American College
of Domiciliary Midwives
PO Bx 60334,
Palo Alto, CA 94306
"Health Check": Dr. Nancy Snyderman
959 Eighth Ave., New York, NY 10019
faith gibson, C.P.M. RE: Your article in October 1996 issue of GH magazine

Dear Dr. Snyderman,

It is always nice to see one of our local celebrities featured in a national publication. And as a midwife, I am always pleased to see a "midwife-friendly" article in a well known and nationally-circulated magazine such as Goodhouse Keeping.
Industrialized counties that utilize a midwifery-model of maternity care have significantly better maternal-infant statistics than the US, so it is appropriate that the public should become informed about the valuable contribution of professional midwives.

However, I want to correct the information in your article about non-nurse or "direct-entry" midwives. You characterized the category of "other" (non-nurse) midwives as uneducated, unskilled, unlicensed and unsafe. I am happy to report that none of these characterizations are factual. In fact, direct-entry midwives are formally and informally educated through a variety of routes, and pass a professional exam deemed "equivalent" to the nurse-midwifery exam by the American College of Nurse Midwives. They are professionally licensed in many states, including those with large urban populations such as California, New York, and Florida. For midwives who meet the stringent criteria of the Midwives Alliance of orth American (MANA), there is a national certification program under the auspices of the North American Registry of Midwives which grants the title of Certified Professional Midwife ("CPM").

The major educational difference between nurse and non-nurse midwives is that Certified Nurse-Midwives originally trained as professional nurses and later took a 12 month post-grad course in hospital-based midwifery.
A "direct-entry" midwife is one who prepares directly for a professional career in midwifery rather than as a nurse. This direct educational route is the same one used in European countries, the majority of whom have a midwifery-based model of maternity care with statistical outcomes superior to our own. The contemporary practice of both nurse and non-nurse midwifery is based on the same scientific body of knowledge. Direct-entry midwives are no less "scientifically-prepared" than their nurse-midwife counterparts.

As you are no doubt aware, the traditional practice of midwifery was historically distinct from both nursing and medicine and only in very recent times has a nursing education become associated with midwifery practice. While sharing the same scientific knowledge base, physicians, nurses, dentists, chiropractors, acupuncturist, midwives and many other healthcare professions each have a distinct occupation with its own educational program. As we respect the unique educational path of doctors, nurses and chiropractors and others, so we should equally respect the direct-entry midwifery route.

While we are fortunate to live in modern times with training programs and legal recognition of traditional midwives, this was not historically the case. There was a well-financed effort by organized medicine in the early part of this century -- embarked on when women did not have the right to vote -- to eliminate the competition of midwives. This multi-generation plan to abolish the independent practice of midwives was never supported by any actual data comparing outcomes of physician-attend births with midwife-attended ones. Rather it was fueled by the medical profession’s desire to utilize the clients of midwives as "clinical material" in the training of medical students. At the time, upper class women of the gentry were not considered "appropriate" as teaching cases for students.

This documented campaign to "Eliminate the Midwife" was in response to a well-founded criticism of medical education by the 1910 Flexner Report which noted that, unlike the famous medical schools of the Continent, obstetrical education in the US was not being taught as a "clinical" discipline.
At the turn of the century, many graduate physicians offered maternity care as general practitioners without every having conducted a delivery on a living person. And sadly for many families, the rate of birth injuries rose as the number of midwife-attended births declined. Luckily we now live in times that has rectified this historical injustice and once again midwives have access to training and the benefits of modern obstetrical science.

The other major difference between nurse and non-nurse midwifery is that direct-entry midwives are community-trained and primarily provide domiciliary-based (home and free-standing birth centers) maternity services to healthy mothers experiencing normal pregnancies. When concerns over the health status of mothers or babies occurs, they refer them to medical services.
Statistics for home-based maternity care which includes access to appropriate obstetrical services, show healthy outcomes for midwife-attended births to be equal to or greater than hospital-based services for parturient of the same risk category. Safety is really not the principle issue here.

Home-based birth services are minority choice in all industrialized countries -- a situation that is not likely to change in our lifetime. As a midwife I can personally attest that home birth is about as popular as vows of celibacy! However, home-based care with a skilled midwife or physician does represent a safe and affordable choice that is just right for a small number of healthy, highly-motivated mothers that are not planning to use medication or anesthesia. It is also very cost-effective and in some states (Washington and Oregon) it is one of the legally mandated options for HMO and insurance reimbursement policies.

The years from 1960 to 1990 saw a tidal wave of hospitalization in which minor of health problems or simple diagnostic texts resulted in days of expensive hospital care. This followed federal funding by the Hill-Burton Act after World War II which resulted in the building or expanding of many hospitals with the idea that every "non-ordinary" life event would be “sanitized” by medical care in an institutional setting. As hospitalization gets ever more expensive, we are already seeing a reversal of this trend. The years from 1990 to 2020 will no doubt see us returned to home-based healthcare of earlier times, in conjunction with the liberal use of hospital services for support and/or brief acute care.

I am a community-based midwife writing on behalf of the American College of Domiciliary Midwives, a professional organization which includes both nurse and direct-entry professional midwives as well as GPs and family practice physicians who provided community and home-based maternity services. We do not see this as an either/or debate between midwives and physicians or between home / hospital care but rather as a
co-operative and complementary activity between physicians, midwives and hospital with an outcome that is mutually beneficial and meets the needs of all parties in a safe and cost-effective manner.

I would like to close with 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.

We in the midwifery community would welcome further dialog on this topic.

Warm Regards,

faith gibson, CPM
North American Registry of Midwives#96050001
American College of Domiciliary Midwives


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