Part 4: How the obstetrical profession can eliminate the “midwife problem” forever but will never do it

by faithgibson on November 14, 2014

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

A possible win-win for mothers and midwives vs. business-as-usual

Since the 1980s, most L&D units have ‘permitted’ unmedicated women to get out of bed, and fathers and family members are now ‘allowed’ to present for the birth, but this only returns us to the central theme for many contemporary women – the absence of an engaged birth attendant except for the drive-by photo op at the very end.

I purposefully characterized the brief presence of a birth attendant at the end of 2nd stage labor as a ‘drive-by photo op’ to point out the most basic fact of about normal childbirth: babies are not “delivered” by the doctors, but by their mothers It is the childbearing woman who gives birth, and the birth attendant (ob-gyn or midwife) who ‘receives’ the infant.

At most normal births, we birth attendants (both physicians and midwives) simply stand very very close to birthing women, and then take all the credit for this miraculous feat of biological engineering and the mother’s grim determination and tenacity of spirit! However, any woman who has just pushed out an 8# baby is not fooled by this little rouse.

From the perspective of the healthy childbearing woman, the major historical and practical difference between obstetric and midwifery boils down to this: Midwives provide a time-tested traditional model of physiological management and are present throughout the intrapartum – active labor, birth of the baby, postpartum and neonatal period.

If the ob-gyn profession were to give needs of such women the same quality of serious attention they already give to the complex management of medical complications, healthy activist women would be ecstatically happy and midwifery would be the last thing on their mind. This shift in the perspective of obstetrics would instantly eliminate the historic economic competition between obstetrics and midwifery. It would also make ACOG members very happy.

All ACOG has to do to negate the ‘competitive threat’ of midwives is simply to steal our thunder. Ob-gyns could provide the very same kind of care as midwives and be personally present during the entire intrapartum period. This would include what older obstetrical textbooks called “patient with nature”, that is attending the active labor of each patient, helping the laboring woman to breathe through each painful contraction, suggesting that she move around, maybe get in a shower or deep tub, and letting her know that you think she has what it “takes” to do the job. As the labor progresses, ob-gyn birth attendants would continue to be physically present to assist the first-time mother try out various positions to assist her to push more effectively. These docs  would of course ‘catch’ the baby, and remain present and actively engaged during the immediate PP and neonatal period.

However, there is another kind of “catch” to one-on-one care — that it require that ob-gyn physicians not perform surgery or otherwise provide any other forms of income-generating professional services during the 4 to 24 hours of intrapartum services for each patient. This would limit an obstetrician’s caseload to the number of labors and births they could reasonably commit to be present for each month. This also presupposes professional acknowledgment that physiologically-based care for the 85% of healthy childbearing women was a proper function of obstetrics and compatible with their scope of practice as obstetricians and gynecologists.

If childbearing women in American are already getting what they want and expect, then direct-entry midwifery as an independent profession that is unable to provide a drop of single pain medication or order an epidural, would have very little to offer that women couldn’t just as easily get from their ob-gyns at a local hospital. Midwives and homebirth would magically vanish without a trace like a bad dream.

New solutions or different problems?

For most obstetricians, the revenue limitations of this plan would be a big problem. There are two obvious solutions.

Option #1: 

The obstetrical profession could partner with professional midwives by integrating the very best scientific and technological contributions of modern obstetrics with the very best evidence-based principles of physiologic care to produce a new, 21st century science-based standard of care for a healthy childbearing population.

The goal is nothing less than an integrated, cooperative and ‘minimalist’ model based on “best practices”.

This would transform our national maternity care policies by reconfiguring the system at its most basic and practical level. Its objective would be to seek out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome for mothers and babies with the fewest number of medical/surgical procedures and least expense to the health care system.

In this new 21st century system, all L&D units would include a staff of professional midwives. As hospital employees, midwives would routinely provide primary care to healthy women and be present full-time for all normal labors and births. As the identified professional birth attendant, midwives would only call on the patient’s obstetrician if a medical problem arose or the mother-to-be requested care from her obstetrician.

As for the hot-bottom issue of ‘planned home births’ that has so vexed the obstetrical profession, it could easily be solved by the development and proliferation of community-based birth centers primarily staffed by midwives (and a few physicians) who provided physiologically-based care to healthy women with normal pregnancies. Since these facilities would be far more cost-efficient than acute care L&D units, hospitals could eliminate the unwelcomed ‘place-of-birth’ competition between in- and out-of-hospital by investing in ‘off-site maternity homes’. This would be an all-around good business move for everyone and midwives would for sure love them!

Option #2: 

The obstetrical profession could continue to insist that as members of the surgical specialty of obstetrics and gynecology, the activity characterized by them as “labor-sitting”, is simply NOT a part of their scope of practice, nor is it a skill set they have or want to develop.

In the time-is-money department, obstetrician-gynecologists might insist that attending normal labors is a colossal waste of their valuable time when it’s compared to performing surgical procedures. They are often reimbursed as much as $1,500 for ten minutes of work as a surgeon; with the help of a good staff, they can perform and bill for as many as six such procedures in a single hour.

Starting with the standard MediCal global obstetrical fee of $2,500, the physiological management of the intrapartum as a routine practice would require ob-gyn surgeons to voluntarily exchange a surgical reimbursement rate of up to $9,000 an hour for an average hourly rate of $208 as a physiologic birth attendant who provided fulltime intrapartum support. This reflects an average time of eight hours per labor-birth-pp-nn, twelve 1/4 hour prenatals and 1 postpartum office visit, for a total 12 hours.

Back to the beginning ~ the obvious and inescapable conclusion

Is it any wonder that ob-gyns prefer performing Cesarean sections? Or that many healthy childbearing women have unwillingly been forced into political activism? Being in constant conflict with the obstetrical profession is a distasteful situation to many of us, given that most women, myself included, very much like their own ob-gyn.

Over the last two decades childbearing families, now referred to as “consumers”, have partnered with childbirth educators and midwives. All three activist groups insist that what we charitably call our “maternity” care system is not actually, as the name implies ‘mother-centric’ or even mother-friendly.

Our national obstetrical system spends very little time or attention on normal childbirth, seems particularly adverse to discussions about ‘demedicalizing’ labor management, is completely disinterested in actually reducing the CS rate (often referred to “as vaginal by-pass surgery!) or the quality of experience for healthy childbearing women and relationship with their newborn babies.

According to surveys published in 2002, 2006, and 2010 {citation #1} of healthy childbearing women who had given birth within the previous year in American hospitals:

  • 93% of obstetrically-managed labors involved an average of seven significant medical interventions — immobilization in bed, IVs, continuous EFM, Pitocin augmentation of labor, bladder catheterization, etc
  • 70% of births included a surgical procedure — episiotomy, vacuum, forceps and/or cesarean
  • 33% of American babies are now delivered by Cesarean surgery
  • maternal mortality in the US stopped falling in 1982; since 1996 MMR has risen to historically high levels for a developed country (the US  ranks 39th worldwide) with the majority of these deaths associated with Cesarean surgery; according to citation #2 below: “over the past 10-15 years, maternal mortality has doubled in the United States and is now comparable to some developing countries”
  • premature delivery rates in the US has risen from 8% in the 1980s to 12%.
  • premature and sick newborns diagnosed with breathing problems accounts for the single most expensive category of hospital reimbursement for Medicaid

When the CS rate was considerably less than it is today (27% vs. 33%) a study published in the Journal of the American Medical Association (JAMA) admitted that previous decades of escalating Cesarean section rates were NOT associated with any improvement in maternal or infant outcomes.

The study’s conclusion was that nothing from within our institutionalized system of obstetrical care, characterized as it is by “high rates of routine intrapartum interventions”, was able to reduce the very high annual rates of cesarean surgery and other medical interventions. According to their analysis neither highly medicalized labors, nor the liberal use of Cesarean were able to demonstrate a significant and consistent reduction in complication rates or improvement childbirth outcomes.

JAMA “Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial”
2002 Sep 18;288(11):1373-81 Hodnett ED1, et al:

North American cesarean delivery rates have risen dramatically since the 1960s, without concomitant improvements in perinatal or maternal health.

In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.”

[note: the CS rate was under 5% in 1960, rose to 25% by 1975 during the ‘medical malpractice crisis’, dipped to about 20% for a decade or so, then marched relentlessly higher each year to our current high-water mark of 32.8%]

A report on the cesarean deliver rate by the Medical Leadership Council (representing 2,000 US hospitals), concluded in its 1996 that:

“… the US cesarean rate was … medicine’s equivalent of the federal budget deficit; long recognized as an abstract national problem, yet beyond any individual’s power, purview or interest to correct.”

The conclusions by JAMA and the Medical Leadership Council shouldn’t surprise us, since we obviously have an obstetrically-centric model of maternity care that is failing to meet the biological and psychological needs of its healthy population.

Apparently that is what G*D made midwives for. I say: Viva la difference!

Bottom line, ob-gyn doctors were never trained for, nor have they ever wanted the job of ‘being there’ during the average healthy woman’s often longer, or slower but still vitally important process of giving birth under her own power and at her own speed.

So lets try something different from the last hundred years, which was characterized by futile attempts to deny the obvious.

Let me suggest a big dose of realism instead.

Let’s give up the illusion that major surgery is the best form of care for healthy women and that a surgical specialty is the most appropriate and cost-efficient provider to a healthy population who would be receiving physiologically-base care.

At the same time, let it be OK that obstetrics and gynecology is a surgical specialty. Let’s applaud surgeons for doing surgery when necessary, since we all know that Cesarean sections can and do save lives. On behalf of my family, friends and clients, I am profoundly appreciate of and grateful for such surgical skills.

Then lets move forward and appreciate midwives for patiently providing the safest and most effective form of care for healthy childbearing women — physiological management. A system realistically built on the combined strengths and knowledge of both disciplines (medicine and midwifery) would really be a ‘win-win’ for mothers, midwives and, in my opinion for obstetrical profession, our national maternity care system, and taxpayers.

Let me end with brief historical account:

During the time the presidency of Franklin Roosevelt (1932 to 1944), a reporter asked his wife Eleanor who she put first – her husband or her children.

Her reply was: “together with my husband, we put our children first”.

After a century of unmitigated acrimony between medicine and midwifery, I suggest that today is the perfect time for physicians and midwives to put new mothers and their unborn and newborn babies first.

And by the way, viva la difference!

{1} Listening to Mothers Surveys; Childbirth Connection, 2002, 2006 and 2010

{2} over the past 10-15 years, maternal mortality has doubled in the United States and is now comparable to some developing countries.[3] 

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 May 2. pii: S0140-6736(14)60696-6. doi: 10.1016/S0140-6736(14)60696-6.


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