Midwives Versus Doctors: The Gloves Are Still Off

The C-section is now the most common procedure performed in the United States. A third of American children are born through the belly instead of vaginally. Every year for the last decade, the States has set a new record for the number of C-sections.

Now that I have your attention, there is an increasing gap between the traditional Western medical community and that of midwife-delivered, woman-based care. A couple of recent articles, in Time and in the LA Times, explore this gap.

Here we are, discussing health care reform, and at the top of that discussion should be the way we bring babies into this world. One Oregonian midwife, Melissa Cheyney, has begun to examine the differences in care.

The U.S. has a limited idea of what it means to have a positive outcome at the end of a delivery. Basically it just means that everyone’s alive.

You’ve heard it, and I know I’ve said it, “You got the prize in the end!” Sure, you have the baby, but did you receive the care that was appropriate to your circumstances?

But when you don’t have a lot of medical intervention, you also tend to have more breast-feeding and reduced rates of postpartum depression.

Sounds great, right? Everyone’s happier, healthier, and the avoidance of interventions costs less: for insurance companies, Medicaid, and our own wallets. The LA Times reports:

As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation’s $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.
Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.
The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large. Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets.

No wonder the American Medical Association isn’t too keen on changing care.

They should be, though. The U.S. isn’t the picture of health in many cases, and with childbirth, we’re lacking. According to the Time article:

About 99% of all births in the U.S. take place in hospitals, yet we rank 29th in the world in infant mortality — below Hungary and tied with Slovakia and Poland — with 6.71 deaths per 1,000 live births. That compares to a rate of about 3.5 deaths per 1,000 live births in Far Eastern and Scandinavian countries such as Singapore, Japan, Norway and Sweden.

Or how about this recent study, from the Netherlands? It showed that for low-risk women, giving birth at home or in the hospital gave an even rate of infant mortality. Not too shabby.

So what can we possibly do for these women and their families?

  • Treat low-risk women as just that. If a woman (such as myself) is young, healthy, and has no previous labor complications, she should be considered low-risk and empowered to labor in a peaceful setting without continual monitoring.
  • Pregnancy Education. I was lucky to have an awesome birth class for my first son, where the instructor not only gave women the low-down on what to expect during labor, she also walked us through the possible interventions and the side-effects of jumping on the drug bandwagon. This kind of education should be a part of every family’s pregnancy experience.
  • Pain Management. Give women reasonable alternatives to drugs to remedy the labor pains (when appropriate), such as massage, birthing pools, walks, and different positions. Those who have used epidurals for their labors may believe I’m crazy (I’ve heard as much), but contractions are the most intense pain you’ll ever forget…and quickly at that!
  • Bridge the Gap. I’m not entirely against doctor care, folks. I know there are many, many PhDs who believe that women can give birth naturally. As a community, midwives should work to show the public all the awesome outcomes of natural birthing. And they are. Now the AMA needs to listen!
  • Normalize Home Births. Many American women are low-risk, but the laws vary from state to state as to midwife care at home. I’m not asking for a federal law regarding home births, but I believe that if it were not regarded as an “out there” practice, we would be able to birth many babies in the peaceful environs of their own home.
  • Legacy. This is a big one to me. I was always told that “Pregnancy and childbirth are not medical problems.” Most women and their partners have been given a legacy of fear regarding birth. But anyone who has given birth naturally will tell you that it was a wonderful, empowering experience. After both of my sons’ births, I could have run marathons, if it weren’t for that pesky bleeding and the obligation to—you know—nurture and breastfeed the chil’ens. So Stop. Telling. Pregnant. Women. Your. Horrific. Birth. Stories. Period. They are not a receptacle for your baggage!

This summer, Cheyney and a colleague will draft new guidelines to help midwives and doctors work together better. She hopes it will be “a model for collaborative care that will be the first of its kind in the United States.” That’s a great first step.

The next step? Bringing down those high costs and the predilection to reach for the epidural at the first sign of pain.

As a gender, we’ve been doing this birthing thing for a looong time. I’d say we should probably work on getting it right.

Image: davhor on Flickr under a Creative Commons License.

Comments

  1. First, unless the entire US med system is forced to change by the government, hospitals will not give up the largest part of their revenue (by far!) for such a piffle as maternal and infant health! This means that the government will HAVE to totally rebuild your health system from the ground up.

    Second, the best possible system in terms of preserving health outcomes and reducing health care costs: adopt the British system. GPs refer pregnant women to the local midwife clinic, the midwives organise and track all of a mother’s early prenatal care, if a woman has high risk symptoms, is high risk, or develops and suspicious symptoms, the midwife refers her to an OB for consult and the OB either assumes care for high risk patients, shares care or sends the woman back to full midwifery care. The women are then offered a choice of delivery location: home or hospital.

  2. I had my baby in the UK system. I rarely saw the same midwife twice. They ranged from OK, to scary to rude. A disinterested midwife did NOT help me out with alternatives pain relief. I had a doula and was looking to avoid intervention and STILL ended up with a c-section. And I had appalling midwife aftercare. The problem with GP/Midwife service/ occasionally seeing an OB (as I approached 14 days overdue)is that NO ONE was responsible for my care with consequences that I live with still almost two years later.

  3. Lynn Richards says:

    Having been a c-section mother (back in the dark ages— 1975), and having had one of the first VBAC’s (long before the term was ever coined) in the country === I empathize totally with your “ripped off” feelings … that those who were supposed to come through for you fell extremely short of your needs and expectations.

    Having been a rebel and revolutionary during the period of the resurgance of midwifery, and the innovator and teacher of the first VBAC classes (once again, before the term was coined) — what I see is that the issues have never really changed.

    So, if we haven’t successfully changed anything on the outside, it is probably not the true purpose of our work in childbirth. All change is internal. I would never have agreed with this statement 30 years ago.

    My stated purpose was to change the practice of obstetrics in this country. In actuality, the one on one, one small step, one new mother seeing herself differently — this was the true purpose of my work. My true soul purpose was to learn the incredible lessons of life that birth presented to me, each and every time. Midwifery was not a profession. It was a spiritual journey. With professionalism in midwifery, we run the risk of losing the essential element — a depth and breadth of calling. It’s not a career. It’s a calling.

    This is the essential loss in your experience.

    So then, the question is, “How can I know, really know, who to trust… who will come through for me? Who will be caring and loving?” “Is there a ‘right system’ that will assure women of ‘true well-being’ in childbirth?

    Systems are systems. People are people. No system solves personal problems. In any walk of life, there will always be those who choose to affirm, serve, and honor. There will also be those who choose to destroy, serve only themselves, and honor no one. These are basic truths, which will not be changed.

    In creating a system which we deem to be “best”, there is always compromise and complication. Keeping things simple is a good guideline. But government always tries to “regulate the hell” out of a simple goal — thus, interfering in the natural growth and changes that are necessary for a system to mold and recreate what is even better.

    In creating the people in our lives… same advice: keep it simple. Watch for the signals of trustworthiness, right thought and action, and soul connection. Watch also for the red flags of questionable character, mental confusion and manipulation, and selfish motivation and depersonalization.

    It is easy to blame others. I have done it way too much. But in the end, it is our own self-deception which is the culprit every time.

  4. If we want things to change, we need serious tort reform. The fear of malpractice suits is a major factor in driving up rates of medical intervention and costs.

    All 3 of my kids measured small for gestational age. With my younger two, I had to undergo intensive monitoring during my last trimester (multiple ultrasounds, and with my 3rd child twice-weekly non stress tests).

    By contrast, with my oldest all I had was a single 1st trimester ultrasound and 1 non stress test at 41 weeks. The difference? We were a military family at the time and under the law, military doctors cannot be sued for malpractice. So they had no need for the kind of CYA testing my civilian providers made such extensive use of.

    All 3 of my babies were born on the small side but totally healthy. I’m petite and my DH isn’t particularly big either.

    • Increasingly, I am thinking this is the opposite of true. We don’t need fewer lawsuits–we need MORE! Why? Simple. We have 3 avenues through which we can effect actual change: the courts, the state legislatures, and education. State legislatures are very hit and miss, and the medical establishment is _definitely_ the 900-lb. elephant in the corner, in pretty much every state. All too many lawmakers are more concerned about who contributes to their campaigns than they are about doing what is right. The same, only worse, applies at the federal level. Education everyone is working on, but, again, the major media outlets are just not going to do too much that will annoy their major advertisers–Big Pharma, for example, so we have to get the word out where we can. It is time to start filing suit anytime women receive maternity care that does not meet the standard of being evidence-based. If unnecesearians DID result in court cases, along with some of the other horrors I’ve read about, like giving a mother amounts of pitocin WAY exceeding the recommended dosage, and worse things, started regularly resulting in court cases, accusing doctors or practicing medicine without the science to back it up, maybe these things would start getting some real notice. Or maybe we’d just end up with a lot of really bad-quality research, churned out to give some “evidence” to back doctors pulling the same old cr*p.

      All that said, from a lot of things I’ve read, I think a law that really needs to be passed would be a federal law, establishing that a patient’s medical records belong TO THE PATIENT (or parents/guardians if a minor), and that the patient has the unlimited right to access those records at any time, without a fee being charged, or the records being altered. The person to carry such a bill in Congress would probably be Ron Paul.

  5. Crimson Wife,
    That’s a fantastic point about your experience with doctors: in military vs out. The interventions are certainly out of control, and I could understand that a portion of that is because of the fear of lawsuits.
    IME, there were tests ordered. Some needed, others most definitely not. I had a previous quick (5.5 hour) natural labor with an average-sized baby (7lbs, 2 oz) and was in good health, but the OBs ordered every test they could. (Same: multiple ultrasounds, NSTs.) There was no “need” for this monitoring. (And as you’ve prob read before, he was also born quickly at 7 lbs, perfectly healthy.)

    I think the medical profession would see more clearly that the best to do for low-risk pregnant women is encourage them–not put them under a microscope–if the threat of lawsuits weren’t looming. (On the other hand, in rare cases, of course it may be necessary to litigate.)

  6. It is government regulation in the first place that prevents women from having the choice of birth method. My wife had ALWAYS wanted a home birth.
    Midwives that are allowed to do anything are illegal in Illinois
    and doctors will have nothing to do with home births, even as a backup.
    We were lucky enough to find a
    woman who had run a birth center in a second world nation, tho she
    was not certified in any official way and was practicing illegally.
    It was a fabulous experience to see your daughter fly out with eyes open and smiling with no wires or tubes attached and no hovering strangers trying to apply
    eyedrops for syphillus, or sticking her heel for a PKU test, or blood typing or demanding a
    name for their damn records.
    She got great prenatal and postnatal care. The labor was not uneventful, which made us very glad we had someone attending who had experienced about everything that could go wrong with a birth.
    To top it off, it cost $500 total.
    I could fill a small book with the interesting details of both our kids’ home births, and the skill
    demonstrated by our midwife, at my
    wife’s labors, and that of friends.
    Unfortunately, she has been scared out of the business by Illinois’s aggressive prosecutions of those illegally practicing medicine, on behalf of the legal monopoly holder, the AMA.

  7. What really worries me, is that all this accumulated
    knowledge about delivering babies in a low tech
    way, is being lost. Will the future midwives who
    are licensd and schooled in the modern way be able
    to improve on the trend to ever higher tech,
    invasive deliveries?
    A friend was having her 5th baby at home, unattended.
    She had been in labor for 30 hours with no motion.
    She called us to get help from our midwife. We
    brokered a deal where no names were exchanged and
    I delivered the midwife. The midwife had the baby
    out in 10 minutes. Would it be possible for doctor
    delivery not to be cesarean?
    I can’t decide whether to get behind the movement in
    Illinois, to start licensing midwives. I’m afraid,
    once the meddlers get control, the money will win
    and mothers will lose.

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