Mamas on Bedrest: Some Things Just Stink!

November 10th, 2010

Some things just stink. I have wrestled with this blog post for over a week trying to find a tactful way to address the battle waging between obstetricians and midwives. I have looked at several articles and commentaries and have come to the conclusion that the tactics that the American Medical Association (AMA) and The American Congress of Obstetricians and Gynecologists (ACOG) are using to limit  in some cases, and frankly ban in others, midwives from attending home births and other births just plain stink.

As previously stated in the blog post A Plea From Mama to OB’s and Midwives, the primary focus should always be what is in the best interest of mothers and babies. Unfortunately, the AMA and ACOG both have not only adopted adversarial stances against midwifery practice, they have gone so far as to use faulty study data to support their claims and to push for legislation to limit or ban midwives from practice. And while midwives have offered their fair share of negative assaults on obstetrical practice one has to admit that midwives have never sought to limit, ban or outright erase obstetrical practice. This is the unfortunate tenor that the AMA and ACOG have taken and why this battle has turned so ugly.

But don’t believe me. Let’s look at what the major issues are. Maternity care in the United States is subpar at best. If you are insured, you fare quite a bit better, but women are still subject to far too many interventions and unnecessary procedures that have lead to a cesarean section rate of 32% nationally. According to Amnesty International’s Report Deadly Delivery: The Maternal Health Care Crisis in the USA, 2 women (or more) die each day from pregnancy related complications. A woman is 5 times more likely to die in childbirth in the US than in Greece, 4 times more likely than in Germany and 3 times  more likely than in Spain. Our maternal mortality rate has more than doubled from 6.6 maternal deaths per 100,000 in 1987 to 13.3 maternal deaths per 100,000 in 2006 and these rates are higher in women of color (Black women are 4 times more likely to die from pregnancy related causes than white women). Amnesty estimates that these rates may actually be low because there is no federal requirement to report these outcomes. Amnesty International also notes numerous barriers to maternity care, noting that poverty is a major factor, but even insured women have difficulty obtaining safe, effective, low intervention maternity care. The US’s own Healthy People 2010 has documented benchmarks to improve maternity care-none of which the current model of obstetrical care has been able to meet. And the World Health Organization reported that despite the large amount of money spent on health care in the United States, The US still ranks 37th out of 191 assessed countries in health care delivery and accessibility, far behind many other industrialized nations. What we are doing is not working and as they saying goes, “The definition of insanity is to continue doing what you are doing while expecting a different outcome.”

Several organizations including The World Health Organization and Amnesty International are advocating for increased use of  “more woman-centered, physiologic care provided by family-practice physicians and midwives”. Yet ACOG and the AMA have balked and have launched aggressive anti-midwife campaigns. Amy Tuteur, MD, in her blog post Midwives and the Assault on Scientific Evidence, repeatedly states that midwifery practice is not based on science and that many practices are based more on ideology. She cites numerous articles and books published by midwives, yet never names specific practices used by midwives that are harmful to mothers or babies. In contrast, there is well established evidence that restricting a woman to bed while laboring, labor induction and cesarean sections increase labor and delivery complications and all are common practices in obstetrics. Dr. Tuteur’s claims are well refuted by the 107 comments to her post, many with reputable citations.

Joseph Wax, MD was the next physician to attack midwifery and home birth in his article, Maternal and Newborn Outcomes in Planned Home Births vs. Planned Hospital Births:  A Meta analysis. His meta analysis concluded that home births attended by midwives resulted in a three fold increase of neonatal death versus birth in a hospital or birthing center housed within a hospital. While Dr. Wax’s analysis was praised by the main physician medical societies, using minimal scrutiny his conclusions were found to be flawed and based on study data known to be insufficient, inconclusive or just plain wrong. Yet, even before the study was officially published in the September issue of the American Journal of Obstetrics and Gynecology, it was “leaked” to the media during the summer-just in time to be read as legal decisions were being deliberated in New York and Massachusetts regarding midwifery practice and home births.

Both of these publications and others like them have the full backing of the AMA, which has been waging its own battle against midwives. In resolutions drafted in April of 2008, The AMA has voted to back legislation that will prohibit home births, AMA Resolution 205-1 and severely limit the scope of midwifery practice, AMA Resolution 204 Midwifery. While the legalese of these documents is sound, the resolutions themselves ignore the scientific evidence, stated by Amnesty International, The World Health Organization, The Cochrane Review and others that all state that midwife assisted homebirths, in uncomplicated pregnancies, are as safe as hospital deliveries.  Additionally, midwife attended births result in lower rates of interventions, lower cesarean section rates, lower rates of complications, lower rates of infants being admitted to the NICU and lower rates of maternal and neonatal death. (See Transforming Maternity Care, in the supplement to the January 2010 issue of Women’s Health Issues, the official publication of the Jacob’s Institute of Women’s Health, George Washington University.)

It’s okay for physicians to oppose midwifery care, in fact it’s somewhat understandable. In their eyes they have a lot to lose; revenue, patients and their status as “top” health care providers. Many obstetricians resent having to “clean up the messes” that occur when a home birth goes bad. But in the face of the evidence in support of midwifery care and the dire maternity statistics that arise out of the current US hospital based, physician driven maternity health care system it’s hard to believe that they are not willing to do more to bring affordable, effective, safe, low intervention care to all women of America. Holding onto this notion that the only providers able to provide quality maternity care is obstetricians in the hospital setting is not only bull-headed but unethical and is completely contrary to the line in the Hippocratic oath that states, “First do no harm.” (Yes, withholding care does as much harm as rendering poor care.) But to go so far as to bar others, who are trained and qualified to provide maternity care from doing so -especially to low income women who so desperately need quality, compassionate maternity care-while at the same time disparaging the work that they do is not only unethical, it just plain stinks.

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