A Plea from Mama to OB’s and MidwivesOctober 30th, 2010
I’ve hesitated to weigh in on this current debate between obstetricians and midwives, over their respectives. Whenever I receive news or editorials about the ever growing chasm between physicians and midwives, it unnerves me because I feel like I’m being called on the carpet to declare allegiance-Are you for us or against us? I hate it. As an advocate for Mamas on Bedrest, can’t I be for both?
For me it’s always tough to choose. I am a Duke University trained physician assistant. (It doesn’t get much more “medically” (anally?) trained than that!) My training dictates that I only work under the direct supervision of a physician and strictly adhere to protocols established for the practice. I have often struggled with many of the established protocols and “norms” of this medical model and admittedly, it’s one reason that I am not currently practicing. But that aside, I worked hard to complete the program, learned a lot of good, solid medicine and am still proud to be a PA and use the skills I learned to serve and advocate for high risk pregnant women.
I have personal appreciation for obstetrical care. 10 years ago I married and (attempted) to start my own family. I had uterine fibroids which caused me significant problems. After miscarrying my first pregnancy and having a myomectomy, I became pregnant with my daughter and ushered in “the pregnancy from hell”. Although I had chosen a practice with midwives and had hoped for a water birth, all that went out the window after my uterine surgery. I spotted and cramped early on. Things then went from uncomfortable to grave. I hung in there-and so did the ever present nausea-9 months worth. My daughter put us both out of our misery by gracing us with her presence at 36 wks 6 days on my second wedding anniversary. I owe my life to my OB’s partner who performed my c-section. After delivery I bled profusely. Every time she tried to stitch, a small geyser of blood would sputter out from my uterus. She worked frantically to mend my “boggy” uterus and with each stitch, I’d hurl and my uterus would bleed. How she ever patched me up I’ll never know, but I’m here to tell you-she did a great job.
Then there is my midwifery heritage. My great Grandmother, Queen Elizabeth Perry Turner was a midwife in Inez, North Carolina from the late 1930’s through the 1940’s. As the story goes, she birthed a generation of “colored children” with no physician back up because black women weren’t allowed to attend or be attended to at the local hospital. With her lay midwife’s training (She also wasn’t allowed a formal education) and extensive knowledge of herbal therapies she provided the care and support to the colored women of Inez before, during and after childbirth. From what I have heard and as the stories go, she never lost a mama or a baby.
A History of Conflict
One can’t ignore the fact that midwives have existed since the beginning of time. In the bible in the book of Exodus (The second book of the old testament if you’re unfamiliar) the author recounts how the Hebrew midwives were instructed to kill the male babies at delivery while enslaved in Egypt (before the exodus with Moses, Exodus Chapter 1. ) Obstetrics on the other hand arose in the 15th and 16th centuries when men, traditionally barred from labor and delivery-began assisting with breech births and began writing about and teaching about various ways to perform such births in medical texts. The introduction of forceps in the 17th century increased male presence and intervention in labor and delivery. (But it’s interesting to note that the first successful Cesarean Section was performed by a woman, Mary Donally, in 1738) It also increased tension between female and male midwives. By the turn of the 20th century, maternal health was taught in medical school and the name midwife was replaced by obstetrician(1) and men replaced women as birth attendants, and have dominated maternal health care ever since.
The popularity and preference of midwife assisted birth re-surged in the 1970’s, and here we sit in 2010, arguing again over who is best to attend expectant mothers-obstetricians or midwives. Physicians, primarily men (although now there are a large number of women on this side of the fence) argue that obstetrics has saved the lives of innumerable mothers and infants and that the former practice of allowing women to labor at home in anyway that they please is absurd, archaic, barbaric and just down right dangerous. Many obstetricians feel that midwives are uneducated about the technical and academic aspects of obstetrics and are unprepared in the event of an untoward event. They cite the decrease in mortality since the onset of the obstetrical sub-specialty as the proof that their interventions are effective and the best treatments for mothers and babies.
Midwives argue that intervening in and forcing women who are experiencing uncomplicated pregnancies, labors and deliveries to submit to innumerable, unnecessary tests and invasive interventions puts both mother and baby at unnecessary risk. They base their argument not only on the sheer longevity of midwifery-without which none of us would even be present today to have this discussion-but also on recent evidence-based studies that show that the lower level of intervention at midwife assisted births is leading to a decrease in infant and maternal mortality worldwide, whereas in the United States, where invasive obstetrics dominates maternal and fetal health, there is actually higher maternal and infant mortality compared to the rest of the world. What is even more alarming (and saddening for me, a woman of color) is that among women who are unable to access obstetrical care-typically impoverished minority women, the maternal and infant mortality rates are higher the the average high rates in the United States.
And it is this rally against unnecessary interventions, the high cost of care, the high US maternal and infant mortality rates compared to other nations-particularly nations with a nationalized health care systems necessarily concerned with high quality care at low costs-and the lower access to quality maternity care among low income and minority women that has prompted midwives to push, hard, with the backing of the World Health Organization, Amnesty International and other maternity and birth organizations for a midwifery model of care with evidence based medicine as the frame work.
The MOMS for the 21st Century Act
“The MOMS Act” amends the Public Health Service Act to require the Secretary of Health and Human Services (HHS) to add additional resources to the act to improve maternity services in the United States. In summary, the MOMS Act will :
- Establish the Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes
- Develop and implement a consumer education campaign to inform women about the importance of making medical decisions based on “evidence”- born out of rigorous research and whose results have been replicated time and time again-and not out of fear, following directions or simply because “that’s the way it’s done”.
- Address the racial and ethnic disparities in health care by increasing recruitment of racially and ethnically diverse students into maternity health care programs, to establish maternity care shortage areas and student loan repayment programs under the National Health Services Corps to increase providers of maternity care in critically under served areas and to address workforce disparities for those who serve in these areas.
- Conduct research to improve maternity outcomes by creating a shared core maternity curriculum that is implemented across all disciplines (obstetricians, nurses, midwives, mid-level providers)
Tht ACOG Moms Initiative
On the heels of the bill’s introduction to the US House of Representatives, ACOG introduced its own initiative called, The American Congress of Obstetricians and Gynecologists’ Making Obstetrics and Maternity Safer (MOMS) Initiative or The ACOG Moms Initiative. ACOG proposes:
- Understand the Causes, Improve Interventions for, and Reduce the Prevalence of Premature Births.
- Focus on Obesity Research, Treatment, and Prevention.
- Improve Surveillance and Data Collection On Maternal and Infant Health.
- Support Maternal/Infant Health Programs at HRSA
- Research Disparities in Maternal/Fetal Outcomes, to Eliminate Disparities.
- Develop, Test and Implement Quality Improvement Measures and Initiatives.
- Test an Obstetric Medical Home Model
Now it doesn’t take a rocket scientist to see that the names of these proposals are confusingly close. However, the approach to patient care and lowering maternal and infant mortality in the United States is profoundly different. The Midwifery proposal is rooted in evidence-based medicine with many proposals tested in other countries throughout the world on maternal care during labor and deliery. The ACOG proposal is based more on theory and research. It doesn’t address the complaints and concerns birthing mothers have expressed nor does it give specifics on how it will lower its intervention rates (c-section rate in particular) or specifically what obstetricians will do to lower maternal and infant mortality. So should we follow an obstetrical model or midwifery model of maternity care? The answer is, we need both.
Each year about 6 million women become pregnant in the United States. While some will miscarry and some will elect to terminate their pregnancies, the vast majority of women will continue their pregnancies to term. That means that 6 million women will need care, support and assistance to safely gestate, labor and deliver their babies. Using the age old statistic that approximately 750, 000 women will be prescribed bed rest during their pregnancies, we can round up and say that about 1 million women will have high risk pregnancies requiring some medical intervention. Purely by extrapolation, that leaves about 5 million American women that will have uncomplicated pregnancies to attend.
According to (ACOG), there are approximately 53,000 members in the organization. Assuming that most practicing obstetricians are members, that means that there are approximately 53,000 practicing obstetricians in the United States. Now this number is inherently inaccurate because ACOG consists of retired physicians as well as OB/GYN’s who only practice gynecology and no longer deliver babies. But the number will suffice for our purposes.
According to the American college of Nurse Midwives (ACNM), there are approximately 11,546 CNM/CM. Again, we know that this number is inaccurate because it doesn’t seem to include Lay Midwives or Direct Entry Midwives. But let’s just take it as it is.
When we look at the totals we see this: Every year in America 6 million women will give birth and need an attendant at that birth. For approximately 1 million of these births, an obstetrician is the attendant of choice because the pregnancy is complicated and will likely require intervention. For the remaining 5 million pregnancies, we can assume that-barring any complications- either an obstetrician or midwife will suffice. So why is there such a war between obstetricians and midwives about who should provide care? Using each professional society’s own statistics, there are some 65,000 providers (combining the two specialties) to care for 5 million women annually (not counting the high risk ladies who mostly sees obstetricians only).
However the numbers are not really the issue. The war between obstetricians and midwives really wages over practice philosophy and, at its core, whose philosophy should “predominate” in the world of maternity care. It’s a turf war, one that really is unnecessary. If a provider’s focus is on providing the most compassionate, supportive, most effective and most health enhancing maternity care to mothers and babies, who has time for these scruffles? If a provider is providing such care, there is be no need to worry about maintaining patients because the reputation of excellent care will bring him/her all the patients he/she could ever care for. And most importantly, if a provider is providing excellent care, surely all childbearing women are being served and maternal and infant morbidity and mortality will naturally go down.
I’m going out on a limb to speak for “the mamas”. For us the real issue isn’t whether a physician or midwife is a better birth attendant than the other, but will he/she listen to our concerns and address them as well as our medical needs. If we don’t want anesthesia, please don’t force us to have it. Same with an episiotomy. Yet, please allow us to have family or other supportive people like doulas present if we so desire. Please provide all women of childbearing age in the United States have access to safe, effective, up to date, supportive and humanistic maternity care. Please don’t make us worry if we have to move during our pregnancies that we will lose quality care. Please don’t create barriers to the births we want. If we do decide to birth with a midwife at home and complications arise, Please nearest hospital, don’t penalize us by delaying or withholding care. Obstetricians, please don’t chastise us like wayward teenagers because we “didn’t listen and do as we had been told.”
Both sides need to come together, pool their resources and provide the best maternity care to American women possible-a combination of midwifery care in uncomplicated pregnancies and deliveries and obstetrical intervention when necessary. Both groups must work together to reduce maternal and infant morbidity and mortality in the United States. Both sides need to give a little. Obstetricians must stop disparaging midwives saying that they are unskilled and uneducated. This simply isn’t the case and the evidence-based research bears this out.
Midwives must stop vilifying obstetricians. Like any other professions, there are good supportive obstetricians who care deeply about their patients and work diligently to support and care for them during their childbearing years (I know, I was cared for by a great group of them!). And then there are the others. It is the same with midwives. If each side could give just a bit and work together I am confident that we could create a maternity care system in this country that would be unparalleled anywhere else in the world. But it can only happen when the needs of mothers and babies come first.
So as a voice for mamas in general and mamas on bed rest in particular, I plead with you both asking, “Please, midwives and ob’s, come together; pool your resources and give mamas the care and support they need during childbearing.
1. The Start of Life: The History of Obstetrics by J. Drife. Postgraduate Medical Journal 2002: