Draft Version -  March 19, 2001

Dear Dr. Partridge: 

I am writing you on behalf of the members of the American College of Domiciliary Midwives, a professional and educational organization committed to preserving lawful access to community-based maternity care as provided by primary-care physicians and professionally certified midwives of all educational backgrounds (CNMs, CPMs, CMs and LMs). Community-based maternity care includes birth services in all domiciliary (non-institutional) settings (client homes and free-standing birth centers). Historical records and scientific research confirms that community-based midwifery care is a safe choice for healthy women when care is provided by a skilled attendant in conjunction with access to medical services should the mother desire or require medical care. (Citation #1, SB1479 intent language, #2, Peter Schlenzka,) 

Midwives who provide community-based care are acutely aware of the crucial role that obstetricians play in our lives and those of our clients. Generally speaking, midwives have a natural affection for obstetricians and are seeking to dramatically improve the quality of the debate between our respective groups and the public at large. There are many areas of mutual concern. Our goal is to better the working relationships between physicians and community midwives so that mothers and babies do not suffer as a result of the historical tension or economic competition between our two groups.

In light of our on-going attempts to facilitate a good relationship with physicians, and promote professional training and credentialing for direct-entry midwives, I was disturbed to read the legislative testimony provided by you as a representative of VA OB/GYN Society, VA-ACOG and the Medical Society of Virginia. The tone of your testimony was particularly troubling in light of your testimony during last year’s legislative hearing on this same topic. At the conclusion of your testimony on that occasion you were asked by a senator if you had any evidence that home birth is unsafe or that nationally certified professional midwives are not performing well in other states. Your answer was "No. No evidence."  In spite of this you returned again this year to advance exactly those notions which your own sworn testimony identified last year as without foundation.  

As a representative of a scientific discipline, I’m sure you realize the ethical and legal burden placed on you to communicate only scientifically valid information in a public forum unless your statements are identified as merely a personal opinion. The very fact that you are the holder of a doctorate gives the public every good reason to believe that statements made by you and other doctors are factually correct and scientifically-based and not unduly influenced by personal bias, professional jealousies, conflicting economic interests or lack of accurate information on the topic. “Due diligence” demands accuracy in these things. When physicians do not limit themselves to accurate and scientifically valid information, it violates the social obligation associated with your status as the holder of a doctorate, as well as the public’s trust in the medical profession.

Unfortunately for us all, ACOG’s official representation of midwifery was factually incorrect and only serves to fuel animosity between doctors and midwives. Your characterization of childbearing by healthy women, home-based birth services and the competence of Certified Professional Midwives all as “dangerous” was misleading to the public and to members of the Legislature and based, in your own words, on “no evidence”. Its effect is particularly detrimental to mothers and babies who depend on the compassionate and unbiased care of obstetricians when risk factors or complications arise necessitating transfer of care from midwifery to medical management. 

Your organization’s opposition to certified professional midwifery in Virginia leaves this subset of childbearing women with only unsafe choices of an unattended birth at home or the care of uncredentialed, unregulated, perhaps unskilled lay practitioners who has unpredictable access to emergency medical services and emergency supplies. This stands in stark contrast to the obviously safer care of nationally certified, state licensed midwives (either CMNs or CPMs) who are professionally educated, technically skilled, experienced, equipped and legally enable to interface easily with the medical community.  I quote from your own most recent testimony “Our concerns are not over turf issues, although that has been alleged, our concerns are over safety, the health and life safety of babies and mothers.”  

The Bible notes that a tree is known by its fruit. If, as you say, the safety of mothers and babies is the highest concern of your organization, then you surely recognize the extreme hazard that ACOG’s position represents and would join the membership of the ACDM in promoting the professional training, national credenticaling and state licensing and regulating of direct-entry midwives in Virginia. Statistically speaking, the independent profession of direct-entry midwifery is the standard worldwide. Sixteen states in the US professionally credential their community midwives and in 18 other states, midwifery is lawful but credentialing is voluntary. In only 8 states is community midwifery illegal, a situation based on politics, not evidenced-based scientific.

Unwarranted fears of professional midwifery on the part of physicians have come about, in part, from the erroneous assumption that licensure of direct-entry midwives will fundamentally change the way large numbers of childbearing women will chose to labor & give birth. Based on many years of both home & hospital birth experience, I can assure you that this is not so. As long as midwives remain faithful to the midwifery tradition (no pain medications, no general or regional anesthetics and no operative obstetrics in a domiciliary setting) only a very small fraction of childbearing families will choose home birth due to the intrinsically painful nature of labor. Being unable to offer narcotics or anesthetics, midwives do not compete with the obstetrical model of medicated labor & birth.  Understanding these points, especially the recognition of the permanent minority nature of home-based maternity care, should bring cheer to obstetricians and hospital administrators all across the country!

From the tone of your testimony I must assume that you have little factual information regarding the modern-day practice of community-based midwifery, the Midwifery Model of Care, or specific information about non-nurse midwives, and the categories of childbearing women and circumstances that are appropriate for domiciliary midwifery care.

Accompanying this letter is a separate essay which provides factual background information (peer-reviewed & cited) on these topics. In addition there is a point-by-point commentary and rebuttal to your legislative testimony. For your convenience I have also included excerpts or synopsis of a small number of published studies and other vital statistics identifying the philosophy and principle of midwifery and community-based care to be equally safe for healthy mothers and babies.

Important Difference Between Obstetricians and Midwives

For the record I would like to state in much more economy of words what I believe to be the most fundamental (and important) difference between doctors and midwives and that is each discipline’s views of the mother’s resources. The perspective is quite different in the medical model of care as doctors tend to see their professional attention as a physician to be the mother’s greatest “resource”. For the most part, modern medicine assumes that unless a doctor/hospital is central to the picture, a pregnant woman is without the most crucial resources permitting her to tolerable labor and a give birth to a healthy baby. 

Midwives see the subject of the mother’s resources from a very different perspective. We see the mother as having an independent set of resources, of which we, as midwives, are just one and not even the most important one. The first resource the childbearing woman has is her own good health, second is her normal pregnancy, third is her inquisitive intellect and a capacity to explore topics of interest or concern to her, to find answers, interpret them intelligently and take effective action on her own behalf and that of her baby. She has as an “asset” her ability to decide what is most important to her and use her life force, her talents and her energy to work for and, in most instances, to bring it about. Once a woman uses these innate resources to choose a “physiological” labor and birth as her goal, she then has the further resources of supportive family members, a helpful mate, an experienced midwife, she has educational sources to help guide her and whenever she chooses can seek out medical consultation or treatment.

Once in labor a childbearing woman’s resources include an innate stamina which testifies to her ancestral “designer genes” for normal birth (if not her own genetic code would have be extinct). She has emotional strength, physical abilities, a determination to carry on and deep intuitive resources which appear at the appropriate time. Her resources include the companions of her choice, location of her choice, position of her choice, oral fluids, favorite foods, and good one-on-one labor support telling her -- should she momentarily doubt herself -- that we all believe in her abilities, that she can do this hard work and that yes, it is well worth the effort. She has the benefit of the centuries-long tradition of midwifery’s supportive, non-invasive management joined with the best of 21st century medicine. Last but not the least of her resources, are the plain facts of human biology, which is that most babies are born healthy without any need to medically intervene – the result of species-wide “designer genes”, the source of that old obstetrical standby - NSVD or ‘normal spontaneous vaginal delivery’, charted and accompanied by the words “unremarkable”, meaning ‘no complications, no medical or surgical intervention, just boring biology’ (but still plenty remarkable to the family!).   

In general, midwives see their role as helping the mother access and make best use of her rich repertoire of personal and social resources. As midwives we are honored to be one of her many resources and respectful of the fact that we are peripheral rather than central to the process of “NSVD”. Maternal willingness and determination joined with normal biology are the crucial ingredients. Midwives consider the mother’s needs and desires and the quality of her childbirth experience, as defined by her, to be an initial part of the outcome equation known as a “healthy baby”. In most instances the most straightforward way to serve the baby’s good health is by meeting the mother’s intrapartum needs. I have never seen a happy mother whose baby was not also healthy, as it is very rare for the mother’s needs or desires to be in conflict with what is best for her baby. 

It is one of those “rules” of midwifery that we do not assume that we must choose between the baby’s welfare and that of the mother’s unless there is a clear indication otherwise. When we do our job right, midwifery is invisible to outcome, it is a translucent overlay that organizes and guides while trying first of all not to disturb the normal process of spontaneous childbirth. Midwifery is a formalized method for trusting in the same Divine plan that brought about the miracle of conception and gestation. This Divine process includes an innate body Intelligence which has amply shown that It knows just what tissues, organs and architectural plan would grow a human baby from the specific genetic code of its two parents, knows exactly how and when to trigger the millions of necessary but sensitive biological processes to make and sustain fetal life for the nine months of pregnancy and is finely tuned enough to know when to bring on spontaneous labor and most of the time, how to get the baby and the placenta out,  keep the mother’s blood after the uterus has emptied itself and how to trigger an adequate supply of breast milk by day three. We refer to the designer genes of spontaneous childbirth as the “Divine Advantage”, a fact of our success as a species. We trust physiological process because, like democracy, it may not be perfect but none-the-less it is way out there ahead of the next best option.

A Request

In light of these obvious facts, we would appreciate it if you and your organization spent some time rethinking your unthinking, unscientific opposition to state-licensed community-based midwifery. All over the world women organize to combat oppressive traditions. If our respective groups cannot come together voluntarily, consumer and midwifery organizations will have to seek out a legal remedy with all the messiness and public scandal that entails. Consider for example, the image we all have a dozen tobacco executives testifying in a Congressional hearing, each answering ‘No” when asked if they believed that cigarette smoking was harmful to human health. After such a denial of the obvious, it is hard to believe anything they say because it is so obviously that they have a massive (and self-serving) blind spot that has rendered them permanently biased.  

Imagine a dozen ACOG physicians having to admit to Congress that “No evidence” is what they have based their Hundred Years War on independent midwifery and community-based birth services. Imagine explaining to Sixty Minutes why ACOG obstetricians misrepresent the truth about the efficacy the obstetrical treatment of healthy women with normal pregnancies or why, under obstetrical management, “healthy” women can no longer be found and normal or “physiological” childbearing is virtually extinct (except for precipitous deliveries on a stretcher in the elevator of premies and grand multips). While 70% of childbearing women are healthy and are carrying normal pregnancies, a 30% operative rate, a 40% pitocin induction and augmentation rate and a 95% epidural rate have become the norm in many places for physician-attended hospital birth.

Imagine explaining to juries why it is OK for over half of the country’s board-certified obstetricians to cavalierly choose to make a healthy women into a reproductive cripple by doing a CS for “suspected” fetal distress but without first employing “due diligence”. A diligent practitioner would apply ACOG guidelines to ascertain if those “suspicions” of fetal distress were the result of an artifact of equipment or a normal variation of that particular stage of labor OR indeed reflected authenticated fetal distress not amenable to other methods. Image your mother, wife or sister goes to a surgeon who “suspects” a hot appendix, imagine how you would feel if surgery was done on your loved one without first doing a CBC to determine if there was a significant elevation in the white count, or not ordering a PPT and platelet count to determine if it was safe to operate. 

I would feel that same way if a member of my family had a placenta previa or percreda, or uterine rupture which resulted in an emergency hysterectomy and a brain-damaged baby subsequent to a primary CS which was done without any attempt to determine if it was actually necessary. Transferring the risks of the current pregnancy on to the next one does not reduce the magnitude of  those risks. Risks transferred to subsequent pregnancies and future babies must still be accounted for as a complication of the original CS. Because of these long-term costs and complications, cesarean surgery should only be recommended and performed after the doctor does his or her homework very well, and establishes factually a “reasonable medical certainty” upon which to base his or her recommendation for surgery. Furthermore, interventions with immediate and long-term consequence this grave should never be employed without first being preceded by a diligent application of the common-sense rules of gravity and a recognition of the importance of privacy and emotional comfort as the first line of response employed by those providing care to normal labor in healthy women. 

A major part of being obstetrically prepared in the 21st century must include as a given that physicians are equally familiar with and able to employ the simple strategies of midwifery management during the spontaneous events of labor and birth. This is a minimum need of each and every healthy childbearing woman. These classical, time-honored and gravitationally-sound principles reduce the likelihood that labor-forcing drugs will become necessary or that narcotics pain meds, anesthetics, antibiotics, episiotomy, forceps, cesarean, emergency hysterectomy or admission to intensive care units for either mother or baby will be called for. Preventing these painful, risky, and expensive interventions reduces preventable maternal mortality and morbidity.

Conventional obstetrics can ill afford to have a public searchlight shined on such an uncomplimentary picture as the routine obstetrical treatment of healthy women can not stand up to forensic scrutiny. Such a penetrating light which would reveal a plethora of unintended consequences resulting from the historical move by organized medicine to medicalize maternity & newborn care. Were the actual scientific truth about normal childbirth and independent midwifery to be as described by ACOG representatives such as yourself, then the nurse-midiwfery textbook written by Judith Rook, CNM, Childbirth and Midwifery in America, would be an outrageous, even dangerous fabrication. More recently a supportive report on 21st century midwifery was funded by the Pew Charitable Trust. It states that: “Midwives should be recognized as independent and collaborative practitioners, with the rights and responsibilities regarding scope of practice authority and accountability that all independent professional share. Every health care system should integrate midwifery services into the continuum of care for women by contracting with or employing midwives and informing women of their options.”

I notice that ACOG did not institute suit against either the Pew Trust or Temple University Press for publishing false information. We all know, technically speaking, that professional midwives are the “technically” the best choice of provider for healthy women with normal pregnancies. This technical definition of “best” is a combination of the high rate of Normal Spontaneous Vaginal Deliveries, high rate of client satisfaction and high ratio of mothers still breastfeeding at 6 weeks and the low rate of medical complications intrapartum and a low rate of maternal and perinatal mortality or morbidity rate. That’s what a successful, cost-effective maternity care system looks like.

The better choice for ACOG is to welcome a reasonable measure of integration between itself and the midwifery model of care. As you may or may not have realized, midwives are physician-friendly and lawyer-phobic. I suggest your organization capitalize on that simple fact.

Doctors and midwives should keep their own independent identify and unique function, but re-configured from an adversarial relationship into a complementary one with mutual goals and cooperation. Better communication and a mutual respect should go a long way towards bringing some measure of stability to this beneficial arrangement. Obstetricians must expect that midwifery will exist in the 21st century, just as it has in each and every other century preceding this one. It is a long-over due improvement for midwives to develop an active interface with medial doctors and medical services which would, without bring disgrace on itself or dishonor on the medical profession, ultimately serve the authentic needs of the childbearing family and the public at large.

Verbs for Family Life

Before closing I would like to change the focus of this letter from medical politics to a personal experience – the one each of us has or will have with our own health & mortality and our closet and most beloved relatives. Since I started this letter two weeks ago my here-to-fore healthy mother was suddenly diagnosed with an aggressively advancing and terminal bladder cancer. As with my father’s fatal illness in 1983, I brought another parent home from the hospital when it became obviously that medical care had no cures to offer, little chance of providing physical and emotional comfort and suffered greatly from a lack of continuality, both in therapy and the caregiving process.

After a week in the hospital and 2 wks in a chronic care facility I and all our family members had many distressing interactions with helpful, well-meaning doctors, nurses, a magnetic imaging center and many different insurance clerks involved in making sure that no service was offered until we had first documented the method by which they would be fully reimbursed.  It became a full-time job to keep up with the medical paperwork. So far, the medical care of my mother’s illness has been dominated by a distressing propensity of over- and under- treatment, incredible delays, misplaced diagnostic reports, inappropriate office visits, near useless advise and an emotionally-tone deaf oncologist who casually discusses by mother’s multifaceted fatal illness in her presence as if he were the vet counseling us on how, when and where to put my mother to “sleep”. 

While this topic is not directly or obviously related to childbirth or maternity care, it is none-the-less instructive. The shortcoming of the healthcare system may not matter so much in a temporary situation such as childbirth and 48 subsequent hours in the hospital but when you or your loved one is facing a fatal illness, how the “system” functions and/or does not function becomes the most important thing in the world. There can be no “second takes” and no anesthetics will dull the suffering triggered by insensitive care, iatragenic and nosocomial mistakes or the commercialization of medicine. 

My mother was seen by her very busy HMO primary physician twice in the 30 days before her malignant disease was discovered and she was deemed to be healthy despite her symptoms.  In just a few days my mother went from being an essentially normal adult with normal consciousness and taking no prescriptions drugs of any kind to instead being heavily medicated with sleeping pills, narcotics, hypertensive medications and a multi-vitamin pill to make up for the fact that she was not eating at all. Several different doctors were sharing the diagnostic process, each leaving orders for tests, treatments or medication. Unfortunately, the right hand seemed never to know where any of the other body parts were or in which direction they were moving. Under this intensely abnormal regime my Mennonite mother became increasingly confused, had daily hallucinations, was combative on one occasion, insisted on sitting on her bed completely unclothed for several hours, wouldn’t eat or drink, wanted to sleep all the time, was so weak she had to be helped to the bathroom and used a walker or a wheelchair when ever out of bed. We were told that her mental deterioration was the result of irreversible disease so sever that no treatment of her cancer was appropriate. So we took my mom home, stopped all scheduled meds and arranged hospice care.

Since returning home a week ago my mother has had the quality of one-on-one care that might best be described by the verb “midwifing”, provided by family, friends and a “home health companion” who is not a nurse. Under this personal care in her own home, my mother has enjoyed the return of almost normal mental function and independent mobility. She had not used the walker even one time since getting out of the car in the driveway of her home. So far she has attended church, kept her weekly hair appointment, gone out to dinner with my siblings, stacked dished up in the kitchens, cleaned spots off the bathroom carpet and rationally discussed what she wants done with the family china after she is gone. She has never complained of pain or requested pain medications and sleeps well without drugs.

It seems that ‘end of life’ care is very similar to my experience with laboring women – that when you normalize the life circumstances of the “patient” which includes meeting their emotional and social needs (better yet, stop treating them as a ‘patient’), people will in turn experience a return of normal function, even if what is meant by “normal” is what it is like to be suffering from a progressively debilitating, eventually fatal disease. This dynamic coping process benefited both of my parents. Among my same-age friends (late 40s, 50s, early 60s), it is a frequent topic of conversation. People want something more than just to have loved one heavily medicated through a stressful aspect of a normal life passage. We are all born one by one, most women give birth and everybody dies. It is not intrinsically a medical phenomenon as there is no medical “cure” for these natural states.

My point is that the Hundred Years War instigated by organized medicine against independent midwifery has had, as one of its many casualties, the loss not only of the noun ‘midwife’ as a professional caregiving role but also the verb “to midwife” and the active voice “midwifing”. To midwife is to help another to achieve an important but difficult goal. I recently heard a BBC newscaster use the verb “to midwife” in regard to ambassadors who were attempting to further the peace negotiations between the Israel and the Palestine. I immediately realized that I have never heard an American newscaster use the verbal form of “midwife”. The active verbs of midwifing describe the actions and states of being that socially and emotionally assist people thru challenging, life-changing times such as childbearing, major illness or injury, and of course, the final frontier in the temporal world – our physical death.

Dr. Partridge, no matter what you personally think of midwives, there will come a time when the last days or weeks are upon you or a beloved relative and you will realize that medical care has nothing left to offer. When that happens, you are going to want, going to pray for, going to appreciate and actively seek out people with the verbs of skillful ‘midwifing’ to be there just for you, to take you out of the busy & brightly lit ICU and into a private, comfortable, emotionally sustaining circumstances and to help you or your loved to gracefully, peacefully, painlessly make that dash for freedom on the outward breath while your family is present to share this all-important moment.  

I look forward to your comments.


Faith Gibson, LM, CPM
Executive Director, ACDM/CC

Cc:       Susan Hodges, Citizens for Midwifery

Judith Rooks, CNM

Joyce Roberts, CNM, Pres. ACNM

Senator Liz Figueroa, California

Catherine Dower, JD, UCSF

Leif, Cabrazer, Heiman and Bernstein

Mark Peterson, Pastor, VCFP


 ( ) Recommendations of the Joint Report-Pew Health Professions Commission and the UCSF Center for the Health Professions- Charting a Course for the 21st Century: The Future of Midwifery, April, 1999


Risk shifting, cost shift, blame shifting