The
best kept secret in the United States is that the midwifery model of care is
the safest form of maternity care for healthy mothers with normal
pregnancies and that midwives are
the most appropriate and cost-effective attendants for normal birth.
(1.
Marsden Wagner & W.H.O Practical Care for Normal BIrth.) (2.
Schlenzka “Safe Alternatives in Childbirth”) (4. Rosenblatt “
Interspeciality Differences in Obstetrics”)
Midwives have the best
record for maternal-infant safety, the lowest rates for medical interventions (such as
induction of labor, episiotomy, forceps and CS), the least maternal
complications (hemorrhage, infections, 4th degree laceratons,
etc) and fewest admissions of babies to neonatal intensive care. (2.
Schlenzka)
Midwives also receive the best reviews from new mothers for satisfaction
with their care and with the birth experience. (3. J. RookMidwifery and Childbirth in American)
Midwifery care costs 1/3 to 2/3s less money than physicians. (4. Roger Rosenblatt)
Midwives come in
two basic flavors – nurse and non-nurse. Professional midwives provide care in hospitals,
free-standing birth centers and clients homes. The safety record for all
three locations and both types of midwives is the same (3), with home-based birth care being a little safer for
babies and having the smallest number of maternal interventions and
complications. It also is the least costly. (2) Developed countries with the best infant outcomes and
most cost-efficient maternity care systems use the midwifery model of care,
with 70% of babies delivered by independent midwives. For example, Holland
has one of the best perinatal outcomes of any country in the world, with 30%
of Dutch mothers receiving “domiciliary” or home-based midwifery
care and another 30% delivered in hospitals by midwives.
Records of the
successful traditions of midwifery go back many thousands of years, to the
times of the ancient Egyptians (3500BC) and the Old Testament and yet the
Eternal Verities of normal childbirth are as fresh and true today. The
success of midwifery is based in a universal respect for an undisturbed
physiological process. This includes a deep trust in the
healthy woman’s ability to give labor and give birth spontaneously
when the physical, psychological and gravitational needs of normal biology
are met. The first priority for midwives (and physicians using midwifery
principles) is not to disturb the normal process.
An undisturbed labor
in a healthy woman that is permitted to be “normal” (for example, no
artificial time constraints, etc) and managed physiologically will usually
progress on to a spontaneous birth. The mother-to-be will neither need
nor benefit from being put to bed, having continuous electronic fetal
monitoring, IV fluids or artificial hormones to stimulation labor (Pitocin)
or narcotics and epidural anesthesia. An episiotomy to expand the birth
canal is not helpful nor will forceps, vacuum extraction or a Cesarean
section be necessary. Instead of medical and surgical procedures, midwives
rely on “patience with nature”, hands-on social support and
encourage upright positions to help the mother’s labor advance,
reducing the likelihood that potentially dangerous interventions will be
needed.
When the labor and
birth are normal, the baby is generally healthy and will not need any kind
of expensive, anxiety-provoking neonatal intensive care. After a spontaneous
vaginal birth the mother’s breastfeeding efforts are more likely to
successful and she is much less likely to suffer from postpartum
depression while enjoying enhanced self-esteem.
(5. Predictors, prodromes and incidence of postpartum depression. Chaudron
LH, J Psychosom Obstet Gynaecol 2001)
~ Pregnancy makes a mother as well as a
baby ~
Active participation
during childbirth is an important
developmental milestone and a natural preparation for parenting.
Being a parent includes a host of “challenging” situations in which
mothers and fathers need to go beyond their comfort zones, to meet
challenging situations with persistence and press on in the face of
anxiety and discomfort. They may have a colicky or sick baby, an injured
child or one with a learning disability or problems in school. They may be
called on to provide long-term care for a handicapped child or elderly
adult. Most adults face marriage or job difficulties at sometime in their
lives or suffer the loss of a loved one and other difficult circumstances
like a house fire or flood.
The ability to
tolerate mild to moderate anxiety over the course of several hours without
being forced to resort to instantaneous fixes (such as prescription or
illicit drugs use) is a big contribution to personal mental health. Labor
and birth offer an opportunity for parents to learn how to work together to
cope with a stressful event. Being able to “raise to the occasion”
of a physical and mental challenge can leave the couple feeling more
confident and competent in their ability to handle whatever life sends their
way, including the responsibility of caring for a newborn. When we eagerly
administer narcotics to laboring women and routinely administer epidural
anesthesia (95% rate in many hospitals), we not only increase the risk
of narcotic addiction for the baby later in its life but also deprived
parents of significant developmental experiences that will be important
long after the memory of labor pains has faded.
~ Right Relationship with Technology ~
Midwives use the best, leave the rest
Modern-day midwives
are not luddites, nor anti-technology, anti-doctor or anti-hospital.
Choosing midwifery care does not mean that women cannot benefit from
ultrasounds during pregnancy, Pitocin to speed up a slow labor or pain
medication and epidural anesthesia if desired or required. It only means
that women do not have to have them because there are no other effective
methods to help them make progress or manage pain. Hospital midwives are
authorized to utilize the same basic drugs and equipment as do physicians
and can order epidural anesthesia if requested by their labor patients.
Community-based midwives are trained and equipped at a level equivalent to
emergency procedures, drugs and equipment found in community hospitals
-- IV fluids, oxygen, doptone, anti-hemorrhage drugs and equipment
for neonatal resuscitation. Many midwives also have portable electronic
fetal monitoring systems and pulse oximetry that can be used in domiciliary
setting.
If midwifery is so safe, successful and
cost-effective, why isn’t it the norm?
The reason that
midwifery has not become the standard for normal birth in the US has nothing
to do with midwives. It is the result of a vitriolic propaganda campaign
against midwives begin in the early 1900s when obstetrics was first being
developed by an all-male medical profession. At the time women did not yet
have the right to vote. Historically there was an irrational and
scientifically-unsound exuberance by doctors to replace the
woman-centered practices of midwifery with operative obstetrics,
substituting instead the interventionist care of doctors and nurses. This
remains the goal of organized medicine today, which sponsors campaign to
eliminate all “non-physician” practitioners.
Historical Backdrop for this Modern-day
Dilemma
In the early years of
the 20th century it seemed only logical to “medical men” that
if informally trained women (i.e. midwives) could do a decent
job of delivering babies without benefit of drugs and surgery then male
doctors, trained in prestigious medical schools and with all the
supposed benefits of surgical interventions at their fingertips, could do
a vastly superior job. This was never true but it was an attractive idea to doctors and an
easy sell to the lay public.
The high rate of maternal-infant
mortality at the turn of the century was not related to midwifery care but
primarily was caused by social-economic conditions such as poverty,
malnutrition, poor sanitation, lack of adequate public health policies or
access to medical care when complications arose. None-the-less, organized
medicine blamed all childbirth-related ills on midwifery and launched an
official campaign to eliminate the independent practice of midwives as
quickly as possible. Publicly they promoted the self-serving
notion that it was unfair to poor women to deny them benefits of the
obstetrical “improvements” of the day – chloroform and ether
anesthesia, episiotomy and forceps.
Within ten years
(1910 to 1920) the rate of midwife-attended births dropped from 60% to 13%
and down to zero in some places. In many locations non-nurse midwifery was
outlawed all together and remains illegal to this day. (4. DeVitt Elimination of the Midwife
1900-1930).
This was especially advantageous to medical schools as it permitted doctors
to use thousands of healthy mothers and normal births formally delivered by
midwives as “teaching material” for medical students. Unfortunately,
this resulted in the routine use of anesthesia and operative delivery, which
was dangerous for both mothers and babies.
Instead of treating childbirth as
a normal body process, physicians related to the care of healthy
childbearing women as an opportunity to develop their skills in
operative obstetrics by routinely using chloroform, episiotomy,
forceps and manual removal of the placenta at every normal birth. Anesthetic
deaths, hemorrhage, infection, brain injury to newborns and long-term
gynecology complications for mothers followed in the wake of these
ill-conceived ideas. Unfortunately it was equally easy to conclude that
these bad outcomes indicated that childbirth itself was intrinsically
pathological when in fact it was the application of emergency
interventions to normal circumstances that was so predictably dangerous.
None-the-less, this false association between normal birth and medical
emergencies fueled the propaganda campaign to further medicalize childbirth
and foster a climate of fear about normal birth.
As a result of the
switch from midwives to physician attendants, maternal death rates rose by
15% each year for several decades and the birth injury rate by 44%, as
doctors replaced the midwife’s “patience
with nature” by “artificial, forcible and mechanical means”. In a
speech in 1932 praising the newly-formed Kentucky Frontier Nurse Midwifery
Service, a physician-statistician for the Metropolitan Life Insurance
Company calculated that the absence of professional midwifery care in the
US resulted in 10,000 preventable maternal deaths each year and
at total of 60,000 avoidable stillbirths and neonatal deaths. Despite
identifying 70,000 avoidable maternal-infant deaths annually and many
more serious birth injuries (cerebral palsy, mental retardation), the
medical profession was unwavering in its continuing efforts to suppress and
eventually abolish independent midwifery.
The cost of eliminating “Right Use of
Gravity” and “Patience with Nature”
The price paid for
systematically dispensing with patience, ignoring gravity and disparaging
social support for laboring women was enormous and far-reaching but
invisible at the time. The result of the historical campaign against
midwifery was an uncritical acceptance by the public and the
medical profession of a totally unscientific premise – that
normal childbirth in healthy women is intrinsically pathological and
dangerous, that right use of gravity has nothing to contribute to normal
birth and that routine obstetrical care for healthy women makes birth
better and safer than would occur under the care of experienced
midwives. Historically, the care of skilled midwives was always safer
than that of physicians, as the use of medical and surgical
interventions by doctors predictably increased the number and seriousness of
complications for both mother and baby.
This historical
effort to eliminate midwifery has contaminated our cultural view of
childbearing for the last 100 years and left us with an exaggerated,
pathological fear of normal childbirth all out of proportion to the real
but rare dangers. For many generations of mothers-to-be, this contagious
fear became a severely debilitating psychological problem that actually
caused medical complications (and necessitated use of potentially
dangerous interventions). This does indeed make childbirth more dangerous
and makes for a self-fulfilling prophecy that reiterated organized
medicine’s “party line” ~ that every baby needs to be delivered by a
physician and surgeon because normal childbearing is so dangerous and
unpredictable.
In our own era this
history of chronic fear translates into a 95% physician-attended hospital
birth rate, with Pitocin accelerated labors and epidural anesthesia employed
over 80% of the time, an episiotomy rate of 56%, an operative delivery rate
-- forceps, vacuum extraction and CS – of more than 1/3 of all births. The
US spends more money on maternity care than any other country in the
world, and yet we are 22nd (third from the bottom) in perinatal
outcomes, 14th in maternal outcomes and have the 2nd
highest CS rate in the developed world. Cesarean section is the most
frequently performed major operation in the United States with
approximately 900,000 every year (a CS every 39 seconds). Episiotomy is the
most frequently performed “minor” surgery -- over 2 million each year.
It seems that American obstetricians have yet to
discovery the laws of gravity and proudly flaunt their membership in the Obstetrical
Division of the Flat Earth Society. This is often accomplished by
keeping the mother in bed, giving her labor-retarding narcotics and
pelvic-floor numbing anesthesia, requiring her to push lying on her back or
sitting at a 45 degree angle on her sacrum, while urging her in prolonged
breath-holding and maximally hard, prolonged expulsive efforts – all
non-physiological tactics amply identified as unnecessary, ineffective and
even detrimental. Weight bearing on the maternal sacrum closes down
the pelvic outlet by one quarter to one third while requiring the
baby to be pushed uphill at a 60 degree angle against gravity through a
partially closed door, a feat many first-time mothers cannot manage
without damage to either themselves or their babies, irrespective of the use
(or not) of episiotomy. These iatragenically-created problems are then
perceived by doctors to be proof of a fatal design flaw in normal
reproductive biology that can only be overcome by eliminating vaginal birth
all together!
Midwifery & the Cone of Media Silence
–
In spite of a high success rate for midwives in promoting safe and
successful vaginal birth, there is a media lock-out of news and
information on normal childbirth and midwifery. Rarely if ever does the
media provide an unbiased opportunity for the discussion of appropriate,
cost-effective maternity care and the “right use” of obstetrical
services. The economic conflict of interest between organized medicine and
midwifery is never acknowledged. This media dead zone is only pierced by
inaccurate information that appears to be designed to carry out the
agendas of organized medicine.
Recently the problems created by a century-long propaganda campaign have taken
on a new urgency. The “new and improved” campaign of organized
medicine is to make normal childbirth itself obsolete, to be replaced
instead by “daylight obstetrics” and electively scheduled cesarean
surgeries, promoted now by obstetricians as the preferred and “safer”
choice, the ultimate in “women’s lib”.
This romance with prophylactic cesarean is based on the erroneous idea
that damage to the mother’s pelvic floor is an unavoidable
“collateral damage” of vaginal birth. The obstetrical profession has
never acknowledged the value or even the existence of non-medical (i.e.,
physiological) management techniques, which historically have proven
successful at preventing prolonged or ineffective pushing (thus
reducing the risk of maternal exhaustion & fetal distress) and at
preventing or reducing perineal trauma during childbirth (and subsequent
pelvic floor damage and gynecological problems).
This sad state of affairs is intimately tied to medical profession’s
historical preference for episiotomy (and a host of other interventions),
coupled with their failure to learn, teach or utilize physiologically
effective (midwifery-based) techniques for managing expulsive labor. It also
reflects the disturbing fact that episiotomy – always promoted by
obstetrical professors as “protective” against pelvic floor damage –
is ineffective for that purpose, while contributing heavily to severe 3 and
4th degree lacerations that do indeed damage the integrity of the
pelvic floor. Like the relationship between routine use of continuous
electronic fetal monitoring, fetal distress and a raising rate of CS, episiotomy
is another obstetrical intervention that tends to cause or acerbate the
very condition it was suppose to prevent.
Midwives and Normal Physiology are out,
Surgeons and Medically-Unnecessary Cesareans are in!
An astonishing notion is now being promoted by the
obstetrical community -- that vaginal birth is so damaging to mothers, so
dangerous to babies, so “old-fashioned” and backwards that only its
total elimination will do. This is one of the most pernicious developments
in the history the obstetrics. (see www.collegeofmidwives.org/safety_issues01/rosenbl1.htm)
It would change the focus of a physician’s care from attending to the
needs of the mother during spontaneous vaginal delivery to determining when
fetal lung maturity was achieved so that the CS could be scheduled before
the mother went into spontaneous labor by mistake and (gasp!) gave birth
naturally!
An example of how far the agenda of the medical
community is from the genuine interests of childbearing women is offered in
an article published in the New England Journal Medicine (May 1985) entitled Prophylactic
Cesarean Section at Term? The
two physician authors (George and Jennie Feldman) make a case for Cesarean
on demand and seriously promote the idea that a 100% scheduled or
“prophylactic” cesarean surgery become the norm for all women. This is
described as “saving” babies with only a “little excess” or “extra
maternal mortality” and opin that the “low cost of excess maternal
mortality may be a price worth paying”. Here is an excerpt:
p. 1266
….the number of extra women dying as a result of a complete shift
to prophylactic cesarean section at term would be 5.3 per 100,000…. This may be the proper moment to recall that the number of
fetuses expected to suffer a disaster after reaching lung maturity is
between 1 in 50 to 1 in 500. … if it could save even a fraction of the
babies at risk, these calculations would seem to raise the possibility that
a shift toward prophylactic cesarean section at term might save a
substantial number of potentially healthy infants at a relatively low
cost of excess maternal mortality.
“We probably would not vary our procedures if the cost of
saving the baby’s life were the loss of the mother’s. But what if
it were a question of 2 babies saved per mother lost, or 5 or 10 or
(as our calculations roughly suggest) as many as 36 or 360? ….
Is there some ratio of fetal gain to maternal loss that would
unequivocally justify a wider application of this procedure?”
p
“p. 1267….is it tenable
for us to continue to fail to inform patients explicitly of the very real
risks associated with the passive anticipation of vaginal delivery
after fetal lung maturity has been reached?
If a patient considers the procedure and decides against it, must
she then be required to sign a consent form for the attempted vaginal
delivery?”
In keeping with these extreme sentiments, the current
president of the American College of Obstetricians and Gynecologists began
publicly promoting medically unnecessary cesareans in June of 2000 as the
ultimate choice in reproductive “freedom”. The mere possibility of
pelvic floor damage subsequent to vaginal birth has become the rationale for
promoting the idea of cesarean on demand as “safer”, “better”,
“maybe should even be routine” and simply a matter of a
“woman’s right to choose”.
On Good Morning America (6/20/00), Dr.
Harer answered Diane Sawyer’s question on relative safety between normal
birth and elective CS by saying: “For the mother, the immediate risks for
a cesarean section are a little higher, but the longer term risks of pelvic
dysfunction, urinary incontinence, pelvic dysfunction -- those risks are
higher for vaginal birth and over the long time I think that the risks
balance out … there really is no big difference.”
Unfortunately, surgical complications (infections, blood
transfusions, emergency hysterectomy) and maternal deaths during and after
delivery Cesareans are 2 to 5 times that of normal vaginal birth. Mothers
and babies are also at increased risk for serious, sometimes fatal,
complications in future pregnancies (such as placenta previa or percreta) as
a result of a previous Cesarean. Apparently this is seen by Dr. Harer as
“minor” price to pay.
In July of this year (2001), the Associated Press and NPR heavily promoted a New England
Journal of Medicine article on inducing labor in Vaginal Birth After
Cesarean women. The conclusion as promoted by the national media coverage
would lead us to believe that we should return to the 1930s idea of “once
a cesarean, always a cesarean”. No one mentioned that a repeat cesarean is
of equal or greater risk to the mother than the complications of VBAC. An
alternate (but unexplored) conclusion was that we should stop the
dangerous practice of inducing previous cesarean mothers. There was also
no mention that elective inductions significantly increase the rate of
first-time Cesareans.
Informed consumers long for a return to the
“..passive anticipation of vaginal birth”. My question is quite
different from Doctors Feldman and Harer, as I want to know if it is tenable
for obstetricians to continuously fail to inform healthy women of the
high risk associated with “obstetrics as usual”, with its high rate
of labor induction and cesarean surgery and rare or non-existent use of
effective and low-cost methods to reduce these problems, such as staffing
hospitals with nurse-midwives. Unlike physician care providers, hospital
nurse midwives enjoy a low rate of interventions (especially induction,
episiotomy and Cesareans) while having superior perinatal outcomes and
achieving all this for a third less money? (
Midwives Deliver Healthy Babies With Fewer Interventions NY Times, Dr. Roger Rosenblatt, MD)
Safe Maternity Practice
~ Reform & Rehabilitation
With
no effective public oversight, our maternity care system has
become a cornucopia of “unsafe maternity practices”. For the last 100
years there has been an inherent conflict of between the professional
interests of obstetricians and those of childbearing women that has
never been publicly acknowledged or addressed. Nor has anyone pointed out
the fundamental error of assuming all obstetrical practices are
scientifically based. Obstetricians
have never been held accountable for scientifically establishing the
safety of the interventions they introduced into normal maternity care over
the last century. Here in
the first decade of the 21st century, doctors are still not
held responsible for applying the elemental body of knowledge --
physiological management & right use of gravity -- that has successfully
underpinned spontaneous vaginal birth all over the world throughout history.
This is as elemental to “safe maternity practices” as washing one’s
hands is to safe medical practice.
Nor are
obstetricians being required to obtained informed consent before using
unproven (i.e., experimental) practices, many of which are potentially
injurious, costly and clearly less successful at facilitating spontaneous
birth than physiological management. In
every other medical discipline, doctors and drug companies are required to
follow FDA experimental protocols, provide truthful information to patients
and obtain “informed consent” before using new or unproven methods. Why
don’t these common-sense rules apply to the obstetrical use of
unphysiological techniques (anti-gravitational positions for pushing,
weight bearing on the sacrum) and experimental surgical techniques
such single layer suturing of Cesarean incisions (causes a 3-fold increase
in uterine ruptures).
The first major area of concern is the absence of
the “right stuff” -- a failure of contemporary maternity care to
utilize the midwifery model of care as the standard for normal birth, both
in and out of hospital. Physiological management can be used anywhere by
anyone but it this is not happening in medical institutions. Midwifery
principles and practices are conspicuous only by their absence.
Approximately 70% of childbearing women are healthy and have normal
pregnancies and yet 95% of these healthy mothers are simultaneously denied
the cesarean-reducing benefits of midwifery management (which can be employed
by physicians as well as midwives) while being subjected to
cesarean-increasing, interventiontist obstetrics. (2. Schlenzka) This is to say, labor
was “managed” by a busy L&D nurse who was out of the labor room 79%
of the time (“Supportive
Care by Maternity Nurse: A Work Sampling in an Intrapartum Unit” 1996
Birth, 23:1; 1-6) and a physician who was not even present in
hospital until the last few minutes before the birth or who only came in to
perform the Cesarean after things began to go awry. (Dr Rubsamen, MD, LL.B The
Obstetrician’s Professional Liability -- Awareness and Prevention, 1993)
The Absent Obstetrician
Syndrome
~ an Accident Waiting to Happen
The second category of concern is the legal
consequence of the absent-obstetrician syndrome, which shows up as a
vastly increased rate of malpractice claims and litigation, making the
profession of obstetrics disproportionately risky and expensive (and way
more defensive!) than it need be. An expert in the field of obstetrical
liability studied a sample set of 63 obstetrical malpractice cases involving
permanent brain damage and subsequent litigation. In a book entitled The
Obstetrician’s Professional Liability -- Awareness and Prevention
the author (a physician-lawyer) presents these cases as
"instructive" and "cautionary tales", designed to
acquaint readers with the malpractice traps that have made obstetrics a
"loss leader" for liability carriers throughout the US.
The absence of an awake, decision-making,
practitioner who actually remains in the presence of the mother
through out labor played a central role in approximately 2/3s of these
malpractice cases, particularly those that necessitated telephone
conversations between nurses at the hospital and the doctor who was not.
This gave rise to misunderstandings or miscommunication between those
present at the bedside (who don’t have the training or authority to
intercede on their own) and those absent from the scene (doctors with
training and responsibility but not present to use them). Continuity of
care is also missing and its lack causes other problems, as the doctor
doesn’t actually know what has and has not been tried or exactly how long
a situation has persisted. It is like trying to steer a car over the phone.
An “absent obstetrician”, combined with an
unexpected medical situation (the basic reason families choose hospital
care!), results in an avoidable bad outcome for mother or baby
far too often, predictably followed by a malpractice lawsuit against the
doctors and the hospital. Litigation occurs in regard to what was said by
whom, whether or not a call was made by the nurse to the doctor or the exact
time of the phone call. The nurse and the obstetrician each blame the other
for the unfortunate outcome. It is the usual malpractice nightmare, but unique
in this respect -- it is the one malpractice risk that is the most
predictable and most preventable. “As a result of a nail, the rider
was lost”. One of the reasons that approximately 10% of obstetricians get
sued each and every year is because doctors do not “do” labor. The
“absent obstetrician” is a preventable accident waiting to happen and
when it does, the rest of us have to pay the bills for artificially inflated
healthcare cost to cover huge malpractice loses.
This problem would
disappear overnight if labor and delivery units were staffed by
professional midwives who were continually present during active labor
and who routinely delivered all healthy women with normal pregnancies
and spontaneously progressive normal labors (unless the mother requested to
be attended by a physician). The economic advantage of this safer system are
astounding.
Episiotomy
– The American Version of Female Circumcision
Last but not least of the urgently needed changes concerns the
right use, misuse and abuse episiotomy. Surgical
incisions into the mother’s perineium are
medically useful only about 6 % of the time (the rate for midwives in Holland). The “right use” of
episiotomy is for maternal exhaustion or when a baby is in trouble and needs
to be born quickly. Both of these situations are rare (1-2%) and yet we have
a current rate in the US of 56%.
With an annual birth rate of about 4,000,000, this would mean 50% or about 2
million medically-unnecessary “injurious procedures” are performed each
year by uninformed doctors. Every decade 20 million unnecessary and painful surgeries are done without informed
consent. An excellent study, exposing the routine misuse and abuse of
episiotomy, was published by
two researchers (Thacker
and Banta) in 1983, and yet there
have been 36 million additional unnecessary episiotomy since that
time. Over the last half-century, a
staggering one billion unnecessary episiotomies were preformed –
sometimes with fatal consequences --
for no good social or medical purpose. The desired change in
physician behavior has two distinct parts – doctors must stop doing the
wrong thing (episiotomy) and must start doing the right thing –
physiological management of 2nd stage labor as employed world
wide with excellent results. Simply not doing episiotomies is not enough,
when the wrong use of gravity results in preventable perineal
trauma caused by the extreme efforts of trying to push the baby uphill
against a closed door or if fear of pelvic floor damage results in increased
use of medically-unnecessary Cesarean surgery.
Why can we do to Improve Maternity Care?
The solution to the
modern-day dilemmas of maternity care does not lie in blaming individual
doctors. Their actions are true to what they were taught in medical
schools. Unfortunately, much of what doctors were taught about normal
birth was wrong and information on many important aspects of
physiological childbearing was completely missing. Most doctors never see
the “normal management” of labor or an unmedicalized spontaneous birth.
These problems are systemic, not individual. The medical system needs
rehabilitation at several levels – educational as well as clinical,
private as well as public, personal as well as professional. Instead of
blame we need a substantial change in the national dialogue about our
maternity care policies. The midwifery model of care needs to be the
legal standard for normal pregnancy and birth in healthy women.
With
Midwives on Staff, Hospitals are a great place to have a baby
Embracing the Midwifery Model of Care would mean
reintroducing the “…passive anticipation of vaginal birth” as the
ideal to be achieved by both doctors and midwives. This would require hospital
labor and delivery units to be routinely staffed by professional midwives
and normal births attended by those midwives. It would guarantee that
healthy mothers would receive continuing, one-on-one midwifery care, with a
Cesarean rate of say, 6% (or less!). Use of episiotomy would be rare and
babies would enjoy a low perinatal mortality rate equal to or better than
that of Japan and the Netherlands.
It would expand the use of physiological management to
all physicians who provided care during normal labor, including
physiological (or “delayed”) cord clamping so that babies are not
deprived of this rich supply of their own stem cells. It would return the
use of episiotomy and operative delivery to circumstances of genuine medical
need. For example, it should be malpractice for an unanesthetized women to
have forceps or a vacuum extractor used on her without first been
encouraged to push in an upright position or squat on the side of the
bed during contractions. “Evidence-based” obstetrics would be legally
mandated, as would informed-consent for unproven procedures or off-label use
of drugs.
Changing
the Cultural Context
for Home-Based Birth Services
Rehabilitation of our maternity care system would also
mean that community-based or “domiciliary” midwifery would be accepted
and respected as another one of several safe options for birth care, just as
it is everywhere else in the world. Mothers should never be forced to choose
between “extremes”, that is, an unnecessarily risky or unattended
labor at home or an unwelcome, unnecessary medical
intervention in a hospital. Recognition that all categories of
professional care providers and all locations for birth are equally safe
would permit us to acknowledge the obvious -- that childbearing
women have a constitutional right to choose the manner and
circumstance of their birth based on their own preferences (including
the choice of an experienced homebirth midwife) and still continue to have
appropriate access to medical services or hospitalization, offered without
prejudice or recrimination.
Acceptance of direct-entry
midwifery as a profession in its own right is necessary so that midwifery
training schools and certification can be established and so home-based
birth services can be compensated by health insurance companies and
Medicaid. Formal training and either national certification or state
licensing makes egalitarian and cooperative relationships between physicians
and midwives possible. Complimentary professional relationships are needed
so that appropriate access to physician and medical care and hospital
services is easily available to clients of community midwives. This is
protective of the safety of mothers and babies who develop complications or
who wish to be electively hospitalized for a “relocated home birth” if a
minor problem arises during labor.
As Mother and Midwife, I have a Dream….
I pray to live long enough to
see a national maternity care policy in which hospital labor and delivery
units are routinely staffed by professional midwives. In this “brave new
world” healthy mothers with normal pregnancies normally receive one-on-one
care from a professional midwife and are never medicalized until all the
known techniques of good midwifery care have been tried and found wanting. I
pray to see the day when mothers and community midwives enjoy the advantages
of home-based maternity care without having to endure the vitriolic insults
of local doctors or be threatened with criminal prosecution.
As Martin Luther King said so much more
eloquently than I, “I have a Dream”. It is a big dream and I have had it
for a long time. Fair and effective news coverage would do much to elevate
the professional discourse between obstetrics and midwifery. A public
education campaign to offset the historical propaganda campaign of organized
medicine would be a great place to interject correction action and would at
the very least head us in the right direction.
A 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. When asked what she put first in her life,
her husband (then 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 well-being of mothers and babies first.
Faith Gibson, LM, CPM
3889 Middlefield Road Palo Alto, CA 94303
650 / 328-8491 goodnews@best.com
College of Midwives @ www.collegeofmidwives.org
Safety Issues @ www.collegeofmidwives.org/safety_issues01/safetyIndex01.htm
Cesarean specific citations ~ www.collegeofmidwives.org/news01/nejm01a_vbac_study_npr.htm
Hx of Medical and Midwifery Politics: http://www.collegeofmidwives.org/safety_issues01/rosenbl1.htm
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