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.
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.
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.
Sincerely,
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
Citations:
(
) 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