California College of Midwives
UCSF Meeting July 30, 1999
Science, Midwifery Politics & the
Clinical Characteristics of the Midwifery Model of Care
-- more than just "non-intervention "The basic informational elements about midwifery need to be made as widely known as the bias that preceded them. Certain facts are not really disputable, given even a cursory examination of the historical record and contemporary scientific evidence. First and foremost is to admit that the propaganda campaign waged by medical politicians in the early 1900s was mistaken and that it is time for modern medicine to reconcile itself with professional midwifery.
Professional midwives are those who meet the "International Definition of a Midwife" -- that is formal training and licensure in the jurisdiction of practice. In California that includes two educational pathways -- nursing and direct-entry -- which lead to the same goal. California law defines the education and scope of practice of CNMs and LMs to be "equivalent". Historically the goal of midwifery training has been to produce safe and effective practitioners so as to better serve the practical needs of mothers and babies. Our legislative scheme for licensed midwives does exactly that. The lobbyist for the California Medical Association described the LMPA as follows: "...we believe that the standards that are in the bill are standards that make for safe, capable practitioners. Yes, we believe in the standards in the bill. There will be competent capable practitioners under the standards that are set up in this bill. So we very much believe in the standards in this bill. ( Midwifery Implementation Committee Meetings, June 1994)
Second point it is to acknowledge that childbearing in a healthy population is not itself intrinsically pathological and that treating it as if it were has its own hazards. There is no moral superiority in routine over-treatment as contrasted with possible under-treatment.
Third point is that the traditions of midwifery -- its philosophy of support for the normal physiology of childbearing, its scientifically-predicated principles of care as provided by "educated observers with emergency response capacity" (in combination with the technical skills of its practitioners) --provide the most appropriate caregivers for healthy women experiencing normal pregnancies who do not want or need pain medication, anesthesia, labor stimulants or prefer physician-only care. Science long ago established the wisdom of avoiding of any form of medicalization, surgery or anesthesia that is not required by a medical condition. It is just a statistical fact that the more medically-complicated the childbearing event becomes through the routine application of medical interventions, the higher the likelihood of medical complications. In that regard, domiciliary statistics benefit both from the absence of medical ministrations and the presence of healthy mothers with normal pregnancies.
In tandem with this is the necessity for appropriate, timely and non-prejudicial access to obstetrical services when indicated by a medical problem or requested by the parents.
The forth aspect is the recognition that the best labor and birth-related outcomes in a healthy population are associated with a very specific set of circumstances (given the voluntary co-operation of the mother and her willingness to forgo or limit narcotics and anesthesia).
These specific circumstances are:
(a) an environment that provides for appropriate emotional and actual privacy to the mother while also permitting non-intrusive surveillance of maternal-fetal vital signs and the continuous presence of a skilled observer;
(b) providing appropriate emotional and social support throughout labor by someone trained and skilled in midwifery principles and who is known and trusted by the mother;
(c) maternal mobility during labor, oral hydration and non-Rx comfort measures used or available (such as therapeutic touch, shower, deep water, etc);
(d) upright and mobile posture for second stage without artificially imposed time limits;
(e) recognition of a perineal stage -- last few minutes of 2nd stage during which the baby stretches the perineum and is born spontaneously without surgical intervention -- (no routine use of maternal episiotomy or forceps/vacuum extraction of neonate);
(f) importance of the quality and quantify of mother-baby interaction immediately following birth, establishment of breastfeeding and the process of parental bonding.
These are the recommendations of the Coalition for the Improvement of Maternity Services (CIMS document included), in their consensus document "Mother-Friendly Childbirth Initiative", ratified by 27 major professional and consumer organizations as well as 25 experts in medicine and midwifery, including Murray Enkins, MD, one of the developers of the Cochrane Data Base and co-author of the Effective Care in Pregnancy and Childbirth.
Most emphatically, there is no scientific justification for perpetuating a mother UN-friendly maternity care system. [8]
Contemporary Dilemma and
Unique OpportunitiesOver the course of the next decade, physicians should gradually find themselves being held responsible for knowing the philosophy of non-interventionist maternity care and appropriately using standard midwifery principles and techniques, either personally or by providing for care by a midwifery practitioner. This would occur naturally if hospital L&D units were staffed by professional midwives. In event of a malpractice litigation, physicians should be required to establish that they utilized the ‘common-sense’ evidence-based practice parameters historically associated with midwifery care -- gravity, patience with nature, one-on-one emotional support, access to non-Rx pain relief, oral hydration, ambulatory mother, avoidance of supine position or vertical position for delivery, etc., before embarking on drug-dependent or surgical solutions such as IVs, oxytocin, narcotics, epidural anesthesia, forceps, cesarean surgery and the like. It makes sense to build familiarity with the philosophy, principles and skills of the midwifery model into medical training in preparation for these inevitable changes.
Most scientifically sophisticated persons recognize the importance of evidence-based maternity practices and expect physicians to provide scientifically-based care. However, as long as the institutions of medicine are blinded by the old prejudices, physicians are kept ignorant of the normal half of the childbirth discipline. Its important knowledge base is currently subsumed and dismissed as merely "midwifery" -- pejoratively defined as a substandard form of medical care instead of a distinct profession in its own right. This creates a dis-articulated, two-tiered system constantly at odds with each other, instead of a continuum of a single standard stretched out across a broad spectrum, with midwives at one end and perinatolgists and a mutual goal of serving the practical needs of mothers and babies as the unifying theme.
Doctors remain convinced that they will be sued or loose their license for failure to impress maximal medical interventions on every normal birth. They are equally afraid to have any professional association with community-based midwives. Midwives are not immune from prejudice either. After years of bearing the brunt of an irrational discrimination, some develop a distrust of the motivations of the medical community. This bias occasionally results in a failure to seek out physician consultation or referral in circumstances in which the mother and/or baby would have been better served by medical care. Both situations leads to poor care and the greater safety and cost-effectiveness of the midwifery model of care is lost to our society (midwifery can be provided by physicians as well as midwives). And it actually means that many well-meaning obstetricians are practicing substandard midwifery (i.e., normal maternity care) when they routinely provide interventive obstetrics to healthy mothers with normal pregnancies who do not desire them.
The artificially-created controversy of the last century needs to give way to a cooperative and collaborative relationship between our medicine and midwifery that augments, supplements and compliments the current maternity care system. I assure you that midwives and physicians share many of the same goals and a common interest in the health and practical well-being of mothers and babies. The basic premise of midwifery as it relates to standard medical care is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was First Lady as well as 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.