There has always been an underlying tension between obstetricians and midwives.
From the doctor’s side, the only times they interact with midwives is when trouble arises. Or, as this article in Time puts it, “When hospital-based obstetricians see midwives and their clients it’s usually because something has gone wrong . . . OBs don’t see the uneventful births that proceed successfully at home [and] doctors in this position find themselves not just being forced to take on someone else’s case, but someone else’s problem.”
It’s no wonder then, that OBs often see the worst of midwifery.
Although hospitals have been traditionally the safest venue for births, and there are cases where home-based midwife deliveries are preferable. In rural areas without poor hospital access, for instance. And studies have shown that home births for uncomplicated cases are no worse – but no better either.
This article was written from a perspective of a midwife, and to her credit, she has taken some lengths to understand the physician point of view.
Doctors should also see things from the midwife’s perspective, and collaborative programs where they can experience successful midwife cases can help resolve the conflict between the two camps.
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- Malpractice woes affecting midwives
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- Midwives in the UK: "Like driving a car without insurance"
{ 18 comments }
I’m interested in seeing what your readers have to say…
“Although hospitals have been traditionally the safest venue for births” – Semmelweis disagrees.
Current gratutitous use of unnecessary and oft dangerous interventions aside (Kendall Regional MC in Miami has a 70% c/s rate now– whoa!), hospitals became safer after that whole puerpural fever and asepsis thing got worked out… http://bit.ly/3Xifv (NIH.gov link)
Of course, then came twilight sleep with prophylactic episiotomies and high forceps deliveries.
As far as the present goes, I think we’re all hoping that we see technology used more judiciously in childbirth and maternal mortality rates fall. http://bit.ly/oG9CF (NCHS blog link)
Not sure if the “hospitals have been traditionally the safest venue for births” holds much water for healthy women with no complications. We try and fix things that are not broken, and then we end up breaking them. Unnecessary fetal monitoring, inductions, cervical exams, episiotomies, and of course, C-sections. It would behoove the US to follow a more European style of maternity care, a midwifery style of care. Let the midwives handle the healthy, low risk moms. Let the OB’s handle what they do the best, high-risk women with medical issues. It would also be a more cost efficient model in these times of skyrocketing health care costs.
I work in a home birth practice now and just had dinner with the midwife who used to run our practice but has since moved on to Vancouver, B.C.. Oh what a difference another health care system will make. Professional midwifery is only very recently recognized and regulated in B.C. and already access to home birth is seen as an important public health measure – especially, as you say, in rural areas. And midwives and physicians work together with physicians in the “consultant” role, not in a “supervisory” role. (As a primary care provider I’m sure you can understand how your practice would be limited if specialists supervised you and determined your scope of practice).
The midwife I was talking to mentioned that when a woman planning a home birth goes into labor, the midwife notifies the physician/hospital and that woman is put on the “white board” on L&D. If she transfers to the hospital, she is already part of the caseload so it is just seen as a medically-indicated change in the care plan. If she births at home, the hospital is notified and she gets erased from the board. Little things like this really matter!
Meanwhile, my practice in CT is about to close because our back-up physicians have merged with another practice and that practice has no interest in backing midwives or doing VBACs (we offer planned midwife-attended VBAC at the hospital.) Because nurse-midwifery training emphasizes hospital birth, we have also been unable to find a suitably trained midwife to join the practice to meet the steadily increasing demand. The burnout related to being overworked and underrested wouldn’t be so bad if we weren’t constantly also fighting uphill battles with a system that has marginalized us and professionals who resent us for bringing them our “problem cases”. Not to mention a disproportionate number of hoops to jump through for reimbursement, malpractice insurance, etc.
Thanks for covering this article and seeing both sides of the story.
While it’s a well-thought out and researched article, I think it still underestimates the emotional impact from the OB side of “being forced to take on someone else’s…problem.” The cases that come into the ER of home births (like placenta previa or hemmorhage) who have serious complications can be gruesome and heartbreaking – think gunshot wound to the abdomen for an equivalent in terms of risk for mom and baby as well as emergency measures required to contain it. I’ve seen emergency cases like this, up to my ankles in blood, with mother and baby dying on the table, having to console the distraught father and family while I myself deal themselves with the loss of 2 young, otherwise healthy lives.
It’s the stuff that nightmares are made of.
The thing is, I’m actually pro-home births in general. And I agree that more communication between OBs and midwives is crucial to prevent these horror stories from happening. But I think its too easy to criticize the concerns of OBs as being greedy businessmen trying to defend their turf. There’s a human story here too. A little bit of empathy both ways won’t hurt anyone.
You’ve already been taken to task by a few other people, but to again emphasize the point, in low-risk pregnancies (which are the majority) one could make a very good argument that the best place to have a baby is at a birthing center or at home. Much less expensive (a vaginal delivery in a birthing center costs on average $1600, while the exact same delivery in a hospital costs over $6000), less interventions, much lower c-section rate. And no evidence that antepartum or neonatal outcomes are any different. It makes sense; hooking a woman up to a machine to monitor the baby’s heartrate (a practice that has never shown to do anything other than increase C-section rate), not letting her eat or drink, not letting her walk around might not be the best practices to encourage healthy birth.
Thanks for bringing this important issue to the forefront!
“And studies have shown that home births for uncomplicated cases are no worse – but no better either”
Depends what you mean as “worse”: If you mean perinatal deaths, then you’re right. If you mean increased invasive procedures, like episiotemies, C-sections, then you’re wrong. Good cohort studies show same mortality rates, less invasive procedures for midwives.
For women who are OK with natural childbirth, it’s the best option. There’s no debate.
No matter what doctors and midwives want, where babies are born will still, for the most part, be patient driven.
The majority of women WANT some kind of pain control for birth procedures, and if they think they don’t, that first “real contraction” often changes their mind very quickly.
It will always be up to the mother and her family, in my opinion, to “prove” they can handle a “non-hospital” birth with commitment to classes and education, or rather a refusal to use a hospital. Remember, people sue based on outcome, and the first mother-child combo death that occurs outside the hospital will send every 18-24 year old gravid woman who hears about it running TO the hospital to make sure it “won’t happen to me and my baby.”
As with all these cases, the first thing that needs to happen is public education.
When the infant is delivered by a midwife and has cerebral pasly who do you sue to get the multimillion dollar judgement?
“The majority of women WANT some kind of pain control for birth procedures, and if they think they don’t, that first “real contraction” often changes their mind very quickly.”
I find this condescending towards woman.
After two hospital births, I would not choose a hospital birth for a third child. My preferences for delivery were ignored and procedures were done without my consent for the convenience of the doctor.
GG: “The majority of women WANT some kind of pain control for birth procedures, and if they think they don’t, that first “real contraction” often changes their mind very quickly.”
A tad condescending and presumputous, no? Evidence? I suppose in the popular active management of labor scenario, the first Pitocin induced or augmented contraction might knock a woman’s socks off and blow her plans to forego an epidural out of the water.
“…will send every 18-24 year old gravid woman who hears about it running TO the hospital to make sure it “won’t happen to me and my baby.”
Do the younger women lack judgment or something?
Hopefully I’m just reading it wrong. It could be the case. I am presently in grave need of coffee.
throckmorton: When the infant is delivered by a midwife and has cerebral pasly who do you sue to get the multimillion dollar judgement?
I see this comment almost verbatim on various sites. I have always assumed it’s a joke but I’ve never asked. It’s a joke, right? It’s a tongue-in-cheek way of saying that it’s not fair that some birth attendants presumably get to walk away from a bad outcome and others get put through painstaking, ridiculously personal, reputation-crushing litigation that can take years and drain one’s life savings, right?
There is no such thing as an uncomplicated labor. Any delivery can develop complications in seconds. You invest 9+ months and countless resources in bringing a child into this world. Why on earth would you take the risk of losing such a life for the simple gratification of being in a more soothing environment. The way I see it, any woman/couple who hires a midwife over an OB/GYN is playing with fire. I applaud OB/GYNs for not working with them.
BMGS – simply a medical view. The vast majority of pregnancies and labours are uncomplicated. The biggest and often first intervention in this is transfer into hospital, and it is all downhill from there. Anyone applauding negativity amongst healthcare professionals is an idiot in my eyes.
There needs to be better collaboration between midwifery and obstetrics, because if I ever have to transport my wife to the hospital for a birth, I don’t want her to be treated like an insane second-class patient who needs a social services consult. We’ve evaluated the facts about home births, and the risks, but I’m sure even if we transported to the hospital I work at, they’d look at us like we have three heads.
I think a better organization of our medical resources, let alone a better collaboration between OBs and midwives, could be achieved by defining obstetrics as the practice of high-risk labor and delivery, and transitioning all other birthing mothers to CNMs and other midwives. I don’t see how it’s an efficient use of resources to make a physician study and apprentice for years in order to attend births that mostly don’t require his or her high level of skill. I think that high level of skill applied to ‘normal’ births in turn artificially raises the medical intervention and c-section rates, which is not good for the mother, the baby, or the insurance companies. In a perfect world, my wife would be attended by midwives who were free to practice in the hospital or at home, and would only ever see an obstetrician if conditions warranted or an emergency arose.
Medicine has already divided family practice from intensive care. Critical care physicians don’t spend 95% of their time taking care of healthy adults. Likewise, I don’t think obstetricians, who possess the management skills for critical births, need to be taking care of every healthy mother and child.
Well said Man-Nurse. Perhaps looking at other countries and their models of maternity care would be a good start.
Midwives have much worse outcomes than OBs in hospitals. Their perinatal death rate is almost 3 times as high as the hospital, and the midwives have all the easy cases.
Midwives benefit everyone but the patients. They are almost always used by women who don’t have the finanical means to get an OB and have no choice. Midwives get careers treating patients when they should die out because women don’t want them. Administrators rake in the money by charging doctor rates for nursing services. Public officials pretend to meet their obligations to public aid patients at a bargain basement price.
Meanwhile, women and babies bear the brunt. They are injured or killed at much higher rates. Women bear the burden of the depression that goes with loosing a child, the burdens of another pregnancy to complete her family, or the extra burdens of raising a child hurt by midwives failure to recognize problems.
So-called research by midwives is frought with huge methodological and statisitical errors. They routinely drop huge numbers of deaths (about 2/3s) by making implausible excuses (they all had SIDS in the first day of life/ they all had fatal anomalies). They also fail to count the huge number of stillbirths they fail to prevent because they are soooo bad that the babies never make it to birth.
wow! I’ve never seen any research to support the accusations that “mom” is making. Do you have any evidence to back up your statements?
I definitely agree with everything man-nurse said…especially the part about changing the practice of obstetrics to a “high risk” category.
Annecdotally, I’d like to add that I always laugh when I read “why would you want to risk…at home when you could be {safe} at a hospital?” as if bad things don’t happen in hospitals! I’ve had 3 children and my first was a horrible (unfortunately very necessary) cesarean-gone-wrong. Well, its up in the air whether or not the cesarean actually “went wrong” but the recovery sure did. Let’s just say it took two additional surgeries and a good 3-4 months of recovery just to “fix me”. Oh, and that doesn’t even mention the PPD, breastfeeding issues….. so life isn’t always perfect, even if you *are* in a hospital!
“wow! I’ve never seen any research to support the accusations that “mom” is making. Do you have any evidence to back up your statements” Kristin
You have heard it. But, like most midwifery proponents you claim it states the opposite.
The study in the BMJ by Johnson and Daviss is cited by midwives to “prove” it is safe.
They have 3/1000 deaths after birth, when the rate for low risk hospital birth is .7/1000.
That’s only because they kill most babies before they are born and they are classified as stillbirths, not infant deaths. In Johnson and Daviss, they killed 5 about of about 5000 during labor. That’s 1/1000 or 10/10,000. The low risk rate of death during labor in a hospital is 1/10,000.
That’s 10 times the death during labor, and 3-4 times after birth for a total of about 14 times more deaths.
They dropped and ignore about 50% and then, out of thin air, claimed a jacked up the hospital death rate. Why bother with Quality Control at hospitals? All you have to do is claim half your deaths didn’t matter and that every one else is as bad as you are.
These midwives are so obsessed with childbirth and gaining control of pregnant women that they will say and do anything. Why don’t journalists, legislators, and (uh-um) physician bloggers **read** the study upon which claims of “safety” and “equality” are based?
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