with women", a quietness of spirit and patience with nature and the intimacy skills which serve childbearing families so well -- are also of great value to the bio-medical sciences and society at large.
Dr. Tom Strong, the obstetrician author of “Expecting Trouble ~ The Myth of Prenatal Care”.