California College of Midwives
State Chapter of ACDM
3889 Middlefield Road
Palo Alto, CA 94303
Tel: 650/ 328-8491
CCM Position Statement on
Midwifery, Obstetrics and a National Shared Maternity-Care Policy
presented at the July 30, 1999 meeting
"Health care Models & Approaches to Birth Care in California
--- A Critical Forum"
Sponsored by the UCSF Center for the Health Professions and Pew Charitable Trust in conjunction the UC Berkely School of Public Health, Berkely, CA
Attended by public health officials, consumer advocates, legislative aides, malpractice insurance representatives (for physicians and community-based midwives) professional midwives, obstetricians, peditricians, an administrative law judge, ACOG representative and other interested parties
Quick-Finder for accompanying UCSF files: (1) Risk Reduction Stratigies (2) History of the "Midwife Problem", (3) Science, Midwifery Politics & the Clinical Characteristics of the Midwifery Model of Care; (4) Hospitals - Help or Hazared?
It is the desire of professional midwives to negotiate a reconciliation between the professions of midwifery and medicine. Even more fundamental than the professional relationships between our respective groups is the repatriation of the historical disciplines of midwifery and obstetrical medicine. Each is, legally speaking, a "distinct calling" with its own unique history, educational process and statutorily-defined scope of practice. Each has a particular gift to contribute to society and the potential to assist the other in elevating the quality of care available to childbearing families. Ideally, this should represent a broad continuum of maternity services with the purest form of non-interventionist midwifery at one end, high-risk obstetrics and perinatology at the other end and the great number of physician and midwife caregivers spread out in between. Within this spectrum we serve different populations, often in different settings. The scope of practice of each and activities of individuals within each professional group should overlap in the middle in regard to routine use of evidence-based scientific practice parameters, such as monitoring of maternal-fetal wellbeing and access to and use of emergency interventions. Midwifery and medicine together have more to give than either one alone.
For the sake of those served, maternity care needs to address the practical needs of childbearing families. The over-arching purpose of reconciliation, while personally advantageous to physicians and midwives, is to ensure that maternity services in the 21st century are complementary, cooperative, cost-effective and assist childbearing parents in successfully taking on the role and responsibilities of early parenting. When society does a credible job of supporting parents, it enhances the number of capable and contributing citizens that live to maturity and reduces the damaging sequela of a fractured parent-child bond. The association between a dysfunctional parent-child relationship and an increased incidence of childhood depression, academic failure, delinquency, drug and alcohol abuse, gun possession, violent behaviors, suicide, teen pregnancy, fatal auto accidents and incarceration is well documented. While no form of maternity care, no matter how comprehensive, can guarantee "good enough" parenting, helping families to get off to a good start is an important contribution to these societal goals. Midwifery care brings a unique contribution to this pursuit.
It is in the context of these overall goals that we seek an on-going dialog about the professional relationship between physicians and midwives and the formulation of national maternity care policies that reflect science-based practice parameters. In particular licensed midwives are concerned with developing policies that are mutually agreeable and bring about beneficial working arrangements between community-based midwives providing domiciliairy birth services and hospital-based obstetricians with whom they consult, refer and transfer care.
From our perspective, this negotiation process does not question whether or not community-based midwifery is safe. Historically domiciliairy care (known in the early decades of this century as "outdoor" maternity services as provided by med students & interns) has always has been both safe and efficacious for low & moderate risk pregnancies and remain so today. Historical sources and contemporary science world-wide in the form of research, published studies, statistical analysis and WHO recommendations all uniformly report the same low perinatal mortality for low-risk pregnancies under non-interventionist midwifery care in free-standing birth centers and client homes without the expense and risk of maternal-infant mortality and morbidity that accompany the routine application of obstetrical interventions. [see "Safety of Alternative Approaches to Childbirth" by Peter Schlenzka, "Cost effectiveness of home birth", Ronda Anderson, et al]
Nor is this negotiation to determine whether or not to replace the physician supervision clause of nurse and direct-entry midwifery practice acts because about that there is no debate -- it is unethical and unworkable for a competing profession to have gatekeeper authority over another distinct profession. It is equally unworkable for the obstetrical profession to have control over a separate and distinct discipline in which they are not trained. In order for physicians to have shared control within the discipline of midwifery, they would first need to include the study of midwifery, its philosophy, its principles and its body of knowledge and skill sets as a fundamental aspect of every physicians medical education and be certified in its practice. Perhaps someday this may be the case.
The real question is how to bring about a shared maternity care system. The most logical place to start is to put the correction in where the original error occurred -- that was the erroneous conclusion and mis-information about midwifery that was institutionalized in medical education beginning in the early 1900s. Before reconciliation can succeed, we must first put to rest the ignoble chapter originating the early 1900s and characterized by organized medicine as "The Midwife Problem" (see accompanying fact sheet entitled "History of the Midwife Problem - 1910-1935").
This unfortunate period leaves both groups with an emotional charge. To clear away the prejudice it is helpful to acknowledge the historical place of the discipline of midwifery in regard to the professional care of childbearing women. Midwifery precedes the practice of medicine as an applied science by more than two thousand years [TAASPIM]. The knowledge base and skills sets of midwives in regard to normal parturition and complications of childbearing became the foundation of obstetrics as practiced by physicians from the time of the Egyptian physician-priests in 1300 BC to the Greek physician and writer Soranus in the first century AD. Hippocrates (460-377 BCE) own mother was a midwife. Historically speaking, the body of knowledge which reflected the discipline of midwifery was taken over by the medical profession beginning in the early 1600s. Textbooks written by midwives in the 15th,16th and 17th century were used as a foundation for obstetrical texts. Madame Du Coudray, the Kings official midwife (Louis XV), invented the obstetrical teaching manikin and taught the science of midwifery to hundreds of surgeons throughout France for 30 years. These resources were built upon by professors of medicine and combined with knowledge gained in anatomy (through dissection) and other scientific processes. The modern art and science of obstetrics is the aggregate of both traditions. Recognition of these shared historical origins does not diminish the contemporary science of obstetrics in any way.
In modern times, midwifery gratefully incorporated the contributions of science and technological assistance from devices such as blood pressure cuffs, fetascopes, the information available through laboratory analysis of blood and body tissues, ultrasound imaging of body organs and services of fully-equipped hospitals. The historical background commonly know as the "oral tradition" and a contemporary knowledge base together form the foundation of the Midwifery Model of Care as an evidenced-based phenomena that results in a modern discipline which is well-rounded and robust. The midwifery model of care in the 20th century is not specific to the type of caregiver -- it can be provided by both physicians and midwives, either in hospital or out. Within that context, professional midwives are capable of contributing to the care of all pregnant women in some measure and particularly well suited to be the primarily caregiver for the 50% of childbearing women who complete pregnancy in a state of health and who experience a normally progressive labor. The question is how do we go about reconciling these divergent positions between midwifery and medicine?
Goals, Suggestions and Requests
Shared maternity Care System:
Overall purpose is a shared maternity care system such as enjoyed in most of the world. This can only come about by sharing authority and control over the provision of maternity care, with lines of demarcation naturally following the inherent differences between the non-interventive scope of practice of midwifery and the specialized scope of obstetrical & perinatal medicine.
Both midwifery and obstetrical medicine aim at a happy ending but our respective roles differ. The practical wellbeing of mother and baby has always been the identified goal of any maternity care system. This is far more than just a live birth or even a healthy infancy. It means a baby that not only survives childhood but enjoys a life well-lived for the allotted fourscore and 20 years and dies of natural causes in his own bed surrounded by loved ones at a ripe old age. Between birth and death, the mother-baby relationship is one of the crucial building blocks of healthy child development and has life-long consequences. According to the traditions of midwifery, the real work of the midwife is to deliver the mother to motherhood and self-sufficiency in early parenting. Midwives are taught to "mother the mother so she can baby the baby". Parent-child bonding, breastfeeding, learning language, acquiring self-control & age-appropriate social behavior are all parent-centered aspects of a healthy life. These strong building blocks help guard against scholastic failures, depression, teen suicide, substance abuse & delinquency. Most midwives consider the care of the mother to encompass this whole maternal-infant developmental process which starts in pregnancy, is influenced by labor and birth, and requires on-going support in the postpartum. Together with other sources of social and emotional support, this helps to bring about "good-enough" parenting.
However, midwives clearly recognize that L&D is only one day. Its goal is a biologically well born baby in the care of a physically & emotionally healthy mother. But still it is only one day in a long continuum of events. For some women motherhood cannot occur without the expertise of many different medical careproviders. The ability to rescue a mother from obstetrical complications is the jewel in the crown of hospital-based obstetrical medicine, utilizing the assistance of nurses, lab techs, scrub technicians, obstetricians, anesthesiologists, neonatalogists, NICU staff, etc. Each of us -- physician, midwife, nurse, other hospital staff -- has a contribution worthy of respect, each plays a vital part. By building a maternity care system that shares these various roles and functions in a complementary manner, the practical well-being of mothers, babies, fathers, families and the nation are best served.
The following suggestions attempt to
bring about necessary changes:
Consent to legislative remedy & recognition of midwives as having a collaborative relationship with physicians: This legislative change would permit the parties involved to institute the malpractice equivalent of a firewall between the professions in regard to the very controversial topic of domiciliary birth services. The most straightforward example of this is reflected by the UCSF Stanford "Consent for Patients Planning Home Birth" (copy enclosed). It reflects a caregiver-relationship between the mother and the medical institution and does not purport to provide any professional relationship with the midwifery practitioner. It serves the basic need and is an OK a place to start.
Corrective Information programs for the Medical Community: The efficacy of professional midwifery in all settings has been establish beyond doubt. Information in numerous studies is widely available and was reiterated in the recently published UCSF Center for Health Professions-Pew Report "Charting a Course for the 21st Century: The Future of Midwifery. And yet, this preponderance of evidence is virtually unknown in the physician community. Institutionalized ignorance has perpetuated resistance and non-cooperation to the determent of childbearing families. The established safety record of midwifery services assumes easy access to medical care when appropriate and so it becomes a matter of utmost importance that physician prejudices be addressed so that physician cooperation can be gained. Cooperative and complimentary relationships with physicians are impossible in the milieu of historical prejudice and misinformation that currently dominates the thinking and policy making of the medical establishment.
The Medical Board of California is in a position to influence physician opinion and has a duty to public safety as well as to its 100 licentiate midwives to responsibly address this issue with the considerable resources it has at hand. We suggest that informative articles in the MBCs quarterly publication, the Action Report, as a first step. In addition, organizationally-sponsored programs for the membership of CMA & ACOG will also be necessary.
Shared Educational Opportunities: Ideally medical and midwifery students should train side by side in both undergraduate studies and in clinical rotations. Interns should be exposed to normal childbirth via midwifery care as provided by hospital midwives before being exposed to the pathology of obstetrics.
On-going in-service education should maintain the dialog between physicians and professional midwives as both have specialized knowledge that should be shared with the other on a regular basis.Professional Liability Concerns: It is well-established that the dangers of over-treatment of healthy populations via obstetrical intervention is greater than those of under-treatment via the midwifery model of care. This means professional liability issues can be resolved by integrating midwifery standards & protocols for a healthy population into the standards of obstetrical care. Shared Authority and Control between physicians and midwives regarding obstetrics and midwifery protocols. Physicians need to equitably share control over midwifery protocols as related to potential medical risks as part of a reciprocal process in which midwives share control over those aspects of "obstetrical" practice falling within the midwifery model of care, i.e.. care for healthy women with normal pregnancies. Correcting the Birth Certificate Problem: Accurate recording of midwife-attended births is a crucial aspect of quality control. Eliminating midwives from the birth registration process, as has been done for the last decade, sabotages the basic principle of accurate vital statistics collection. According to an employee of the Alameda County Health Department, the state Office of Vital Records has explained the problem as one originating with the California Medical Association, who said they "did not want midwives signing birth certificates as it would give them too much authority" and that "the midwives were too afraid of the CMA to do anything about it". This disgraceful situation must be promptly rectified. Full time Practitioner presence (physician or professional midwife) when laboring women are hospitalized: Labor and delivery units should be primarily staffed by professional midwives. Practitioners (either physicians or midwives) should be physically present and awake in the immediate area of the laboring woman during the time women are in active labor or hospitalized due to complications requiring "intensive" intrapartum care or observation. Nursing staff should be present to assist the practitioner and not instead of a practitioner:
Only practitioners are formally educated and trained to detect the full spectrum of possible complications and likewise skilled and legally authorized to deal immediately with the emergent situations that sometimes befall women in active labor. It is this capacity for immediate medical response that is one of the primary reasons that families choose hospital-based obstetrical care (rather than community-based midwifery) and why they bear the added expense of those arrangements. Malpractice litigation occurs with great frequency when these unmet expectations by the family for immediate response are coupled with a problematic outcome that would conceivably have been avoided through the immediate intervention of an on-site practitioner.
The scope of practice of the nursing profession does not include either the formal education or authority to make many of these crucial decisions. Regardless of how well trained or experienced staff nurses may be, they do not have the legal authority to make independent medical judgements or independently carry out necessary remedial actions. Only a practitioner -- either the mothers attending physician, a professional midwife employed by the physician or a midwife employed by the hospital has the requisite training, skill and authority to identify and respond immediately to potentially problematic situations. The full-time presence of a practitioner reduces bad outcomes and subsequent litigation.
[See accompanying information from Dr. David Rubsmen, MD, LL.B. author of the Professional Liability Newsletter and The Obstetricians Professional Liability -- Awareness and Prevention and list of "Risk Reduction Strategies"]
Go on to other files in the
series of UCSF documents
presented at the July 30th meeting
Reduction Stratigies -- Full-time Practitioner Presence in L&D
- midwives or physicians on site reduce bad outcome & litigation
(2) History of the "Midwife Problem" - 1910 to 1935
(3) Science, Midwifery Politics & the Clinical Characteristics of the
Midwifery Model of Care -- more than just "non-intervention
(4) Hospitals - Help or Hazared?