Part 3: How the obstetrical profession can eliminate the “midwife problem” but will never do it

by faithgibson on November 13, 2014

in 21st Century Healthcare in US, AB1308, new regs & new legislative efforts, Midwifery Council


Part 3 ~ Turning a backlash into forward action ~ women’s groups plan to acknowledge and protect the human dignity of childbearing women

As judged by worldwide standards, the historically poor performance of interventive obstetrics in the US represented an uncritical acceptance of an unscientific premise — a ‘one-size-fits-all’ obstetrical model that repeated and continually fails to distinguish between healthy women with normal pregnancies and those with serious complications.

The uncritical acceptance of this particularly unscientific premise didn’t just apply to the ob-gyn profession. It represented the ‘common wisdom’ of all segments of society — the general public, the medical profession, public health officials and the policy-setting functions of state, local and national governments. The underlying problem was a widespread lack of understanding by the public about normal childbirth, and the general behavior of people to trust whatever they were told by doctors.

With this as background it is not surprising that the obstetrical profession didn’t see criticism as indicating either an unscientific practice by the medical profession or a human rights issue. Unfortunately, it was both.

The obstetrical profession’s reaction to its critics was to continue denying the lived experience of childbearing women and ignore the danger resulting in the unwise use of obstetrical interventions. Their unwillingness to make safe and supportive care available — a situation so graphically described in 1958 in the Ladies Home Journal’s  article Cruelty in Modern Maternity Wards — was disturbing enough on its own merits. But the brazen and stiff-armed reaction by doctors doubly incensed many women.

The result was an organized activism by maternity nurses, housewives and grandmothers who’d never before taken a public stand on anything more controversial than PTA elections. These agitators for childbirth reform didn’t think of themselves as “human rights activists” but nonetheless recognized the obligation of civil society to provide appropriate maternity care as a fundamental aspect of human decency.

Where to start, what to do next?

The first attempt at reforming the US maternity care system was insider pressure by L&D nurses. But given the power disparity between female nurses as hospital employees, and the much higher status of a mostly male medical staff, activism by nurses failed to produce any substantial change.

With few resources and very little money, next best idea by birth activists was to organize childbirth education classes for prospective parents. Their goal was the same as the whistle-blower nurses — to replace a dysfunctional system that routinely medicalized healthy women with a responsive one that protected and promoted science-based childbirth practices as they apply to a healthy population.

The original plan was for maternity nurses to offer classes on the biology of normal childbearing. The curriculum was simple and straightforward: Spontaneous labor and birth is a subtle, naturally orchestrated and easily disturbed form of reproductive biology that needs to be carefully watched and supported by professional birth attendants; however, the physiological processes of normal labor and birth are best left undisturbed whenever possible. The role of professional birth attendants (including L&D nurses) is to know and respect these time-tested principles.

Birth educators also realized that perspective parents needed to know about the negative effects of medically unnecessary interventions on the physiological and psychological of childbirth. Routine us of interventions during labor such as being immobilized in bed, frequently repeated vaginal exams and administration of narcotic drugs often disrupts the mother’s biological ability to labor effectively. This is often taken as an abnormality, which triggers a progressive cascade of additional medical and surgical interventions that sometime results in serious complications for mothers and babies.  {😉 for Rosanna}

Childbirth educators hoped that pressure from educated consumers to liberalize hospital protocols would be more effective in the long term than bad press and agitation by hospital nurses. Requests by ‘prepared’ parents-to-be ran the spectrum from simple issues such refusing unwanted drugs and being ‘permitted’ to walk around during labor, to really big ticket items like changing the policies of obstetrical units so the supportive care healthy women believed they deserved became part of a hospital’s routine maternity services.

Birth educator also knew the traditional principles of physiological management, which had been eliminated from medical education in the early 20th century, would need to be included again in the medical school curriculum. Then the new version of mother-baby friendly ideas and associated skills for obstetricians could become normal practice when providing maternity care to healthy women.

Obstetrical pushback: What part of “no-way” didn’t you ladies get? 

Of course the obstetrical profession rejected all this hook, line and sinker, holding itself above such mundane notions as “consumer demand”.  However hospital PR departments were directly in the bull-eye of these consumer demands and this began to move the needle ever so slightly.  The heads of obstetrical departments eventually (abet grudgingly) acceded to requests by parents for de-medicaliing childbirth practices by offering window-dressings that included colored bedspreads and curtains in the labor rooms. In some very ‘liberal’ institutions OB policy even permitted the patient’s husband (occasionally even her mother) to be present during labor, but didn’t allowing either one to accompany the laboring woman into the delivery room.

But as time progressed, many consumer-centric policy brought about by birth educators were directly sabotaged or eroded over time. Yes “they” (L&D nurses) would let you get out of bed and walk around, but that was increasingly impossible for laboring mothers due to the pre-emptive use of IVs and continuous EFM.

As hospitals competed furiously with each other to have the most ‘advent guarde’ maternity department in town, some of the bigger obstetrical units began offering 24-7 access to epidural anesthesia. This became such a ‘hot item’ that it spurred a whole new sub-speciality — that of obstetrical anesthesiology. Suddenly any obstetrical unit could hire it very own anesthesiology staff and successfully compete high-volume regional hospitals. But from the perspective of the obstetrical system, nothing was better for the obstetrical process of total control over childbirth than women immobilized in their beds after being giving an epidural, with all the afford-mentions interventions of IV, EFM, Foley catheter, etc, hanging off their bodies.

Thus was born 21st century obstetrics, which is an even more aggressive use of modern technology married to the same classic 20th century policies and protocols. Its more than a hundred years since Dr. J. Whitridge Williams’ invented the hybrid profession  of obstetrics and gynecology as a new surgical specialty but its basic assumption  — that childbirth is so dangerous no amount of intervention is ever too much — remains the same.

Business-as-usual for American obstetrics includes the routine speeding up of spontaneous labors with Pitocin, routine induction of labors at 40 wks plus 4 days, and liberal recommendations for Cesarean delivery anytime the doctor believes a vaginal birth might not easy (i.e. fear of big-babies). The latest addition is the ‘maternal choice’ Cesarean for women who are to afraid to labor normally, have been frightened into believing the normal childbirth will permanently destroy their vaginas, too busy to take the time to labor normally, and those who suffered childhood physical or sexual abuse that makes the idea of normal birth intolerable to them.

When you mix these practical realities with the ever escalating pressure of the medical malpractice insurers, the result is our 33% Cesarean section rate, escalating maternal mortality rate AND  hospital charges of $50,000 for an essentially normal (abet long) vaginal birth and 24 hrs of just-to-be-safe nursery ‘observation’ of their newborn, with mother and baby both discharged within 48 yrs.

When parents points out the obvious “break-the-bank” aspect of this system, they are accused of being hedonists willing to risk the life of their infants just to have a ‘good’ birth experience.

Ghosts of Christmas Past ~ maternal discontent and community-based midwifery

After more than a century of continuous tension between what healthy childbearing women need and want, and the obstetrical profession’s continuous refusal to acknowledge its validity (and greater safety of physiological management) mothers, midwives and birth activists are exactly where we have been for the last 100 years — yelling into the wind. Virtually everyone else in society thinks we are nuts and that obstetricians are gods.

This brings us back to the direct connection between the re-invention of midwifery and the professional stonewalling of obstetricians – the folks who invented: “we won’t cooperate and you can’t make us ”. In the castle of a hospital labor and deliver unit, obstetricians are still undisputed king.

ACOG’s most recent volley was to use its ability to control the legislative process via Assembly Bill 1308 to take over the California’s Licensed Midwives Practice Act (LMPA) .

The “you-can’t-make-us-cooperate” folks unilaterally repeal the Standard of Care for California Licensed Midwives (SCCLM), which was in place for the last 8 years, without the knowledge of licensed midwives or the permission of California consumers. This summarily eliminated a regulation that previously acknowledged and protected the constitutional right of self-determination by healthy childbearing families. This important provision had wisely allowed parent to decide to whether (or not) to be medicalized for a potential risk based on a direct understand of what was in their own best interest.

In the place of parental self-determination, ACOG mandated involuntary obstetrical referral for women with certain risk factors. If a woman refuses obstetrical evaluation, or declines obstetrical advise to be prophilacticly-medicalized (a response the new bill acknowledged as lawful) AB 1308 turns the LMPA  into a ‘denial of services’ document that prohibits Ca LMs from attending their births.

From the legal standpoint of midwives, the unilateral manipulation of our licensing act constitutes restraint of trade/unfair business practice described as a disguised restriction on the provision of services”.  From the perspective of childbearing families, our midwifery licensing law was turned into another mechanism for the obstetrical profession to violate the human rights and dignity of healthy adult women to choose the manner and circumstances of a normal childbirth.

The result of these provisions in AB 1308 is yet another re-invention of lay midwifery. The affect of this new law has already increased the number of unattended births for women who were otherwise unable to receive physiologically-managed care for a normal labor and birth. While unable to get the ‘system’ to take their needs seriously, these unfortunate women were still legally blocked from alternative forms of care by professionally licensed midwives.

To paraphrase a popular religious verse: “Who among you if his child should ask for bread, would give instead a stone?

We must make sure our maternity care system does not unintentionally offer a stone while it claims to be offering a kindly extended helping hand.

The Bell that can’t be un-rung!

Given this historic backdrop, there is no mystery about the intimate connection between the politics of midwifery and those of the obstetrical profession. In the US, the problematic nature of contemporary obstetrics is the single most important predisposing fact in the ‘reinvention’ midwifery as a non-medical, community-based phenomenon.

The very existence of community-based midwifery care reflects a history that is already a century long in which healthy women remain unable to get the obstetrical profession to acknowledge the validity of their practical needs. Trained midwives are the safest and most acceptable maternity care alternative for a substantial segment of essentially healthy women who will otherwise be forced to choose between the Devil and the Deep Blue Sea —  between medically-unnecessary, unwanted, risky and expensive obstetrical interventions or unattended births by mothers who claim to be ‘surprised’ that their baby came so fast!

Midwifery is the archetypical “bell that can’t be un-rung”. Midwives will not shut up, or stop agitating for change until we are either dead or have successful rehabilitated our national maternity care system.

Here is the bottom line:

No healthy woman should ever has to choose between a midwife or an obstetrician, or between a home or a hospital in order to have a physiologically-managed normal labor and birth.

Period.

 part 4 ~ A possible win-win for mothers vs. obstetrics-as-usual

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