American College of Domiciliary Midwives
Palo Alto, CA 94306
Julia Lange-Kessler PO Bx 336
Homebirth Options New Hampton, NY 10958
Midwifery Independence 914/355-3529 Fax: 335-1416
April 24, 1996
Unfortunately, Im not surprised that you lost the civil suit in Federal court defending the right of women to choose midwives and home-based birth services. It is customary for lower-level judges (at least those with career aspirations!) to rubber-stamp the position of the state. However, I believe it is to the advantage of midwives that we have this extra time as there is a lot of material uncovered recently that bears positively on the issues.
I sending you an essay on the Bowland Decision, which was quoted by the judge as a justification of dismissing the suit. One of the major activities of childbearing women must be to nullify this out-dated and VERY bad decision, which is to midwifery what the Dread Scott Decision was to slavery (made slaves only 3/5th persons). This decision was made even more reprehensible since the 1989 Leigh v. the Commonwealth of Massachusetts reversal of the Hanna Porn ruling. The original 1907 Porn decision was used by the Bowland court to establish by case law precedent that midwifery was a illegal practice of medicine. Leigh reversed that interpretation.
"A women's right to choose" and the language of the abortion debate
As for the political activities of midwives, my observation is that the manner in which we present the issue of midwifery and domiciliary care is of utmost importance. It is an unfortunate reality that in the 1990s, "a women's right to choose" is the language of the abortion debate. While there is a place for us to creatively use the energy of the abortion debate, I dont believe it to be in the basic presentation of the issue.
It is a strategic error, in my opinion, to use concepts that mirror the abortion controversy in regard to home-based midwifery. The entire legal and legislative system seeks to protect an amorphous concept of public "safety" against those who threaten societal values in the name of "personal liberties". If a "right to choose" customarily prevailed in law, drug use, homosexual marriages and non-payment of income tax would all be "legal". They aren't and neither will home-based midwifery care if predicated on that argument.
When talked about as a "right to chose", it makes it seem as if any homebirth- friendly ruling would open up the legal "right" to a home cesarean or even an appendectomy on the kitchen table. Obviously, we must side-step that trap. We must expect to deal with medically-ignorant judges whose idea of being "medically educated" is to call up their wife's obstetrician and soliciting his opinion. This same poverty of understanding, combined with fundamental fear of childbearing and a proclivity for jumping to conclusions, extends to just about everyone connected with the legal system including jurors. Many people still think the right to homebirth equates with a right to let your baby die. What the judicial system is most interested in, when it come to individuals, is safety. For instance, the tragic plane crash killing 7 y/o student pilot Jessia Dubroof has generated a call to make such flights illegal. As you know only too well, the death of even one baby at home from an unpreventable cord accident generates a hysterical backlash to outlaw homebirth. It is always an error to think of the US as interested in expanding personal freedoms.
The concept of "right to choose" is not the high moral ground. Frankly, if the issue was simply a choice between equal circumstances, I would still happily be employed as a labor room nurse instead of a criminally prosecuted, starving midwife. Im tired of fighting a 35 years loosing battle and want to retire. If institutionally-based obstetrical care were in fact superior to or even equal to the midwifery and home-based care, I would happily urge all mothers-to-be to find themselves a good doctor and have a hospital birth. Unfortunately that its not the case. However, until we establish midwives as autonomous practitioners, neither of us can quit!
Safety -- The High Moral Ground
The high moral ground is not "choice" but parental and societal obligation, at the very least, to maintain the legal availability of the safest and most satisfactory course of maternity care as established by evidentiary standards. The truth doesnt have to be defended -- only revealed. The truth is that superior outcomes of midwifery-based maternity care for healthy women, obstetrical care for complicated pregnancies, liberal breastfeeding, and valuing of the parent-child bond have long been documented in maternal-infant statistics. These cost-effective methods are strongly associated with lower rates of mortality and morbidity and the long-term well-being of mothers and babies.
As parents and citizens of a democracy, we have a moral obligation to protect the health and wellbeing of mothers and babies. Midwifery-based maternity care for healthy women and complementary obstetrical care for complications has been established for more that 100 years to provide the best maternal infant outcomes and the lowest mortality and morbidity. Studies in industrialized countries around the world, going back to the late 19th century and early 20th century, established the superior nature of this combination of art and science as a foundation for a safe and sane national health policy. (Note: midwifery and obstetrics both represent a specialized body of knowledge that is art and science.) The situation is unchanged today -- the same countries that had the best maternity outcomes in the early 1900s, still have the best outcomes in the 1990s. Ditto for the five worst countries. The US is in the ignoble, latter category. What each of the five fortunate countries has in common is a midwifery model of care for normal birth and access to medical care whenever deemed appropriate by the midwife or the family.
Hospitalization for normal birth not scientifically justifiable
In contrast, hospitalization for normal birth is not a rational or logical premise based on ANY scientific premise or statistically-demonstrable body of knowledge. It cannot be justified on ground of safety, efficacious, or economic advantage unless the mother or baby have a demonstrable pathology for which an established medical or surgical solution exists. Hospitalization for normal birth was brought about in this country because it served the perceived needs of medical education and the self-interest of physicians. As the plan to eliminate the midwife gained success, resulting in fewer midwife-attended births and more physician-attended, maternal and infant mortality INCREASED. It was not until the medical advancements produced by the Second World War that maternal mortality was reduced in the US. This was only because the iatragenic complications of intervention could be better compensated for by such medical advancements as antibiotics to treat doctor and hospital induced infections, blood products to treat hemorrhage from intemperate use of labor stimulants and safer anesthesia for unnecessary forceps deliveries. In no instance do countries that combine obstetrician management of normal pregnancy with universal hospitalization for normal birth have better outcomes than countries and localities that utilize midwives, even when the care by midwives is combined with universal hospitalization.
Midwifery and Evidence-based Health Care
-- a marriage made in heaven!
Respectable statistics in great numbers are available through the records of our own government (Childrens Bureau, etc.) and the W.H.O which clearly document these facts. Under category #4 -- forms of care that should be abandoned in light of available evidence, the work of Murray Enkin (author of Comprehensive Guide to Pregnancy Care) and developer of the Cochrane Data Base lists "involving doctors in the care of all women during pregnancy", "involving obstetricians in the care of all women during pregnancy", "insisting on universal institutional confinement" (i.e.. hospitalization). Frankly, from a standpoint of litigation, it doesnt get much better than that. The reason so many hysterically underhanded, illegal, unethical, immoral, unconstitutional, anti-trust and unfair business practices have been employed by the hospital-industrial complex is that they dont have a leg to stand on and know it!
Hospitals are dangerous places, filled with supervirulent viruses and other peoples germs, and endless opportunities for medication errors, drug reactions, and surgical mix-ups (in addition to negligence and incompetence by the staff). According to Dr. Jarvis of the CDC in Atlanta, more people die in hospitals each year from iatragentic and nosoconial causes than all the deaths from auto accidents, plane crashes and house fires combined. Statistics from the Harvard Medical Practice Study published in 1990, which analyzed health care in New York, estimated that 0.5% of hospitalized patients died from the deleterious consequences of hospital care or 5 out of 1000 (1:200). According to the American College of Obstetricians and Gynecologists, "Obstetrical delivery is the most frequent cause of hospitalization in the Unites States", so these statistics are of more than academic importance. When the financial cost of unnecessary hospitalization are factored into insurance premiums and the tax burden generated by the cost of caring for the medically indigent (especially when combined with iatragenic complications), hospitalization for healthy women having a normal birth must be seen as a problem, and not a solution.
If the beneficent presence of a
skilled labor companion
were a patentable drug or marketable technique,
the AMA would want patent it!
While the misguided proponents of hospitalization cannot prove efficacy for universal hospitalization, many fine statistical sources document the biological and emotional deteriment subsequent to unwanted and unnecessary hospitalization without benefit of midwifery principles. The consistent presence through out labor of an "experienced women", either doula or midwife, is the single most demonstrable factor in lowering the need for pain medication, anesthesia, labor stimulants and the incidence of operative deliveries. If the presence of a skilled labor companion were a patentable drug or marketable technique, the AMA would first patent it and second, lobby to make it mandatory! Respect for the need of mothers and their newborns to remain in intimate contact (not be separated) is likewise one of the most demonstrable factors in establishing good mothering behavior, success in establishing breastfeeding, extended time of breastfeeding and reducing the incidence of child abuse. Ditto for the lobbying effort of pediatricians if maternal-infant bonding could be made into the proprietary right of doctors. The work of Marshal Klaus is excellent in regard to both of these issues.
The Medical model and the "cascade of intervention"
The next issue is the role that obstetrical intervention plays in triggering complications both singularly and as a trigger for the "cascade of interventions". Again, there is no dearth of statistical data documenting the deleterious consequences of drugs, anesthesia and other tactics for hastening the physiological processes of birth. It is a well-developed conversation in medical journals and textbooks that is not even controversial (well represented in obstetrical textbooks). I have one quote from a 1823 Edinbrough "Medicine, Midwifery and Churgury" textbook which states that "for every one women saved by manual removal of the placenta, a 100 mothers are lost to the hasty and ill-advised use of it by impatient physicians who refuse to let nature take her course." Manual removal of the placenta was the first routine surgical intervention in childbirth, the 18th and 19th century equivalent of unnecessary cesarean surgery, and appallingly high maternal mortality from puerperal sepsis.
The Loss of Midwifery Principles and the
erroneous concept of Obstetrics as a "Value Added System"
Next is the absence of midwifery principles in contemporary obstetrics practice. Up to the early 1900s, medical education was based on the historical concepts of midwifery, which represented the valuable intellectual property of midwives, added to the medical advancements of the day (the intellectual property of physicians). For the sake of argument, one could make the case (which wouldn't actually stand up to scrutiny) that when doctors first engineered the "elimination" of the midwife from the profession of midwifery, at least the care substituted for it was substantially the same, as the teaching of obstetrics included the principles of midwifery.
To phrase this concept in contemporary terms, obstetrics was "value-added" to midwifery -- i.e., that care provided to childbearing women included both the foundational principles of midwifery PLUS the "valued added" concept (though erroneous) that obstetricians could make childbirth "better" and thus prevent complications from developing. This historical fact can be documented in early man-midwifery textbooks. However, this is no longer the case as modern-day textbooks DO NOT teach the principle of normal midwifery-based maternity care. For instance, the most recent edition of Gabbe's excellent obstetrical text does not even contain a heading for spontaneous birth -- it starts the two-page section (out of 1500 pages) on the conduct of a normal birth with "assisted spontaneous birth", subtitled "episiotomy". What started out as a "value-added" system has become a "value-subtracted" one. What this means for childbearing women is two fold -- first the quality of care available and second, the quantify, i.e., the issue of availability itself.
The medical plan to replace midwives with
(free care) origin of our contemporary Medicaid system
When the plan to eliminate midwives was first proposed, physicians readily admitted that some suitably inexpensive substitute must be offered in its place. Many proposed that government funding be secured to do this, since the education of physicians was such an important "public service". However, the immediate solution was a system of obstetrical charities (Rockefeller money!) who provided free antepartal care, staffed primarily by recent graduates looking for opportunities to build up a private medical practice, combined with universally free hospitalization in charity wards for birth (with free obstetrical services provided by medical students). This capacity to "replace" the profession of the midwife with free care was identified as the corner-stone of the medical solution to the "midwife problem" (and the origin of our present-day system of Medicaid!).
From a litigious standpoint, one could argued that a basically "equal" form of care (physiologically-speaking) replaced the lower-cost domiciliary care of midwives. However, a universal "right" to maternity care in charity wards of hospitals as part of the medical education of physicians NO LONGER exists. The US does not have universal health care, and public assistance is something one must both qualify for and then find physicians who will accept Medicaid and institutions able to provide the required care. This leaves thousands of childbearing women (30,000 in California annually) without any recourse save emergency hospitalization in advanced stages of active labor. The vastly increased number of premature births and expenses of neonatal intensive care resulting from this reprehensible situation is a financial scandal (not to mention the human suffering on the part of mothers and babies).
Institutionalized Forms of Negligence -- the safe, the simple and the
are exchanged for the complex, dangerous and expensive
The inability of modern obstetrics to assure its "customers" that the principles of midwifery-based care (with its higher standards for psychological support) will be employed for normal parturition is an institutionalized form of negligence. Even more important, the ignorance of midwifery skills results in the incompetent practice of medicine as physicians eschew the use of the safe, the simple and the economical for the complex, dangerous and expensive. Complex medical and surgical procedures are routinely employed, such as pitocin augmentation and cesarean section for failure to progress, forceps, and the Zanvanelli maneuver for shoulder dystocia without ever trying the simple techniques as maternal mobility, emotional support, the creative use of gravity, upright and mobile positions for birth and other specific postures such as "hands and knees" for shoulder dystocia. This information should be available to the public so that legal accountably to midwifery principles will once again be included in obstetrical practice.
Consider what the legal, legislative and insurance industry response would be if "patients" who experienced normal muscle fatigue and soreness following strenuous exercise were "treated" by orthopedic surgeons with high doses of potentially dangerous drugs and even surgical removal of muscle mass without ever recommending bed rest, aspirin, and the passage of a few day time. Ignorance on the part of practicing physicians of the low-cost and common-sense responses (both in money and human terms) sets the scene for malpractice litigation. While doctors now days are unimpressed with the Hippocratic Oath, the general citizenry (and potential jurors) still see the obligation of medicine as "In the first place, Do No Harm". It is our obligation as citizens and childbearing families to see that the medical profession is held accountable to that standard. Clearly, the lack of a midwifery-based maternity care system is harmful to the public safety. The valuable contributions of the midwifery model as knowledgeable guardians of normal birth cannot exist without autonomous practitioner status.
Constitutional Issues and
to Autonomous Midwifery Practice
As for the hot issue of the "regulatory right of government", one must accept as a given that state legislatures do have a constitutional "right" to regulate. But legislative bodies, as agents of organized medical interests, do NOT have a constitutional right to use the regulatory process to erect barriers to midwifery practice in which regulations themselves function as a mechanism to prohibit the practice of midwives, thus denying to the American public the safety of midwifery care. Historically, physicians engineered the hostile take-over of midwifery by dividing up the functions of the midwife between the two professions of medicine and nursing. However, in contemporary times, obstetrics has become a high tech industry, and no longer teaches the principles of midwifery in medical schools or otherwise recognizes the distinct knowledge it represents. Obstetricians are no longer trained as man-midwives, and nurses can not function as midwives because nursing licensure prevents the independent "treating" of patients, thus requiring the primary loyalty of hospital nurses to be to the doctor and the hospital, and not mothers and babies. This only leaves midwives themselves as the repository for midwifery and as Dr. Kloosterman says so elegantly "guardians of normal birth".
Midwifery -- the intellectual
childbearing women and their midwives
Normal midwifery is NOT a step-child of medicine and modern obstetrics is NOT a hybrid form of care that synthesizes the "best of both worlds" for easy, one-stop shopping. Midwifery is a historical body of specialized knowledge upon which our current obstetrical knowledge was based. It is the intellectual property of childbearing women and their midwives. Midwifery care cannot constitutionally be eliminated without an equal or superior replacement. To the chagrin of the AMA and ACOG, contemporary obstetrics, estranged from its historical midwifery roots, has NO "equal or superior" replacement. All maternal-infant healthy policies in which midwifery for normal pregnancies is not pivotal are in opposition to their own goals as the purpose of maternity care is to make childbearing safer and more satisfactory. We must insist that the autonomous profession of midwifery, which is based in the premise that childbearing is a normal and physiological event be respected, legally protected, and promoted, along with a complementarily model of high tech obstetrical medicine for complications. However, the best treatment of "complications" will always be, prevention.
The only thing that works to
break the spell is another spell.
Midwives must become weavers of a spell!
To bring this about midwives and their supporters must develop a public information campaign that includes a variety of different public educational materials, PSAs, documentaries on midwifery and normal childbearing, script outlines suitable for the television and film industry, in-services education programs to teach the history, principles and lost skills of midwifery to professionals, informational packets for healthcare providers (especially smaller insurance companies) pointing out the increased profit to them in home-based midwifery care, and a very solid legal strategy.
This should include the potential for tapping into energy of the abortion debate based on the repugnant, oxymoronic use of Roe v. Wade as an excuse to criminalize domiciliary care by midwives and parents who choose homebirth. No intelligent person, including physicians, wants the potential for the violence that the abortion debate can sometimes trigger to be mobilized in opposition to ones own position (nor do we). However, the propaganda machine of organized medicine has been successful in mesmerizing the American public for the last century. I heard an anthropologist remark that when people are under a spell, no amount of rational argument can sway them. The only thing that works to break the spell is another spell. Midwives must become weavers of a spell. Our conversations and our media must be spell-binding. I want this to the last century that we suffer under the spell of ignorance.
The ideal strategy would be to have a well-constructed, well-organized plan which would permit us to approach ACOG and other players in organized medicine and strike a "deal" aimed at avoiding the necessity to litigate. In return for the end of hostilities on the part of the state chapters of the AMA and ACOG, we wont make a big public stink. We must insist that they cease and desist with the legal and legislative diatribes denigrating midwifery care and blocking legislative relief. What they get in return is another 20 years of the status-quo (which means they get to keep the lions share of political power and financial gain!) as home birth with a midwife is something that you cant give away. In fact, Id say that home-based maternity care is about as popular as celibacy and has attracted about the number of women as are interested in joining a convent! From my perspective, doctors and hospital have nothing to fear from community-based midwifery. Not until women routinely experience midwife-attend hospital birth will home-based care every become "popular" and then one can not expect that it will ever be a dominate form. Even Holland has a rate less than 50%. You and I will not live to see it as a majority choice but that doesnt mean we have to suffer "more of the same" for the rest of our professional careers. As mothers and midwives, we will prevail.
faith gibson, community midwife
North American Registry of Midwives (CPM application pending)
American College of Domiciliary Midwives
Editor, International Journal of Domiciliary Midwifery