The American College of Domiciliary Midwives

April 10th, 1995

Ms. Charlotte Newheart
American College of Obstetricians & Gynecologists- District IX
1409 Sutter Street
San Francisco, CA 94109
415/474-1818 ** Fax 474/1832

Dear Ms. Newheart,

I am writing on behalf of the American College of Domiciliary Midwives, an
educational organization representing the professional concerns of midwives and general practice physicians who provide home-based birth services. The ACDM promotes the recognition of domiciliary (home-bases) maternity care as a bio-social specialty domain with a unique curriculum and scope of practice distinct from the standard bio-medical education and hospital-based obstetrics. Low-tech, high-sociology care as traditionally provided in a home setting by both midwives and GPs is seen as one end of a continuum with high-tech hospital obstetrics firmly anchoring the other end. We are entirely supportive of obstetrical care but also perceive the need to rectify educational imbalances which reflect a cultural blind-spot in the conventional approach to childbearing. In particular, we advocate integrating traditional bio-social principles back into standard medical training, including experience with domiciliary birth and community-based maternity services as a facet of a well-rounded  professional education.

We request your cooperation in resolving the historical tensions between our
respective professional groups. These tensions arose out of a Campaign originating in the late 19th century (pre-dating ACOG by 50 years) to eliminate midwifery care [encl#1]. The set of assumptions driving this effort have since been subjected to scientific research which have proven them incorrect. Documentation of this fact is now widely available to the public [encl#2]. For low and moderate-risk mothers, the safety of skilled midwifery care in a domiciliary setting has always been equal to (or greater) than physician-attended birth. This information is not meant to cast aspersions on the obvious skill of obstetricians - it relates not only to the art of midwifery but, equally important, to the absence of narcotics, anesthetics, operative deliveries, exposure to hospital infections and medication errors, in conjunction with appropriate access to obstetrical care and a client population free from pre-existing disease and the serious complications of pregnancies.

ACOG's official position concerning domiciliary care is out of date and represents a liability to the obstetrical community. In order to protect its credibility as a modern medical discipline based on demonstrable scientific facts, ACOG's official policies should square with these facts. Reputable, repeatable research from many different sources clearly confirms that home-based maternity care provided to low and moderate-risk mothers by trained practitioners and including appropriate access to obstetrical services, provides a safe and satisfactory outcome equal to routine hospitalization. The disciplines of physiology, psychology, neuro-immunology, sociology, veterinary medicine, and medical anthropology have all made substantial scientific contributions expanding our understanding of the mechanisms of physiological childbearing and the often deleterious effects of medical interventions.

The Winterton Report by the British House of Commons in 1992 is just one of
many reputable studies [encl#3]. The World Health Organization has also been outspoken on the subject. Some research even indicates that for very low-risk mothers, care in low-tech, low-intervention locations (such as the mother's home) is actually safer [encl#4]. Concomitantly, the Women's' Movement has introduced other important forces for change.  The Yale Feminist Law Review recently published an extensive article by a nurse/attorney entitled "Midwifery Is Not the Practice of Medicine".

Another example is research by nurse-midwives in hospital settings employing a video camera,  zoom lens and microphones to record vaginal exam during second stage by many different birth  attendants. The activities of the birth attendants were then analyzed frame by frame, word-by-word. The conclusion was that "the examinations were performed in a ritualistic manner by all caregivers, and the way the ritual was enacted repeatedly demonstrated the power of caregivers over the women." [encl#5]. Of particular note are the supportive comments (page 3) by Dr. Murray Enkin, a Canadian obstetrician and author of the Comprehensive Guide to Obstetrical Procedures.

The information superhighway and computer literacy is narrowing the information gap between professional and lay person at break-neck speed, especially for those with a modem and on-line service like MedLine. Statistical studies from around the world that 5 years ago would have taken a Ph.D weeks to amass are now easily printed up in a few minutes without leaving home. As the information superhighway trickles down into wider segments of modern society, the lay public is becoming increasingly aware of the disparities between the espoused beliefs of the obstetrical community and mounting scientific evidence to the contrary.

Using such high-tech resources, it is easy to document that: a) home-based care is not high-risk for appropriate client populations; b) that high-tech, high-intervention models of care for low-risk populations are statistically more risky with a corresponding increase in malpractice litigation. The recent Merrill Dow v. Daubert Supreme Court decision requires that scientific claims be supported by a preponderance of credible scientific research. In the event of anti-trust litigation, the obstetrical community can not scientifically support the claim that midwifery is second-class care or that home-based birth services are dangerous to appropriate client populations or that obstetricians are prepared by training, experience, or professional philosophy to medically supervise domiciliary practitioners. Contemporary obstetrical textbooks teach neither the principle of physiological labor & birth nor the principles of domiciliary care [encl#6]. Nor do obstetrical texts deal with the qualities of classical and contemporary midwifery practice or the professional relationship between physicians and modern midwives.

Easy access to the information superhighway is becoming the professional norm and the broadening data base statistically supporting a resurgence in non-interventive maternity care is no longer a well-kept secret. The InterNet and other electronic bulletin boards have become a major source of professional communication and education for midwives [encl#7]. Other technologies such as low-light video cameras have resulted in the routine video taping of childbirth by families in both home and hospital settings. A vast amount of real-time information is now available both for comparison studies by medical anthropologists and as teaching tools for birth educators. These tapes make compelling testimony for the re-examination of many routine obstetrical practices. The pervasive influence of these 20th century technologies has resulted in dramatic and permanent changes in our social structure.  Like the Berlin Wall and the Iron Curtain, the old forms will not work in the new century.

We believe that it is clearly to the advantage of the obstetrical community to step away from this unwinnable controversy by issuing a simple statement acknowledging the scientific facts, i.e. that for healthy mothers experiencing a normal pregnancy who do not plan to use labor stimulants, pain medications or anesthesia, cared for by a trained attendant and having access to hospital-based obstetrical services, statistical analysis shows home-based maternity care to be an acceptable choice. This is an essentially neutral comment that neither encourages nor specifically discourages this "minority" choice. As with the VBAC issue, it is doubtful that such a statement would change the minds or professional practices of obstetricians but it would permit ACOG to adroitly distance itself from the controversy. It would also prevent obstetricians and midwives from becoming locked on a collision course.

The predictable effect of increasing opposition by ACOG to domiciliary care is an increasingly effective political organization on the part of midwives and supporters, in conjunction with the liberal use of Silicon Valley technologies and a global Internet. In a word, that means to draw the media spotlight into the controversy. However, sensationalist publicity and media hype are never an optimal method to resolve complex issues. Considering the number of difficulties facing healthcare providers, it would seem to be to the advantage of ACOG members to have a mutually supportive relationship with midwives and home birth physicians so as to better negotiate healthcare reform and threats of government interference. Midwives have a lot to teach about their areas of expertise.

The ACDM does not expect domiciliary birth services to EVER be a dominate
system. The largest percentage of home births in the industrialized world (Holland) is only about 30%. Realistically, no more than about 10% of American families will ever meet the criteria for domiciliary birth services because the choice requires both good health, a high level of personal responsibility AND a commitment to drug-free childbearing. Of the 10% who meet this stringent criteria, an additional 10-15% will ultimately desire or require antepartum obstetrical care or intrapartal hospitalization. Even thought we can safely predict that domiciliary services will remain a minority choice, we firmly believe that society needs the balancing effect that home-based care represents. Home-based maternity care has the same quality of contribution to society in regard to childbearing that hospice care has in regard to death with dignity. Without the mediating influence, both birth and death become technologically-dominated, and malpractice-centered. These negative forces result in a devolving experience for both patients and physicians.

Clarification of some basic terminology may be helpful. The American College of Domiciliary Midwives purposefully reserves the term "normal maternity care" to denote the low-tech (non-obstetrical) care of healthy mothers experiencing normal pregnancies -- including palliative treatment of minor deviations and the capacity for emergency response by the practitioner (midwife or GP) -- as distinguished from the art and science of obstetrics which is a recognized surgical specialty that addresses the diseases, dysfunctions and disabilities of reproduction and fertility. We see these to be quite different disciplines which serve remarkably different client populations and situations. Only if one collapses these common-sense distinctions does maternity care by midwives or non-specialty MDs become a threat to the obstetrical reputation. The classical form of maternity care is not intrinsically in competition with the true purpose and glory of obstetrical care -- the compassionate correction of dysfunctional states and the treatment of pathological ones.

The Non-Competitive Nature of Domiciliary Care and the
Non-Medical Nature of the Domicile (homes are not hospitals)

Unwarranted fears on the part of California physicians have come about, in part, from the erroneous assumption that the recent passage of a non-nurse midwifery licensure bill will fundamentally change the way large numbers of childbearing women chose to labor & give birth. Based on many years of home & hospital birth experience, we assure you that this is not so. The non-medical approach is simply not "in" and hasn't been for most of the 20th century. Its unlikely to change in our lifetime. Non-medical midwifery care has always been lawful in California (under the original Article 24 & Section 2063) and yet it has been rejected by the majority of childbearing women -- most usually due to the intrinsically painful nature of labor.

For the safety of childbearing families, the innate non-medical nature of home as a location must be recognized, regardless of the credentials of the caregiver -- be it physicians or professional midwives. No narcotics, anesthetics or operative obstetrics are permissible in a non-medical setting due to their intrinsic risk to both mother and child. Homes are not hospitals and visa-versa. This principle must be acknowledged to prevent home-based care from being inappropriately substituted for hospital care in a misguided attempt to economize by parents, the insurance industry or government officials. As long as practitioners remain faithful to this common-sense requirement, only a small fraction of highly-motivated childbearing families will ever choose home birth. Being unable to offer narcotics or anesthetics, midwives & homebirth physicians 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 nation!

However, for a small number of families, the choice of non-interventive care in a domiciliary setting is a central factor in their childbearing choices. Many of these are members of religiously fundamental congregations or of ethnic backgrounds which define childbirth quite differently than mainstream Americans. While the numbers are small, it is still a fact of life that will not go away. With the rise of Christian conservatism, many religiously-oriented families are re-examining the conventional assumptions in regard to both childbearing and childrearing. Many of these families home-school their children and quite naturally, seek to give birth at home as well. Efforts by the obstetrical community to scare them only backfires, giving the impression that doctors can't be trusted or that they are hostilem to religious values.

As a religious practitioner, this only makes my job harder when circumstances arise in which medicalization is clearly indicated. This group tends to have larger families and have often experienced both hospital and home birth, thereby making them very articulate advocates  of the latter. As a sub-culture, they are developing their own educational materials  (including birth videos) that are passed hand-to-hand among their respective congregations and effectively influence the childbearing choices of their members.  Speaking as a member of a conservative congregation, our prayer is for a peaceful conclusion to the Hundred Years War on traditional caregivers and the sanctity of our homes. Both are non-negotiable points. For us , a "good outcome" is one that gives us appropriate access to medical services and at the same time, does not interfere with our lawful and ethical choices.

The basic premise of modern midwifery as it is related to contemporary medical care is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was First Lady and the mother of young children. When asked what she put first in her life, her husband (who was President of the United States), or their children, she replied that "together with my husband, we put the children first". I have always appreciated that story as portraying the ideal relationship between physicians and midwives -- that together we put the practical wellbeing of the mother and baby first. The art of the midwife is to facilitate the spontaneous events of the intrapartum and failing that, to seek out the assistance of medical science. We would like to know that we can count on your organization to help us achieve the goal of a truly complimentary practice of our respective professions in a joint effort to serve childbearing families within the wider goals of a democratic society.


Sincerely,

faith Gibson, cpm
community midwife
North American Registry of Midwives #96050001

ENCL:
1. Edited Presentation of the Research of Neal DeVitt, MD
2. Obstetrical Myths Versus Research Realities by Henci Goer
3. 1992 Report on Britain's Maternity Services / House of Commons
4. Safest Birth Attendants, Dutch evidence; Tew M & Danstra-Wijmenga
5. Vaginal Exam During Second Stage; Bergstrom, Roberts, Skillman & Seidel
6. Excerpt Gabbe's Obstetrics: Normal & Problem Pregnancies
7. Midwifery bulletin board sample printout, the InterNet
8. Excerpts The Myth of Vicarious Liability, Susan Jenkins, JD
9. Excerpt A Midwife's Code of Practice; Central Midwives Board, London, UK