American College of Domiciliary Midwifery 
3889 Middlefield Road, Palo ALto, CA 94303

 The Definition and Scientific foundation 
for Community-based Midwifery

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 “artifical, mechanical or forcible means” to bring about the birth of a healthy live baby revealed that approximately 70% of labors would not have necessitates referral or transfer of care from midwifery to medical management. (citation #3 -- Peter S Safety in Alternative Childbirth”). Among the subset of women who self-select for home based care the figure is even higher, depending on the parity of the parturient (2% for multips, 10-20% for primips). 

Less than 1 % of childbearing women choose 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 are 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 60 per 1,000 where as the rate drops to 3 per 1,000 (significantly less than the state average) when mothers are attended by a skilled midwife. When good midwifery care is available the rate of good outcomes in greatly increased via recognition and appropriate transfer of complications that occur. These statistics clearly demonstrate that midwifery care and appropriate access to medical services is protective. This makes availability of those services a public safety issue and creates a responsibility on the part of the medical profession to see that road blocks to hospital services are not erected

Obstetrical Care to Remain the Majority Choice: Please note that while a high proportion of childbearing women technically qualify for midwifery care, only a tiny percentage actually are interested in it. In hospital settings about 6% of mothers are attended by CNMs. For the last 30 years the domiciliary birth rate has held steady at about 1% -- an already small number divided equally between free-standing birth centers (1/2% CNMs) and client homes (1/2% LMs and CPMs). ACOG can find comfort in the obvious – 94% of pregnant women prefer physician providers and hospital-base birth services while only about ˝% will utilize a licensed midwife for home-based care.

Science-based Evidence: A large and very crediable body of scientific literature has for the last 100 years documented the relative safety of midwife-attended birth for healthy populations in non-medical settings. This body of historical and scientific evidence also establishes that when take the same cohort of healthy women was taken over by physician providers, 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.

The reason that physician care increased morbidity and mortality is that doctors who were uniformly unfamiliar with the scientifically sound principles and practices of midwifery inappropriately medicalized normal labor and birth with the routine use of narcotic drugs, labor stimulants, anesthesia, episiotomy, forceps, and the manuel removal of the placenta. Over a 100 scientific studies, and the peer-reviewed professional journal articles and reports from the World Health Organization statistically support the efficacy of domiciliary midwifery services for low and moderate risk women as provided by professionally trained midwives with appropriate access to medical services.

Obstetrical Hospitalization Not Safer: In contrast, not a single study has ever been published proving hospitals to be a safer place for this same low risk population to give birth or establishing obstetricians to be safer caregivers for healthy women.  In fact, scientific literature historically and in world-wide contemporary literature identifies professional midwives to be the safest and most cost effective category of caregiver for healthy women with normal pregnancies.

Malpractice Prevention: 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 it the most frequently preventable factor relative to brain damaged babies, expensive litigation and multimillion dollar judgments against physicians and hospitals. These are described by Dr Rubsamen as one of several “malpractice traps” that makes “obstetrics a loss leader for professional liability insurance carriers throughout the US”.

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.

 Qualities of Childbirth Experiences, their impact on Spontaneity

The quality of the childbirth experience as defined by the mother extends beyond the moment or manner of delivery and can affect the mother physically and physiologically for months or years, perhaps even becoming a pivotal point in her life. The cumulative effect of the events of childbearing in combination with other influences extend into the mother-child relationship and can profoundly effect the quality and satisfaction in that central and important fact of day to day parenting. Problems          within the mother-child relationship can trigger a cascade of difficulties that not only negatively effect the individuals and their family but also the stability of the community and greater societal goals. While there is no immutable evidence that a good-parent-child bond prevents teen delinquency and violence, there is evidence that birth complications in combination with a fractured mother-child bond is a strong contributor to violent behavior in adolescents, especially boys. Therefore, events that contribute to the fracturing of the mother-father-baby bond are to be avoided and those that protect and promote it are to be pursued and supported by society. This is  "mother-friendly" maternity care.

Non-erotic sexual nature of childbirth: Acknowledgement of the non-erotic but none-the-less sexual nature of childbearing which involves the same biological structures and psychologically includes many of the same principles necessary for physiological function in both sexual and excretory biology. These principles include acknowledgement of the mother’s physiological need for privacy and her right to voluntariness in participation of  persons and procedures that transgress the boundaries of her body or sexual psyche. It also includes freedom from performance pressure and arbitrary time constraints. Spontaneous biology is heavily influenced by psychological factors (both mental & emotional states) which are themselves an extension of normal reproductive sexuality.

The childbearing woman has a right to that quality of care from her companions and her caregivers that does not disturb or interfere with normal physiology of spontaneous progress in labor & birth (such as the "maternal-fetal ejection reflex" -- for description of M-FER, see addendum)  In the absence of this quality of support, which is the core of the traditional midwifery model of care, the mother will frequently need narcotic medication and secondarily the use of oxytocin to overcome the labor retarding effects of narcotics. Additional surgical interventions of episiotomy, forceps, vacuum extraction, cesarean section often represent the failure of the maternity care system (or individuals within it) to account for the influence of the mother’s psyche in regard to the events of labor and birth. [Safety of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]

A socially appropriate environment in which the mother feels unobserved and yet secure, with emotional support as necessary, is the purposeful mechanism of midwifery care which addresses the mother’s pain, her fears and  privacy needs so that labor can unfold naturally. It is also necessary to take into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this process along but also diminishes the mother’s perception of pain (perhaps by stimulating endorphins). To ignore the well-known relationship of gravity to spontaneous progress is to do so at the peril of mother and baby. The complex interplay of the physical and the psychological are such a biological verity of childbearing that women have an undeniable right to have the maternity care provided to them be structured to address gravitational influences and the quasi-sexual nature of spontaneous labor and physiological birth. [Safety of Alternative Approaches to Childbirth; Peter Schlenzka, 1999] 

 A Plan for the 21st Century ~ Workable Midwifery Laws

Midwives and home birth families would like to see the energy currently expended in fighting 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 which makes this a safe choice. The best option, given these realities, is for your organization to support a workable midwifery law, one that adequately protects all parties (including mothers and babies) and which includes 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 you not restrict your official respect for informed consent and your 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, 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 midwives caring for healthy mothers in the 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 your organization 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 wellbeing 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; that the full-time presence of a practitioner (either physician or professional midwife) be routinely required at the bedside while the woman is in active labor; 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; re-defining the normal “standard of care” for healthy women to be 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).

 Futures Market ~ “Off-Site Birth Technology”

I often wonder why obstetricians don’t seem interested in being part of this active dialogue so that your membership 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 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 oxymetry 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) which 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 cross pollenization 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 others 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 wellbeing 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.