The Forever Debate

I have a cousin who is very dear to me who is a wonderful obstetrician.  Back when I was first working as a doula, fresh-faced and mesmerized by the magic of birth, I would pummel her with questions and beg her for stories every time I saw her.

Since then, I have completed over three years of midwifery school, including clinical training with three Certified Professional Midwives and one Certified Nurse Midwife.  I have attended well over 100 births and caught dozens of babies.  I have led or participated in a handful of infant resuscitations, two of them being difficult.  I have assisted with a handful of shoulder dystocias, all successfully resolved.  I have seen lots of variations of normal, and I have not yet been involved in a bad outcome.  It’s not a lot of experience, but I feel that it is a respectable level of experience on which to build, for a licensed midwife such as me, who practices carefully and  thoughtfully, and who only attends births in the company of two licensed midwives, as do most midwives in my area.

I have held hands with mothers, hugged dads, cried with grandmas, sung with sisters, done middle-of-the-night food runs, and given gifts to big sisters and brothers.  I have watched SO. MANY. MOTHERS. realize that they are so much stronger than they knew. I have seen them discover their babies and fall in love, knowing that they have everything they will need already within themselves.  I am a new midwife, with a brain full of the latest obstetrical information on normal birth, variations of normal, and complications.  My hands are confident but not yet lined and softened with the memory of a thousand babies.  I am still fresh-faced and mesmerized by the magic of birth, and I still have much to learn.

Recently my cousin posted some comments in support of an article written by a non-practicing OB, which claims that birth is dangerous, that home birth in the US is unsafe, and that the Certified Professional Midwife designation (my designation) should be categorically abolished.  Most of the assertions in the article are actually untrue.  It hurts me, because it attempts to negate everything I have been doing with my life, everything I have believed in and fought for, and my future life’s work.

But misunderstandings between OBs and midwives are a common theme in the divisive, never ending discussion over birth choice in our country.

Why am I writing about this here?  Because I really believe there are good points on both sides of this tiresome debate, and I love my cousin and want to promote mutual understanding rather than disharmony in a profession that should exist to promote safety, informed consent, and justice for women, babies and families, in a unified way. 

Some OBs may think midwives practice unsafely because they only see them when the birth process goes awry.  It is human nature not to think about the other 90% of births attended by that midwife that the OB never even knows about.  But the fact that a midwife comes in with a mom who is having late decelerations is not a knock on the safety of home birth.  It is, in fact an example of a system that is working. 

How so?  Well, even though birth is generally safe and usually doesn’t require much intervention, sometimes things go wrong.  Mothers who birth outside of hospitals know that, and choose out-of-hospital birth anyway, because they know the risk is small, and they trust their midwives to transport them to safety if something does go wrong.  (They also know there are tremendous potential benefits to birthing outside the hospital for them and for their babies, and they have also been meticulously pre-screened and judged to be at low risk.)

But since complications can still arise, it is critical that midwives recognize problems and decisively initiate the next level of care when indicated.  The next level of care is likely a highly trained physician, such as my brilliant cousin, who specializes in just this type of thing.  I have no doubt that my cousin has saved lives with her expertise.  I am so grateful for her and the work that she does.  Without OBs like her, without such a safety net, out-of-hospital birth, and all birth, would NOT be as safe. 

I think we could all agree that the systems within a community that support a seamless transition from birth center or home to hospital are critical to home birth safety.  Midwives need to know when to transport and all involved caregivers – midwives, EMTs, charge nurses, and OBs - need to communicate effectively about the situation without wasting time blaming, accusing, defending, or refusing to listen. 

Knowing that there will always be families who choose out-of-hospital birth, we should all be making sure we have a system in place to maximize their safety.  We should all be working to improve communication and understanding between midwives and the experts to whom we need to transfer care at times.

Most midwives I know, and I know many, respect obstetricians and urgently desire more positive relationships with them.   We know we will need to transport in labor at some point, and we will do so when the time comes, but it would be really nice if we could do so without the OB or hospital filing a complaint against our licenses and without risking our families’ livelihoods and our professional reputations.  Needing the next level of care happens.  It’s part of birth.  It doesn’t mean the midwife did something wrong; rather her recognition of the problem and her decisive action shows that she did exactly the right thing. 

The OB who wrote the article my cousin posted doesn’t respect Certified Professional Midwives and really wishes they would go away and we could all just go back to having our babies in the hospital where it is “safe.”  She is well known and generally ignored, and she devotes much of her life to attempting to destroy the midwifery profession.  But here’s the thing.  We can debate forever about where women should give birth and what the benefits and risks of out-of-hospital birth might be.  But there will always be women who just don’t want to have their babies in the hospital. 

Calling for the abolition of an entire professional designation and making divisive, inflammatory statements about other people’s choices is surely not helping.  Citing only studies that support one’s point without mentioning all the other studies that support the opposite view is deceitful.  Propagating distortions of fact for the apparent cause of removing women’s choices is hurtful.  Claiming that there is only one right answer and that you are on the right side is hubristic.

I think there is a better way.

I am not a surgeon (although I do suture minor perineal or labial tears.) I am not the expert at resolving major complications of pregnancy and birth.  If I had wanted to be, I would have needed to devote many more years to study and practice, as my cousin has done.  And so I thank all the OBs out there who have devoted their careers to this excellent and necessary cause.

I would just ask that in turn I might be allowed to exist without persecution.  That my fellow CPMs who also care about women and babies and safety in birth might receive a warm welcome for our clients’ sake, when we come in for that inevitable transport.  We can work toward building a level of mutual respect, for the sake of smooth and safe transitions, if not for the midwife, at least for the birthing mothers.

I get that it is exasperating to receive last-minute, problematic patients.  I get that sometimes the midwife should have moved faster.  I’m sorry for that, but I know that happens from inside the hospital, too.  We are all human.  Nevertheless, it probably feels like being expected to clean up somebody else’s mess.  I wish it didn’t feel that way.  But couldn’t we all improve this scenario by talking with each other a little more?  Let’s create availability for consultation and the potential for midwife/OB co-care in certain, appropriate cases.

We may never all agree on how birth should happen.  After all, the traditional medical model of obstetrics is born out of a very different world view from the Midwives Model of Care.  Maybe that’s okay, because we are all necessary for the mothers and babies and families.  We are not in competition, after all.  We serve very different patients with very different needs, except for those rare times when our two worlds meet.  There are enough mothers and babies for all of us.  Let’s coexist without negativity and slandering, at the very least.  And perhaps we could consider working together more.

Here are some studies on home birth safety that provide an alternative viewpoint from those cited in the article. 

Oucomes of Care for 16,924 Planned Home Births in the United States: The Midwives of North America Statistics Project, 2004-2009

Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America

Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003–2006: A Retrospective Cohort Study

If you are an obstetrician or a medical doctor who cares for women during the childbearing year, please consider attending a few out-of-hospital births as an observer.  Please go out to lunch with some midwives.  Ask them about their experiences and tell them about yours.  Explain what you need from them in a transfer situation.  Promote understanding and mutual respect. 

CPMs are real people, with families and a deep passion for their work.  They want to do right.  If you are worried they aren’t succeeding, then be part of the solution.  This forever debate doesn’t have to be persecutory.  It can become a place of learning and ever improving patient care.