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

April 28th, 1997

Dr. Maurice Druzin, Chief of Obstetrics
300 Pasteur Drive, Rm HH-333
Stanford, California 94305-5317

Dear Dr. Druzin,

As you are no doubt aware, the Licensed Midwifery Practice Act of 1993 has resulted in the licensure of direct-entry midwives in California. Licensed midwives provide primary, non-medical maternity care in a domicilliary setting (the client’s home or a free-standing birth center). A facet of that provision of home-based care by midwives is a supervisory relationship with a physician who has hospital obstetrical privileges. Licensed midwives on the San Francisco Peninsula, as in most other areas of the state, have not been able to locate any physicians who are willing to provide the mandated supervision. The reasons for this are complex, having to do with limitations imposed by malpractice carriers and the general resistance of doctors to domiciliary birth services. To complicate matters further, obstetricians who in the past have made themselves available to domiciliary midwives have been threatened with loss of their hospital admitting privileges if they did not disassociate themselves from these midwives.

This creates major difficulties for client families of licensed midwives who need or want hospital obstetrical services. They must be admitted through the emergency department and assigned either to the ‘on-call’ obstetrician of the day or the resident staff. Emergency room care from a doctor unknown to the patient is always the most expensive and the least satisfactory way to deal with non-emergency problems. While this usually meets the most basic medical needs of the mother or baby, it is not a very satisfactory circumstance for either the family or the doctor who is required to provide care under these circumstances.

Physicians who have been assigned ER duty for the day (an obligation that accompanies hospital privileges) are never very happy about walk-ins and due to the ideological resistance to home-based midwifery care, are particularly ill-suited to deal with homebirth transfers. This puts maximum strain on the doctor-patient relationship and sometimes compromises care due to the tension between the expectations of the family and the belief by the physician that parents should be some how be "punished" for having made the "unwise" choice of a midwife-attended out-of hospital labor and birth. This prejudice is not only unfortunate, but illogical. A risk-adjusted statistical analysis of home-based care, as provided by skilled midwives and in conjunction with access to hospital services for complications, proves it to be the equal to hospital-based obstetrical services. This has been amply documented by many different researchers.

In order to address the total absence of "physician supervision" from within the private sector and avoid the problems associated with emergency room admission, I am asking, as spokesperson for the ACDM, that the clients of licensed midwives who are planning homebased maternity care be seen in the Women’s Clinic at Stanford to establish a relationship with obstetrical careproviders and to receive routine lab work and any diagnostics such as ultrasound through your clinic. Should they desire or require medical services during pregnancy or in association with the labor, birth, postpartum or postnatal period, they would then be admitted as patients to the teaching service or, if appropriate, the midwifery service.

Approximately 95% of our families either have economic resources to pay for care (insurance or other financial means) or they qualify for medical reimbursement. Currently families requesting elective transfer are admitted to the midwifery service of San Franciso General Hospital. However, both we and our clients would prefer to stay on the Peninsula and to keep this economic resource in our local community.

I and the other domiciliary midwives (both nurse-midwives and licensed midwives) would be happy to meet with you in person to discuss this possibility.

In addition to this request, I have a second proposal for your consideration. Many midwives and families are interested in maternity services in which the mother sees her midwife during pregnancy, labors at home under the care of the midwife and then electively transfers to the hospital during the last few hours of the labor for a planned hospital birth. Assuming that there are no complications for mother or baby, the new delivered "couple" transfer back home within a few hours of the birth, where the midwife continues to provide on-going postpartum and postnatal care.

This form of care is quite common in Europe -- especially the Netherlands which has one of the best records for maternal-infant outcomes in the industrialized countries. It is known as "Domino" care, which stands for "Domiciliary in and out". In Holland and other European countries, the mother is usually delivered in the hospital by the same midwife who provided the domiciliary care. However, this system is also employed where the mother is delivered by a physician (for instance a complication requiring MD care). In this country, only CMNs with hospital privileges could routinely provide domino birth services.

We are proposing that your institution design a study and experimental model of domino care in which the teaching staff, through the Women’s Clinic, would link up with community midwives -- both nurse-midwives and licensed midwives who do not have hospital admitting privileges. Under these circumstances, the midwives would provide customary midwifery care during the pregnancy. In conjunction with that, the expectant women would be seen by the staff of the Woman’s clinic at least once during the pregnancy to receive any diagnostic services (blood work, ultrasound, amnio, etc.) and follow-up care as indicated. At the time of the birth, the mother would then be delivered by either the resident staff or a nurse midwife from the Stanford Midwifery Program.

It is the suggestion of many public health officials that medical students and interns be assigned to participate in midwife-managed births as a part of their medical training. Having med students see normal labors and births managed by midwives before participating in complicated deliveries managed by obstetricians is an important facet of medical education in countries that use the midwifery model of care. Interdisciplinary education is associated with a reduced use of obstetrical interventions afterwards by such physicians.

Over the course of the next decade, physicians will gradually find themselves being held responsible for knowing and appropriately using standard midwifery principles and techniques. In event of a malpractice suit, they will be required to establish that they first used the ‘common-sense’ approaches historically associated with midwifery care -- gravity, patience with nature, one-on-one emotional support, oral hydration, upright and mobile mother, vertical delivery, hands and knees position to resolve shoulder dystocia, etc. before embarking on drug-dependent or surgical solutions such as IVs, oxitocin, narcotics, epidural anesthesia, forceps, cesarean surgery, procto-episiotomy or fracturing the baby's clavicle (to resolve a shoulder dystocia), and the like. It just makes good sense to build familiarity with the philosophy, principles and skills of the midwifery model into medical training in preparation for these inevitable changes.

In addition to the educational value, there are three other distinct advantages to your institution in regard to this research project. First, the insurance companies are already aware that midwifery managed birth services provide equally good outcomes and patient satisfaction at significantly less cost. Dr. Roger Rosenblatt’s study, which documents 40% reduction in Cesareans, and substantial reduction in induced labors, episiotomy rate and epidural anesthesia, has gotten much friendly press and even coverage on National Public Radio. Earlier this year, a similar study in the United Kingdom also documented higher patient satisfaction and lower intervention rates in the "midwife-only" arm of their study (as compared to co-managed care between physicians and midwives). While the cliché "time is money" still holds true in most areas of modern life, in maternity care this premise is often revered. Additional time spent with the laboring mother often saves the expense of obstetrical interventions. It is still true that an ounce of prevention is worth a pound of cure. Midwifery is a preventative discipline.

It is simply a matter of time before the ‘bean counters’ in the insurance industry begin to impose additional limitations on obstetrical services, such as requiring low-risk "normal" pregnancies to be managed by midwives and making coverage available for domiciliary birth services. Your institution basically has the opportunity to be on the cutting edge, laying the track for how this kind of change takes place and shaping it to be more compatible with contemporary obstetrical thought. Another alternative is to be in the caboose complaining that the train is going too fast and headed in the wrong direction. Secondly, your institution could enjoy the financial gain of providing hospital delivery services to families that otherwise might have planned a home birth or utilized another hospital in event of a desire for medical care.

And third, Stanford has had a reputation for leadership and innovation in healthcare. Some of the most famous pioneers of transplant surgery did so at your institution. Within the next 6 months or a year, some institution will design a study because the ideas are out there. Insurance companies, which have the same information available to them as to you and me, are giving people the economic incentive to do so. Why not be in the forefront and get the glory, the money and some measure of control over this "innovative" approach?

As long as doctors only cross paths with midwives when there is a complication, they will continue to find it difficult to see them individually as competent practitioners. In order for physicians to be comfortable working with midwives and develop a respect for the art and science of midwifery, they need opportunities for regular professional interaction. It is our hope, as midwives, that "domino" midwifery care could bring that about.

Unwarranted fears 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, anesthetics or operative obstetrics in a domiciliary setting) only a 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!

This philosophy of reconciliation is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was mother of young children as well as First Lady of the land. 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.

Warm Regards,

faith gibson, community midwife
NARM Certified Professional Midwife #96050001
Executive Director, ACDM


Senator John Vasconcellos, 13th District
Members - Division of Licensing, Medical Board of California
Ina May Gaskin , President, Midwives Alliance of North America
Maria Iorillo, President, California Association of Midwives

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