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 ½% 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”.
