American College of Domiciliary Midwives
Vonnie Gurgin, CMA
California Medical Association
PO Bx 7690
San Francisco, CA 94120
July 15th, 1994
Dear Ms. Gurgin,
This correspondence may surprise you, as it would appear to the casual observer that we are on "opposite sides" of the fence regarding midwifery practice and other aspects of modern health care. In many large and small ways we are. But I believe we do share a common goal in that we are each committed to bringing about a workable solution to SB 350 so that we can get on with other matters of importance. As central as implementation of midwifery legislation is to my profession, I don't want to spend the rest of my life fighting about it. With the goal of an amicable solution in mind I offer you the following insights, hoping that perhaps they may assist us to bring about a speedy resolution. But before diving into these somewhat treacherous waters, let me add that I have great respect for you and although we've had little personal interaction, I believe that you are doing a good job in particularly hard circumstances.
I have spent my adult life associated in various ways with the provision of health care, for the first 20+ years as a nurse in the ER and labor & delivery rooms. I begun this Odyssey in the very early 60s, a time I refer to as "BC" -- Before the malpractice Crisis. I remember an era in which physicians in general and obstetricians in particular, experienced a great deal of professional satisfaction. In 1962, when I first began working as a new graduate in the Labor and Delivery Room, obstetrics was a "happy" calling and obstetricians were happy with their calling. Physicians were still permitted to exercise the art as well as the science of medicine. Until the beginning of the malpractice crisis in 1975, professional medical conduct was a synthesis of religious, ethical and professional standards. Since 1976, it has been a rapid down hill slide as the vehicle of medical progress has been abducted by a headless driver. In the 33 years that I have been an inside observer, I have seen the user-friendly OBs forced out by astronomical malpractice premiums and similar factors and they are NO longer happy about their calling.
People generally assume that after 30+ years of devoting oneself to one's profession, that the last decade or so of one's career will be a pinnacle of fulfillment and that one's younger colleagues will respect and honor the hard work and years experience that it represents. Well, not so today. Rather than exercising more authority, older physicians often find themselves being treated like medical students. It seems that all of life has been cheapened by the tyranny of the malpractice model of medical practice.
Historically, one of the most elemental definitions of medical practice was the authority of the physicians to make exceptions to "business as usual" - whether in treatment modalities or other areas of hospital life. It is this ability to synthesis from one's years of valuable experience that the "art" of medicine arises. Now days insurance companies, malpractice policies, department protocols, the rumor mill, oversight committees, public opinion and a host of state, federal, county, city, and other unofficial regulators have virtually succeeded in eliminating the authority (author-ship) of medical careproviders. Without that authority/authorship, the creative function of the medical careprovider is extinguished and satisfaction plummets.
As beleaguered as midwives are, I believe physicians face a worse plight. They do not even have the hope that it will get better -- passing a licensure bill will not change things for them. While it is midwives who get prosecuted for "practicing medicine without a license", in truth it is the inursance industry that practices medicine these days. This should not be. I would suggest the midwives and physicians explore the possibility of a new "shared goal" -- that of joining forces and working together to return the "art" to the "art and science" of modern healthcare.
Myself and other midwives do not expect domiciliary birth services to EVER be the dominate careprovider system. And yet I and many others believe that we desperately need the balancing effect that home-based care represents to healthcare in general and maternity care systems in particular. Home-based maternity care has the same quality of contribution to society in regard to childbearing that hospice care has in regard to death with dignity. Without the mediating influence, both birth and death become technologically-dominated, and malpractice-centered. These negative forces result in a devolving experience for both patients and physicians.
While road blocks may appear from time to time along the path of progress, midwives are looking forward to the cessation of the hostilities between themselves and obstetrical medicine. We are ever hopeful that complementary practices between our respective groups will support the practical well-being of mothers and babies and with that, advance the stability of modern society to the mutual benefit of all. Traditional or non-nurse midwifery is not intrinsically in conflict with the true purpose and glory of obstetrical care -- the compassionate correction of dysfunctional states and the treatment of pathological ones. As non-interventive, non-medical caregivers, we seek to augment, supplement and compliment contemporary medicine.
Speaking of my own first-hand experiences in this realm, I have learned many valuable lessons during the eleven years I was privileged to "co-manage" clients with a "user-friendly" obstetrician. Most germane to this relationship is that I have always felt as midwife-of-record, that I had a twin duty -- one to the well-being of the mother/ baby diad and the other to the physician who had been so good as to make himself available should the family desire or require medical care. As a home-based, non-interventive caregiver, it is my job to serve the practical needs of the childbearing family as well as to protect the physician from "unnatural" liability and, when necessary, to transfer clients to medical care BEFORE urgent situations arise.
One of the main strategies that protected my obstetrician and friend was the autonomous, collaborative and voluntary nature of our relationship. My good relationship with physicians is only possible because they are not tied to my actions by the threat of vicarious liability. I can therefore protect the doctor by not bringing him or her into the childbirth event at a time or in a manner that would render them legally culpable either for my actions/inactions OR his/her perceived "failure" to act (as defined by contemporary medical protocols).
I believe that we have gotten off-tract in regard to midwifery legislation due in part to the lack of real communication between traditional midwives and medical doctors. While I do not purport to speak for ALL midwives, I do speak for quite a substantial segment, many of whom are members of the ACDM (American College of Domiciliary Midwives), and what we have been attempting to bring about is the recognition of a co-operative and non-medical function that augments, supplements and compliments the contemporary medical model. This is commonly referred to as a bio-social domain (as contrasted with the bio-medical).
Except for the most elemental first-aid or in a national disaster, I and many other midwives DO NOT want to be forced to practice medicine in any way. I am appalled that SB350 contains a medical scope of practice such as routine GYN care, electronic fetal monitoring, administration of pain medications, pudendal and paracervical anesthesia to name but a few. We don't want to be put in the position of HAVING to provide medicalized care, thus putting us in competition with fully-trained physicians who "calling" IS the practice of medicine. Personally, I want to be able to call my obstetrician friend up for the most mundane, even trivial of reasons so that medicalization is done by medical practitioners and in a medical facility.
It grieves me greatly that midwives have been catapulted inappropriately into competition with physicians, based (I believe) on the erroneous assumption that one way for physicians to reduce competition from midwives was to expand the years and the qualities of medical training, hoping that a rigorous curriculum will flunk out the majority of candidates.. Unfortunately, what you get from this approach is mini-obstetricians who feel (with some justification) that they are as prepared to provide primary medical care as a general practice physician. This is one of the reasons that the profession of nurse-midwifery continues to have such a hard time fitting into the "system" -- it is neither fish nor fowl. Forcing direct-entry midwives into a nurse-midwifery curriculum is counter-productive to the goals of BOTH physicians and traditional midwives. As the French are fond of saying "Viva la difference"!
Non-Medical Nature of the Domicile - homes are not hospitals
The non-medical nature of domiciliary care must eventually be officially acknowledged to prevent home-based care from being inappropriately substituted for hospital care. For the safety of childbearing families, the innate non-medical nature of home-based birth services must be recognize, regardless of the credentials of the caregiver -- be it general practitioners, nurse-midwives or SB 350-licensed midwives. Understanding this principle should reduce the unnecessary anxiety of the medical community that implementation of SB 350 is going to, somehow, dramatically and drastically change the nature of obstetrical care in the US. It will not.
The Non-Competitive Nature of Domiciliary Care
Unwarranted fears on the part of physicians have come about, in part, from the erroneous assumption that midwifery licensure will fundamentally change the way large numbers of childbearing women will chose to labor & give birth. Based on many years of home & hospital birth experience, we assure you that this is not so. Ten years from now we may see a higher ratio of home to hospital births but nowhere in the modern world (not even Holland!) are mothers abandoning medicalized childbirth and jumping into the arms of domiciliary midwives. The non-medical approach is not "in" and hasn't been for most of the 20th century. Its unlikely to change in our lifetime. Non-medical, non-surgical home-based maternity care has always been lawful in California (under the original Article 24 & Section 2063) and yet it has been rejected by the majority of childbearing women -- most usually due to the intrinsically painful nature of labor.
Domiciliary midwives do not give pain medications nor do we administer anesthetic agents. It is not safe. All practitioners (including nurse-midwives & home-birth physicians) who function in a domiciliary setting must abstain from the use of these potent medications and anesthetic agents due to their intrinsic risk to both mother and child. As long as midwives remain faithful to the midwifery tradition (no pain medications, anesthetics or operative obstetrics in a domiciliary setting) only a small fraction of childbearing families will choose home birth. Being unable to offer narcotics or anesthetics, midwives do not compete with the obstetrical model of medicated labor & birth. Understanding these points, especially the recognition of the permanent minority nature of home-based maternity care, should bring cheer to obstetricians and hospital administrators all across California!
Midwifery As A Bio-Social Speciality Domain
A core concept for home-based birth care is a respect for the normal biological, psychological and social needs of a normal healthy mother during labor. Within this model, the identified function of the caregiver is to meet that broad spectrum of bio-social imperatives while remaining articulated with bio-medical science. It is predicated on a body of knowledge which is primarily non-pathological (educational experiences developed, acquired and focused primarily in the normalcy of childbearing). Therefore, it is of compelling concern that the fundamental non-medical nature of the domicile be acknowledged and respected. Homes are not hospitals and visa versa.
The home is and must remain a non-medical location -- the safety of mother and baby in a domiciliary setting depends on it remaining non-medical. We insist that non-medicalization be a fundamental principle of domiciliary care; it is not safe to conduct medicalized childbirth at home even if one is a physician or acting under the supervision of one -- no routine use of IVs, oxytocin inductions or augmentations, pain medications, anesthesia, epidurals, blood transfusions, or operative deliveries such as forceps and vacuum extractions. This is an immutable core concept and must be widely taught both in domiciliary midwifery programs and in medical schools.
The basic premise of traditional midwifery as it relates to standard medical care is perhaps best described in a little-known story told about Eleanor Roosevelt. When asked what she put first in her life, her husband (then-president of the United States), or their children, she replied that "together with my husband, we put the children first". I have always appreciated that story as portraying the ideal relationship between physicians and midwives -- that together we put the practical wellbeing of mothers and babies first. To do so puts the wellbeing of society first.
I see three areas that would benefit from further communication between physicians and midwives. The first is the wisdom of maintaining the bio-social nature of midwifery educational and domiciliary practice parameters. While certain basic competencies are common to all three disciplines (medicine, nursing and midwifery), preserving and emphasizing the distinctions is of benefit to all categories and to the families served.
Secondly, to defuse the malpractice monster, we must emphasize the legal concept known as a "distinct calling" in regard to domiciliary midwives and medical supervision provided by physicians. I am currently working on a letter to the NorCal representatives specifically dealing with this aspect of the malpractice issue. Third, the problems associated with first-response emergency transport and care rendered in the ER by non-obstetrician/neonatalogists physicians must be addressed. I have asked an obstetrician-friend of mine and a neonatalogist on the medical board to meet with me for the purpose of developing recommendations to improve the quality of midwifery/medical interface, in regard to the satisfaction of practitioners and the safety of mothers and babies. These are only a few of the most pressing areas of concern. I am sure that many others areas would also benefit from expanded communication between physicians and midwives.
I hope that the information contained in this letter will prove useful to you. If you wish clarification or expansion of any of these points, please feel free to contact me.
faith gibson, community midwife
Certified Professional Midiwfe#96050001
North American Registry of Midwives