Assoc of Women's Health, Obstetrical and Neonatal Nurses  

American College of Domiciliary Midwives
PO Bx 60334, Palo Alto, CA 94306
Correspondance with AWHONN

Joy Grohar, RNC, MS, Representative of AWHONN
1105 Grandview Ave
Lockport, IL 60441
Fax 834-1374

April 11th 1996

Dear Joy,

It was a pleasure to meet and work with you at the Mt. Madonna consensus conference. I believe that our efforts were vitally important to the future well-being of childbearing families and their careproviders. I was personally very honored to be a part of this important process as I’m sure you were too.

Goal of Direct-entry or Non-nurse Midwives

I realize that the issue of non-nurse midwifery is a very controversial one, especially to the membership of your organization. However, I hope that what I have to say will shed needed light on the topic and help put to rest the erroneous idea that the goals of direct-entry midwifery organizations are in conflict with the goals and standards of practice supported by AWHONN. In particular, I want to assure you that the many traditional midwives already practicing across the US are appropriately prepared for the task of providing safe maternity care in a domiciliary setting. The historical body of knowledge that home-based midwifery represents and the many skills that make for an efficacious practice, including appropriate emergency medical responce to maternal bleeding and skilled neonatal resuscitation, are the norm for “direct-entry” midwives who qualify for certification by the North American Registry of Midwives. As traditional midwives, we have been eager to document and demonstrate our excellent skills and have been working toward that goal for more than 20 years.

In particular,
your membership should know that it was the medical community -- California Medical Association, American College of Obstreticians & Gynecologists, etc. -- in our state (and many others) who have been fighting for the last 20+years against competency validation and state-recognized certification of midwives. One demonstration of this resistance in California has been the regrettable policy of the department of vital statistics who refuse to register domiciliary births as midwife-attended. By insisting that the father (and not the traditional midwife) sign the birth certificate, the statistics go into the national data bank as “unattended home births”, thereby making the numerical incidence and the good-outcomes of home-based care statistically invisible. This also means that the rare incidence of a complication takes on a statistical value all out of proportion to reality and leads to hysterical accusations of danger that bear no relation to the facts. Statistically, home-based care by skilled caregivers is equal to or superior to hospital-based care for mothers of the same risk level.

I want to be sure that the certification of domiciliary midwives by the NARM and the mechanism for California licensure of direct-entry midwives is not confused by your membership with voluntary registration in which anyone, regardless of skill (or lack thereof) may call themselves a “professional” midwife and become licensed just by “signing-up”. You may be assured that
the actual licensing process for the California Licensed Midwife challenge mechanism is very rigorous and was in fact written by the California Medical Association (state chapter of the AMA). As a dis-incentive to licensure, they made it as complex as they could possibly get away with. To qualify one must be able to document 235 discrete caregiver activities by both an MD and CMN (20 new antepartum visits, 75 return antepartal exams, 20 labors, 20 deliveries, 20 newborn exams, 40 postpartum-neonatal visits -- 0 to 5 days -- and 40 postpartum/well-woman gyn visits). Only after successfully meeting this criteria can a practicing midwife apply to take the challenge exam by the Seattle Midwifery School. The challenge mechanism requires successful passage of an extensive written exam (6 hours) and also requires a clinical demonstration of all midwifery skills. After completing these three steps, the candidate then must take a midwifery state board exam. So rest assured -- domiciliary midwives licensed in California will meet professional standards (and then some!).

American College of Domiciliary Midwives

As you know from our conversation, the ACDM is committed to preserving and promoting midwifery care in both homes and hospitals as provided by midwives of all backgrounds and family practice physicians. While the educational efforts of the ACDM focus particularly on home-based care, we are not in any way opposed to hospital-based midwifery care. In addition to domiciliary practice of midwives (both direct-entry and CNMs), we believe that the practical well-being of mother and babies would be greatly improved by two other substantial changes and are committed to bringing this about. First, we want to see a larger number of GPs and family practice physicians provide normal maternity care, both in hospitals and domiciliary settings. Second, we are firmly onvinced that all “normal” labor and birth care in hospitals should be “midwifery” in nature. Please note here that “midwifery” is a basic form of care recognized world-wide that historically has been provided by physicians as well as midwives. Our goal is for all healthy mothers experiencing a normal pregnancy and spontaneous onset of labor to have midwifery-based care, both in and out of the hospital, by the year 2000.

Labor & Delivery Room Nurses to be cross-trained &
Reclassified as hospital-based midwives

The only logical, cost-effective way to achieve this goal is by reclassifying the current pool of experienced (older “seasoned”) L&D nurses as hospital-based midwives after six months of cross-training in midwifery. Unless the mother has a complication requiring medical intervention, all spontaneous births would be attended by nurse/midwives employed by the hospital. Obstetrical medicine could then be free to do what it does best -- to provide medical care for women who require or desire medications, surgical interventions or anesthesia and unborn babies who need help. Here in our local area we have a superb example of what this means in hard cold cesarean numbers. Kaiser Redwood City now uses midwives for all normal births and enjoys the lowest C/S rate in the entire United States -- 6.6%. Meanwhile a hospital 10 miles away with the same demographics, which has no midwives on staff, has a 20% cesarean rate -- three times higher! These numbers speak louder than words and are of more than academic interest to the 13.4 % of mothers and babies undergoing unnecessary, painful and potentially dangerous surgery.

To illustrate this idea I must relate to you the classic story of the English midwife who came to this country in the early 1940s and was hired as an L&D nurse working midnights in a small hospital. On her first night a young primipara was admitted in labor. In the morning, the English “nurse” called the physician to tell him that his patient had delivered a lovely 7# little girl over an intact perineum and the mother was looking forward to a visit from her doctor that morning on the postpartum ward. Of course the doctor was livid about this "outrageous" behavior of the nurse/midwife but in fact,
this patient got precisely the care that was ethically and economically indicated. Every spontaneous hospital birth should be managed the same way.

Obstetricial Nurses as Advocates for Hospital-based midwifery

I am excited about the enormous potential for change that would be created by bringing obstetrical nurses into the conversation as advocates for hospital-based midwifery. I believe that the time is right for the rehabilitation of midwifery consciousness in North America. To do this we must re-examine the idea of “labor and delivery room nursing”. This modern convention splits the caregiving process apart into two factions -- on-going care during labor provided by the nurse (mostly female) and “delivery” by the Johnny-come-lately (mostly male) physician. This arrangement depends on the nurse abdicating her central role in midwifery management whenever the physician arrives on the scene. The unfavorable power dynamics are clear -- in the presence of the doctor, the nurse is demoted to the role of hand-maiden. This splitting up of autonomous, woman-centered midwifery into two separate parts with male physicians taking the autonomous role and assigning to nurses the lower-paying dependent role of nurturer and order-taker was one of the earliest strategies for eliminating the midwife from her own profession.

Historically, it was this elimination of the midwife as a practitioner of midwifery that eventually lead to the loss of the midwifery model of normal maternity care, and its replacement with a pathological definition of childbearing and the current obstetrically-based hospital model. In addition, the legal definitions of nursing (in most states) include the concept that a nursing license does not authorized nurses to “treat” patients and therefore a nurse can never be a “practitioner”. Not only does this denigrate the hard work of labor room nurses but because they are not autonomous practitioners, but the primary loyalty of L&D nurses must be shifted to the doctor and institution and NOT to mothers and babies. This is detrimental to both the childbearing couple and the nurse.

Unlike our conventional concept of L&D nursing, a hybrid classification of
"Intrapartal Practitioners" (i.e. hospital-trained, hospital-based midwives) would provide continuity of caregiver for labor, delivery and the immediate postpartum. Because such midwives would be practitioners with their own autonomous sphere of responsibility, their role provides for primary loyalty to the practical wellbeing of the mother and baby and not to the doctor. Of equal importance, this system honors the work of those women/nurses who do the hard work of “midwifing” on a minute by minute basis. From my own 15 years as a labor room nurse I would describe this as “delivering the mother to deliverability” and consider it to be the central issue.

If "midwifing" is a verb, L&D nurses are midwives!

As you well know, the crucial skills of midwifery are in those endless hours of minute-by-minute “midwifing” the laboring woman up to that moment just before the baby spontaneously slides across the perineum. At the point when the mother has already been “delivered to deliverability”, it matters very little whose hands are actually on the baby at the moment of birth -- the doctor, the nurse (and/or) midwife, the mother, father, a student or just a soft surface. For instance, the protocols in hospitals that use deep water tubs for labor and birth is that the mother (or father) catch their own baby. The point here is simple and non-negotiable -- whoever does the “midwifing” should quite naturally “catch” spontaneously-born babies. As those union bumper stickers declare: "Honor Labor". We should especially honor the labor of the labor-room nurse whose job it is to assist the laboring mother to do her job of giving birth normally.

If an obstetrician should object to having a generic hospital midwife provide "midwifery management” to their patients, he or she can “attend at once” and “midwife” for themselves. Classical midwifery instructions to obstetricians, as published in a 1953 English obstetrical textbook for medical students entitled A Practical Guide to Midwifery & Gynecology, states that the primary duty of the obstetrician at the onset of a normal labor is to “Attend at Once”. If doctors prefer to be present when their patients are delivered by the “nurse/midwife” who has provided the on-going care, they are most welcome to be present like any other “back-up” midwife or other hospital personal.
Only if obstetrical interventions are medically indicated OR requested by the mother (pain meds, anesthesia, oxytocin, etc.) would the physician take on medical management of the birth process. Of course this shift in intrapartal care will naturally lead to changes in obstetrical education. Medical personnel will need to be trained in midwifery principles and midwives must be responsible for the primary education of medical students in normal maternity care.

The Hundred Years War -- Doctors, Nurses and Midwives

Speaking as one who has personally experienced all sides of obstetrical oppression (as a labor room nurse, laboring mother and a criminally-prosecuted midwife), I see the untapped potential in this Hundred Years War between physicians and midwives to be labor and delivery room nurses. When physicians first began plotting to eliminate the midwife from her own profession in the early 1900s, they looked to nurses to take over the nurturing function of the midwife so that they, the physicians, would only have to “doctor”, which is to say, show up at the last minute. This is known by some as “reaping what you did not sew”. By bringing L&D nurses back into the picture as practitioners and therefore, equal players, it tips the scales in favor of women. There are only 32,000 obstetrician members of ACOG in the entire US whereas there are hundreds of thousands of nurses. While not all nurses will welcome the idea, I believe that most will recognize benefits to childbearing women and the expanded opportunities presented to nurses by practitioner status and therefore be supportive of these changes.

We must bravely take the stand that it is simply unacceptable for us as citizens of a democracy to continue supporting a maternity care system that
systematically ignores a 100 years of factual data supporting midwifery management for normal birth as the only safe and cost maternal-infant health policy. The classic pledge upon which medicine is founded, the Hippocratic Oath, states it simply enough: "In the first place, do no harm". As consumer advocates we must compel allopathic medicine to operate under the Hippocratic Oath. Midwifery-management for healthy women is fundamental to safe, cost-effective maternity care. Obstetrician-centric births for healthy mothers experiencing normal pregnancies who neither need or want medical interventions, carries with it a significant potential for harm from iatragentic and nosonical causes. We must keep in mind that truth does not have to be defended -- only revealed. The truth is that the superior outcomes of midwifery-based maternity care for healthy women, obstetrical care for complicated pregnancies, liberal breastfeeding, and valuing of the parent-child bond have long been documented in maternal-infant statistics. These cost-effective methods are strongly associated with lower rates of mortality and morbidity and the long-term wellbeing of mothers and babies.

The truth is that
high-tech obstetrical care for normal pregnancy is like kidney dialysis for people with don’t have kidney disease (or scuba gear for a fish!). Now days we not only have the testimony of evidenced-based practice parameters such as the Cochrane data base but also the recorded experiences of many families who have video taped both home and hospital births. Without saying a word, the contrast between management styles speaks for itself. Obviously, most doctors have never seen normal, midwifery-based intrapartal care or personally conducted a birth based on these principles. Nor does obstetrical education any longer include the principles of normal birth in its professional training. For instance, the latest edition of Gabbe’s excellent obstetrical textbook does not even have a heading for spontaneous birth -- the only entry for normal birth management (just 2 pages out of 1500) is for “assisted” spontaneous birth and begins with instructions for performing an episiotomy. Murray Enkin (author of Comprehensive Guide to Pregnancy Care and the Cochrane data base) in his published commentary on a nurse-midwifery conducted study of vag exams in 2nd stage, expressed dismay at having a “video camera with a zoom lens and omni-directional microphone” turned in his direction.

Technological Impact on Birth Practices not limited to EFM

Technological impact on birth practices is not limited to electronic fetal monitoring and ultrasound. The video camera is a technology that is more and more accompanying childbirth and making the Emperor’s scanty wardrobe into common knowledge. In the near future every delivery room will have a video camera in the corner routinely documenting events, just the way banks and other institutions do. When combined with other aspects of the information superhighway, the Internet as a public education forum, e-mail news groups for communication between midwives, etc., we must acknowledge that we are in a period of broadly-based rapid change and one that will be characterized by sustained input of childbearing women as nurses, midwives and mothers. As stated in the document I circulated at the Childbirth Congress “there can be no alibi for not knowing what is known” (quote from the 1963 edition of Davis Obstetrics). Evidence-based practice parameters are the future of maternity care in North America. And evidence-based care is the midwifery-model for normal pregnancy and spontaneous birth.

For far too long the financial interests of healthcare providers, particularly the institutional aspect of high-tech services and hospital beds, has taken its half out of our middle -- women as nurse, midwives and mothers. This exploitive system systematically exploits obstetricians as well as women and babies.
It is not individuals doctors or even obstetricians as a class that are at the core of the issue -- it is the general acceptance of unscientific principles as the foundation for maternal-infant health policies in North America. Initially this was brought about by the private and professional biases of allopathic physicians who became willing participants in a public dis-information campaign financed by the economic interests of organized medicine.

Co-operation of physicians, nurses, midwives and
consumer groups key to the 21st Century

To off-set the negative propaganda of the last 100 years we must have the co-operation of physicians, nurses, midwives, birth educators, breastfeeding organizations, concerned parents and consumer advocacy groups. Bringing these diverse opinions together is challenging but not impossible. The Childbirth Congress consensus conference was a huge step toward that goal and Suzanne Arms and ASPO are to be congratulated for facilitating such an important event. However, we cannot do what needs to be done by compromising midwifery principles or pretending that if we just conduct ourselves so as not to piss off doctors (or others within the power structure), that all will eventually be well. More of what isn’t working will not work either and we have been compromising and appeasing for more than a century without success. It is easy to see the exploitation of mothers and midwives, not always so easy to see the exploitation of nurses and very hard to see the exploitation of physicians. Yet all are equally true although different in content and outcome. We must address the concerns of each exploited segment on a one-by one basis and facilitate a willingness to entertain the idea that there is something important to know that they don’t already know. Above all we must give hope.

In particular,
the current exploitation of obstetricians by a system that doesn’t permit them to enjoy any real autonomy needs to be given voice. It is out of the self-interest of hospitals that administrators promote the idea that domiciliary birth services are so dangerous physicians better not even think about attending (or providing backup) for one. After all, what would the hospitals do if doctors and their maternity patients went elsewhere? At the same time, hospital politics demands that physicians jump through increasingly higher hoops to protect their hospital privileges while malpractice premiums soar by the hour. Obstetrical rage at the “hubris” of midwives is to be expected -- hospitals have physicians by the balls, women doctors are graduating from medical school in carload lots and fast becoming the “preferred provider”, the birth rate is plummeting, HMO payments are less than half of what OBs were charging 5 years ago and now midwives (and nurses!) come along taking business away from them while wanting them (the doctors) to take legal & financial responsibility for home births for God’s sake (poor babies!). Frankly, the currently system systematically disadvantages all the players (except for the financial interests of profit-making businesses). It badly needs to be changed.

On our side are the financial facts of life and the good old American profit motive --
good maternity care, based on a world-wide midwifery model already been proved successful in other countries, is even more profitable than the current system. It eliminates both the unnecessary expense of the physician’s time and expensive medical and surgical techniques and complications triggered by the cascade of interventions. I truly believe that our time has come. We will prevail. Evidence-based parameters, video technology, the Internet, consensus-building and consensus conferences and the hard work of many will help us to rise up a whole order of magnitude -- one that will bring maternity care in the North America into line with world-wide standards which are based on the midwifery model for normal pregnancies and obstetrician care for complicated ones.

Warm Regards,

faith gibson, community midwife
Certified Professional Midwife #96050001
North American Registry of Midwives
American College of Domiciliary Midwives
Editor, International Journal of Domiciliary Midwifery
(on line peer-review journal)

Suzanne Arms, Organizer for the Childbirth Congress
Ina May Gaskin, President, MANA
Jan Triton, Editor of Midwifery Today
Jack Travis, MD; Editor of the Wellness magazine
Cheri VanHoover, CNM; Kaiser HMO, Redwood City, CA


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