Why Midwife-Led Care Should Be The Norm
The King’s Fund– a UK health care think tank– recently looked at studies from the UK and other countries to determine how to best increase safety in maternity care without increasing spending. Based on all the research they complied, the organization is recommending an increase in midwife-led care for low-risk births. One of the UK studies concluded that £2.5 million could be saved just by getting midwives, rather than doctors, to examine healthy newborn babies.
The Fund noted that last year only 10% of hospital births in England were in “midwife-led wards.” In America, I’m guessing that number is even lower. Our model of care if very much obstetrician-led. Now, let me be clear: midwife-led does not mean doctors have no role. Quite the opposite. It simply means that everyone does what they do best. Midwives handle the care of women throughout pregnancy and birth, and doctors handle medical problems that come up.
Just for fun, let’s see what midwife-led care would look like if we had it here:
You get pregnant, you go to a midwife. She does the initial consultation and orders any tests that might be necessary–routine blood work, etc. Most women, whose pregnancies fall within the wide range of “normal,” would continue with the midwife. If necessary the midwife will set you up with sonograms, prenatal screening or testing for chromosomal abnormalities, gestational diabetes screening, blood pressure monitoring, nutrition counseling, etc, etc. Basically everything an ob/gyn does. (This can be surprising to people in the US, as midwives are often associated with a strong opposition to technology or “medical” procedures; they are, in fact, trained medical professionals who can write prescriptions, etc. etc.) Those women for whom a particular health condition requires more specialized, “high risk” monitoring or treatment would either consult with doctors who specialize in such things or be transferred to them for full prenatal care.
When birth comes around, midwives are the first line of support, tending to most mothers throughout their entire labor and delivery and newborn assessment. In the case that a c-section is required the midwife will arrange for a doctor to perform the surgery– whether this is ahead of time due to a medical condition such as placenta previa or in mid-labor due to fetal distress.
Birth, while extraordinary, is actually just a bodily function. Sometimes it goes from being a normal bodily function to a medical situation, then you get your specialist to step in. Think about it, you only call a doctor when you’re sick, right? Well, pregnant women aren’t inherently sick. They are pregnant. If they become sick, call the doctor! But if they don’t, as is the case with the majority of pregnancies, we have an entire midwifery profession to provide incredibly smart, noninvasive, low-risk support. The midwifery model of care is pretty hard to come down on– it’s very respectful of each woman’s individual circumstances both in terms of her health and her frame of mind.
Midwife-led care is the norm in most of Western Europe where statistics for maternal and fetal health are excellent. Unfortunately, the numbers of midwife-led births are starting to decrease in Australia and England. The King’s Fund reports that last year only 10% of hospital births in England were in midwife-led ward, and warns that, due to financial pressures, it’s unrealistic to expect that this will improve. You can read more about the situation in England here.
As for America, I think that the Obama Administration should be looking closely at how midwife-led care as a way to save us untold billions in health care costs. (According to a recent study, we could save 3.5 billion dollars in those health care costs just by cutting the national c-section rate by 11 percent! Based, on examples from around the world, it’s clear that midwifery care reduces the overall number of medical and surgical interventions.)
But we wouldn’t just save money, we’d be providing women with the best of both worlds: quality midwifery care and outstanding obstetric back-up. We have both of those things to offer in this country! We’ve got to stop fighting about which kind of care is *better* and instead fight for what we need: Midwives and doctors working together, serving women.
“Like” The Big Push For Midwives on facebook to help join the fight to bring midwives into the mainstream.
This is post #4 in a week-long series on themes in “natural” childbirth.
Post #1 “10 Home Birth Lessons For Hospital Births”
Post #2 “Are Natural Birthing Supermodels Miranda Kerr & Gisele Bündchen Inspiring Or Smug?”
Post # 3 “10 Things I Learned From Ina May Gaskin”
photo: vox photo/flckr
Great post. One point that so many folks miss, too, is that women who use OBs are usually not “attended” by their doctor during most of their labor. OBs usually don’t show up at the hospital till you’re pushing. Prior to that, labor is managed by nurses on the L&D floor, with your doctor just a phone call away.
Contrast that with midwifery care: even in hospital births, midwives often arrive at the hospital earlier in your labor and stay with the laboring woman (of course women giving birth at home have their midwife with them the whole time).
Unlike L & D nurses, midwives are competent to handle all aspects of labor except surgery, on their own. Your midwife also knows you and your prenatal history, unlike a L & D nurse who is likely a stranger, and is also attending to three other women in labor, and whose shift might end in the middle of your labor.
This means women using midwifery care are actually getting better trained, more expert continuous care during the normal course of labor than most women using OBs, who are sharing one busy nurse with other laboring women. Why on earth not shift to midwifery care, instead of RN care, as the standard, with a doctor “just a phone call away” if necessary?
Meredith, Thank you for this comment! It’s absolutely true– another reason this is the direction we should absolutely be going in.
“Midwife-led care is the norm in most of Western Europe where statistics for maternal and fetal health are excellent.”
That is flat out false.
The country that has the most comprehensive system of midwife led care is The Netherlands and it has the WORST perinatal mortality in Western Europe and poor maternal mortality as well. This has been the case for years and the Dutch government has sponsored a variety of studies to find out why Dutch perinatal mortality is so high.
A paper published in the British Medical Journal recently revealed and astounding finding: the perinatal mortality rate for LOW risk women cared for by Dutch midwives is HIGHER than the perinatal mortality rate for HIGH risk women cared for by Dutch obstetricians!
According to the study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study, which appeared in the BMJ in November 2010:
“We found that delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care. This difference was even greater among the cases that were referred from primary to secondary care during labour… [T]he results are unlikely to have been overestimated, because risk factors such as low socioeconomic status, higher age, or non-Western ethnicity were more prevalent among the women at high risk…
In summary, the Dutch obstetric care system is based on the assumptions that pregnant women and women in labour can be divided into a low risk group and a high risk group, that the first group of women can be supervised by a midwife (primary care) and the second group by an obstetrician (secondary care), and that women in the primary care group can deliver at home or in hospital with their own midwife… We found that the perinatal death rate of normal term infants was higher in the low risk group than in the high risk group, so the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought. This also implies that the high perinatal death rate in the Netherlands compared with other European countries may be caused by the obstetric care system itself …”
Therefore, in contrast to your claim Ceridwen, the midwifery model is far from being the ideal model of obstetric care. The Netherlands has the highest perinatal mortality in Europe, and midwifery care may very well be the cause of this calamity.
Honestly, I can’t take it. Dr. Tuteur I’ve asked you numerous times in these pointless debates what the hell you propose we do to improve maternity care in the US and you WILL NOT answer the question. I’m not even getting into your pathological obsession withThe Netherlands but if someone wants to read any number of incredibly unproductive debates with this adamantly one-sided unbudging woman you can start here where Ina May Gaskin takes her on. http://blogs.babble.com/being-pregnant/2010/12/21/pregnancy-related-deaths-rising/ It’s too depressing Dr. Tuteur. You’re mean. You scare women. I’ve read your website extensively and I wish you’d seriously find a way to be productive instead destructive. You cannot criticize the home birth community for a stubborn one-sidedness and a fact-spinning agenda when you are the epitome of that kind of bullying and manipulation. I’m sorry, I’ve been polite before but I’ve had it!! I am not interested in these polarizing debates and anyone with any sense is with me.
Right on, Ceridwen. The post is not information, but a barrage of off-point data that is designed to overwhelm normal pregnant women and scare them into thinking it’s all Very Complicated and obviously they are not equipped to make even the most basic decisions about their own bodies. Hateful, misogynist scaremongering is not “debate.” It doesn’t add anything. I can’t fathom why any good person would choose to be destructive when there is so much possibility to work together to build a great system that serves women, as your blog thoughtfully does. I cannot comprehend how a doctor, whose responsibility first and foremost is to do no harm, could make her career on spewing hateful, destructive misinformation designed to undermine women.
” I can’t take it. Dr. Tuteur I’ve asked you numerous times in these pointless debates what the hell you propose we do to improve maternity care in the US and you WILL NOT answer the question.”
Excuse me, but we are not discussing what I personally propose, we are discussing an empirical claim that YOU just made and it is FALSE. You said something that wasn’t true and you need to KNOW that it wasn’t true. And you need to CORRECT it!
And wailing that it is “mean” for me to point out your falsehood is rather pathetic to boot..
Will you amend what you have written or are you going to continue to spout misinformation because you like misinformation better than the truth? And if you aren’t to be trusted on such a well known and easily verifiable fact as the terrible perinatal mortality rate in The Netherlands, why should anyone trust what you say about any aspect of pregnancy and childbirth?
If I may make a suggestion to the editors at Babble: you need a technical editor for this column. Your bloggers routinely fabricate claims and have no idea what the scientific evidence on pregnancy and birth actually show. That’s not surprising because they insist on writing about medical issues without having any medical knowledge.
I never mentioned The Netherlands.
http://www.amnesty.org/en/news-and-updates/usa-urged-confront-shocking-maternal-mortality-rate-2010-03-12
“I never mentioned The Netherlands.”
Oh, please, that it a particularly pathetic excuse.
You said:
“Midwife-led care is the norm in most of Western Europe where statistics for maternal and fetal health are excellent.”
But statistics are NOT excellent and the place with the most midwife attended deliveries has the WORST perinatal mortality rate.
There is NO EVIDENCE that more midwife attended deliveries leads to better national statistics, none, zip, zero, nada. I realize that that’s not what midwifery advocates tell each other, but what they tell each other isn’t true.
Before you write a post on a medical topic, check the MEDICAL literature to find out if what you have been told by celebrity midwifery advocates is actually true. A great deal of it is not.
This entire blog is particularly frightening because many of the bloggers spread absolute MISINFORMATION as if it were fact. Please stop!!!
“http://www.amnesty.org/en/news-and-updates/usa-urged-confront-shocking-maternal-mortality-rate-2010-03-12″
That is a politically motivated piece by an organization that wrote it with the express intent of increasing access to medical care (I sympathize with the motive, but not with a “study” that interviews midwifery advocates instead of experts in maternal mortality.
What it neglects to mention is that more than 80% of the observed increase in maternal mortality is due SOLELY to a two separate changes in the reporting of maternal mortality. Real experts on the subject are not sure that there has even been an increase, but Amnesty didn’t interview real experts, they interviewed Ina May Gaskin whose ONLY contribution to research on maternal mortality is making a quilt.
I’m sorry Ceridwen, but most of what you believe is just plain WRONG. Natural childbirth advocates wonder why obstetricians have such a hard time taking them seriously and this is why. They literally have no idea what they are talking about and make up “facts” to suit themselves.
Please correct the misinformation in this piece!
Whatever. I’m not doing it. You can see the above link for a whole endless conversation on this. But I’m not. Do you think midwifery should be banned globally? And do you think a c-section rate of over 30% nationwide is acceptable given the significant risks it brings to mothers and babies? And do you think that the maternity care system in America is working? And do you think it’s OK that poor and African American women have a MATERNAL mortality rate that is abysmal? And how do you propose we fix it? Tell us all your plan.
“Whatever. I’m not doing it.”
You refuse to correct misinformation? You refuse to write honestly about the fact that the country in Western Europe with the most midwife attended homebirths has the worst perinatal mortality?
You ought to follow the example Cathy Warwick the head of the Royal College of Midwives who was publlicly forced by The Guardian to retract her claim that The Netherlands has the lowest perinatal mortality rate when it actually has the highest in Western Europe.
“The Guardian, which conducted the interview, has already been informed of Ms. Warwick’s error. Their story contains the following notification:
This article was amended on 16 august 2010. The original reported Cathy Warwick as saying that Holland has Europe’s lowest perinatal mortality levels for babies. This has been removed from the article temporarily, pending clarification.”
Correct the article! Whether or not the statement was intentionally meant to mislead may be up for debate, but the fact remains that your article is incorrect. The mature, professional thing to do is to correct it!
“Whatever. I’m not doing it.” is just childish. Do you have any self-respect?
What do you mean correct it? I never mentioned The Netherlands or perinatal mortality. I’m sorry but you guys are missing the point.
And what I meant by “whatever, I’m not doing it” was that I’m NOT getting involved in this dialog with Dr. Tuteur again– it’s all been played out elsewhere (I linked) with all the stats being brought up over and over. That’s all. The point of my piece was to talk about bringing together midwifery and medicine.
DON’T FEED THE TROLL!!!
I was once at a party. A woman called the cops. She yelled at the cops. The cops came to the party. We were nice to the cops and pointed out that the party was in an industrial space. The woman had no right to expect quiet. They agreed. Then they said, “you know you get a lot more flies with honey than you do vinegar- and left.”
This obviously has nothing to do with birth issues. However, I stumbled upon this post and while I belive that Dr. Tuteur has an interesting point, I have to say that I am so amazed by her vitriol that I find it hard to believe anything she has to say. i read the post- it said the” majority of western europe”. I don’t know the facts but I do know that The Netherland is a very small country- and even if it does have high negative rates- that doesn’t say a lot about the continent in general. The article spoke to average people in generalities. It is meant to bring down the level of anxiety that often surrounds birth issues.
As an expectant father I read Ina Mae’s book- I laughed at the pictures of hippies holding babies- but I got the subtext of the whole thing- relax- shit happens- but if you’re stressed it’s gonna happen a lot more.
I think the same thing is true of conversation. It’s quite possible for you to bring up the issues you have without using a pedantic tone. It’s clear that you have a great deal of knowledge, it might help to spend a little bit more time being thoughtful about how you convey it.
If you want more women to take homebirth and NCB seriously, here’s what you need to do:
Get rid of the CPM and the DEM; only the CNM credential matches those of midwives in other developed countries. Have clear guidelines for defining a low-risk pregnancy (hint: if you’ve got GD, pre-eclampsia, are attempting a VBAC, have a breech baby, or multiples, you’re high risk), and require homebirth midwives to adhere to them. Make sure that there is a dedicated transport system in place for when an emergency happens (this means having a professional affiliation with both a hospital and an OB). Don’t recommed worthless, unproven remedies for treating dangerous conditions (ex., garlic as a means to clear up GBS – a baby died because he caught it from his mother who was following this protocol, given to her by her midwife).
Alright, I’ve dragged out some statistics so that pregnant women unfamiliar with your persuasive negativity will not think I just make this stuff up.
Italy, Sweden, Ireland, Spain, Germany, Denmark, France, The Netherlands and the UK all have better maternal mortality stats than the US. (see this easy to read report: http://www.guardian.co.uk/news/datablog/2010/apr/12/maternal-mortality-rates-millennium-development-goals) Dr. Tuteur I hear you on perinatal mortality in The Netherlands and I hear you on the debate about how to make home birth safest. But in my sentence I was speaking generally about maternal and fetal outcomes in countries where midwives are more involved than in the US. I think the problem is extremely complex and that there are many statistics to consider including lack of universal health care, class inequality in America, poverty-related health and obesity issues… there’s so much to discuss. My openhearted blog post today was meant to inspire people to think about how much better off we’d be if we had midwives and doctors working together.
@AT, MD: With regard to “the fact that the country in Western Europe with the most midwife attended homebirths has the worst perinatal mortality,” correlation is not causation. Perhaps you didn’t learn about logical fallacies in the course of your medical training. Not only do you attack a non-existent claim in the original post (why should the author “correct” something she didn’t say?!) but even the article you quote as support for your misguided argument doesn’t single out midwifery as the cause of the problem; instead, it says, “We found that. . . the Dutch *system of risk selection* in relation to perinatal death at term is not as effective as was once thought.” I could go on, point by point, but I won’t.
Bottom line: if you have any hope of persuading people to adopt your position, you can’t make arguments in the way that you do. A good first step in the right direction would be to consider the difference between debate and dialogue; see here for a primer: http://www.nald.ca/library/learning/study/scdvd.htm
@Ceridwen: your final comment is diplomatic and, I’m sure, much-appreciated by all the reasonable people reading; all the same, you shouldn’t feel any obligation to engage in dialogue with those who don’t seem at all interested in addressing a common problem.
Ceridwen,
Having spent most my life living in two European countries, I find this quote intriguing: “Midwife-led care is the norm in most of Western Europe “. I would really like to see a reference that substantiates this claim, and to which European countries it refers too. Europe is a set of heterogeneous countries with separate identities, customs and laws, so it always irks me when it is referred to as a homogeneous lump. I am curious to know which countries have midwifes as the norm when it comes to maternity care, and if indeed they make up the majority. Also, I have seen this claim made before, again without a reference, and I am wondering if it a meme that is doing the rounds.
(Anecdotally, all the women I know that live and have birthed in European countries had MDs as care providers.)
“This can be surprising to people in the US, as midwives are often associated with a strong opposition to technology or “medical” procedures; they are, in fact, trained medical professionals who can write prescriptions, etc. etc.”
I think you need to qualify your statement in that Certified Nurse Midwives (CNM) are trained medical professionals who can write prescriptions, etc. etc. The problem as I see it with advocating for greater midwife-led care in the US is we have two classes of midwives with CNMs being true medical professionals with the education to back up their care and direct entry midwives/CPMs that many times do not have adequate training or schooling. I have no issues with more CNM led care with standards for risking women out and I believe that might be an option to help alleviate some of the budgetary issues, but we need to get rid of the many times undereducated direct entry/CPM.
Just ignore Amy. She has an agenda and falsifies everything without a shred of evidence. In fact you should just ban her if you are even able to do so. She is a troll and is misleading so many women; don’t let her snare your following. I think the article is well-written so thank you CERIDWEN!
Wow.
It’s crazy that this article gets written with false information, and then when corrected the response is “you’re mean.”
I mean, being touchy-feely is all well and good, but pregnancy and childbirth are, um, “Very Complicated.” Seriously? You think that a lay person, or someone who has taken a few night classes, can really have enough experience to deal with the “Very Complicated” issues involved with pregnancy and childbirth– more so than someone (an OB or CNM) who has actually been medically trained to handle complications?
I don’t think that homebirth should be banned anywhere, but it seems extremely immoral to promote it without acknowledging the actual facts. Women sign up for homebirth most of the time because they do not know how dangerous it is. The risk of a baby dying at homebirth is not enormous, but it is three times the risk of a baby dying at the hospital. I think if most women were aware of this, they would not choose to put their baby at risk like that. Of course, for some women they would decide that other factors are worth taking that risk, and they should have every legal right to do so.
But, the main focus in giving women full information to make choices about their pregnancy and birth should be HONESTY. Not how nicely you say things.
Sorry SMDCM– I have always been professional with Dr. Tuteur until today. You have to understand this woman will not engage in productive dialog and I finally lost it. But I agree, in general, that civility is a good thing, hence my blog post about trying to work together. And I certainly believe good information is important. And while we’re on that topic: Home birth IS NOT synonymous with midwifery care. I was not promoting home birth. Nor even discussing it.
A couple things. Moto_Librarian, I’m not talking about home birth here, that’s a separate issue. Midwifery care is not synonymous with home birth. Cal– Thank you for commenting. I can look for some more stats on this one, here’s one footnoted article below. I have read in a number of places that midwives handle low risk births in more Western European countries than in America. And yes, Western Europe certainly has diverse countries and practices.. http://nwhn.org/routine-midwifery-care-why-not-here
Dr Tuteur, I believe you may be familiar with Cochrane Collaboration of Systematic Reviews?
A recent Cochrane Review of the literature (Hatem et al, 2008), which included 11 trials and 12, 276 women, concluded that, “Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects” (p. 2). The main benefits of midwife-led care found in the study were a reduction in the use of regional anesthesia, fewer episiotomies and instrumental births, reduced risk of pregnancy loss prior to 24 weeks gestation, and shorter hospital stay. The review concluded that most women should be offered midwife-led models of care and encouraged to request this option, exercising caution with medically high-risk women.
Amy, perhaps you should look into the MEDICAL literature, also called EVIDENCE, because we midwives certainly are.
Martie Sahuc, CNM, MS
Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S. (2008). Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2
Hear, hear! In the middle of my first pregnancy, I decided I’d had enough of my doctor and the local hospital and hired a homebirth midwife. The quality of the prenatal care I received from the midwife was FAR better than the doctor. The doctor told me “any prenatal vitamin is fine;” the midwife had a list of things to look for in a quality vitamin, and knew of a few good brands available locally. The doctor never once asked about my eating habits. He never offered me remedies for morning sickness, back pain, constipation, or any of the other discomforts that come with pregnancy. He once sent me to the hospital for monitoring, where they forgot me in an observation room. Twice in the same day. After that, I figured I was better off giving birth alone in my bathroom, where at least the paramedics would show up if I called.
Luckily, I found a great midwife and that wasn’t necessary. Also luckily, I found a pediatrician who accepts homebirth babies — that’s a strange problem in our area, with no logical explanation.
Some of us actually want a highly trained expert (that would be an OB) attending our baby’s birth – not a midwife with less training and a major agenda to push regarding “natural” birth.
April, certified midwives are “highly trained experts.” Also, your comment about the “major agenda” touches on something very important and complex. The primary reason childbirth advocates push for a woman’s right to have a non-medicated birth is not because everyone SHOULD, but because it’s actually quite hard to do in many places in America right now. You’re not interested in that kind of birth. But what if you were? Shouldn’t a woman be able to labor without medication IF possible? Midwives can easily call for c-section, inductions and epidurals. I have been studying with midwives and educators for many years and I’ve always heard about the benefits of technology from these women. In fact I’ve been with midwives fighting for more doctors/c-sections, etc in countries where there is insufficient medical/technological care. These are not women who want to just give you a juice box and make you suffer. Of course because of situation in the US now (with soaring c-section and intervention rates) people have to “FIGHT” for the rights of women who don’t want excessive technological care. And hence the “agenda” situation… This is really why I try so hard to bring together these different strands and to try and imagine a way that women could get IT ALL.
Ceridwen, your comments about MWs and MDs working together makes sense – neither should scorn the contribution of the other. For this cooperation to work constructively, though, we need to accept that the MWs need to be trained to masters level, with a thorough clinical education first (such as CNMs in the US). There is no place for the type of MW who scorns science and promotes false information about antibiotics, epidurals and caesarians. A mother needs a MW who can appropriately call in other team members when these things are required (or desired).
I am interested, however, in this comment of yours: “When birth comes around, midwives are the first line of support, tending to most mothers throughout their entire labor and delivery and newborn assessment.”
I must say that is a very idealised statement – I have heard so many first hand accounts of HBs where the MW turned up at the last minute, or after the birth had occurred. Childbirth is no paradise of satisfaction and safety, whatever “helper” you choose. The benefit of MW care, using a trained health care professional MW and within a hospital, is that you get all the benefits and minimise the risks.
CERIDWEN:
“certified midwives are “highly trained experts”
How do you figure? Especially in comparison to an OB/GYN or a CNM?
Have you ever taken a good look at the curriculum for a “certified midwife”? Highly trained experts? Yes, in flowers and fragrance maybe.
When I first got pregnant about 4 years ago (like many people) I started reading all the material I could find, in books, classes, and of course the internet. I have followed over a dozen bloggers and journals during that time and I have found the midwife/OB and hospital/homebirth debates to be very interesting (my field is psychology just for reference).
I respect your approach to people with different opinions than yours Ceridwen. Open discussion should be the rule in forums and blogs, not the exception. The knee-jerk name-calling and insults from “Joy” and it’s demands to ban another poster for disagreeing are typical of an actual “troll” and ignorant of what sites like this are for. I am glad you can go above that, stand up for yourself and post your own opposing information.
A way to improve maternity care? Stop disseminating misinformation and checking your facts might be a good start.
Why so angry? Babies are dying .
“Midwife-led care is the norm in most of Western Europe where statistics for maternal and fetal health are excellent. ”
FALSE, FALSE, FALSE, FALSE.
Mid-wife led care is NOT the norm in most of Western Europe. The ONLY country where midwife-led care is the norm is the Netherlands.
I live in Europe. I was born in Europe. I kept hearing this claim in discussions about natural child birth, and so I wondered whether I just wasn’t familiar enough with the practices in other European countries (because it sure as heck wasn’t my experience!), and was missing something, so I investigated it, and it is patently false. The ONLY country with midwife-led model is the Netherlands (and the Netherlands has the worst maternal and perinatal death rates in the entire OECD, which is why their system is being scrutinized).
Then, I went a step further. I checked out international statistics on perinatal and maternal mortality, and correlated them with their approach to maternity care. Guess what I found? The countries with the lowest mortality rates had the MOST medicalized births, many with no midwives in the system.
I am not advocating any approach based on this, but did find it interesting.
But back to the issue of the Netherlands… the picture there is pointing to the midwifery-led model. Midwives are not identifying or referring high-risk patients which are beyond their scope of practice to OBs. They do not all routinely check for pre-eclampsia for example, or gestational diabetes. Taking choice away from women — forcing them into a midwife-led system where they have to rely on the midwife to refer them to an OB — would not be an improvement in maternal care in the U.S.
That woman is such a hater. My. God.
Here is some personal experince…my US ObGyn delivery sucked, point blank. I had intervention after unecessary intervention pushed on me. Yes, baby and I were fine, but nothing that happened was really needed. It simply suited the on call doctors schedule better and I was young and didn’t know any other way and thought the dr would do what was best for ME, but that wasn’t exwctly the case. I had never seen the doctor before and nobody gave me almost constant care in labor. One nurse asked if I had ever had any miscarriages before and when I mentioned that I had lost a twin from that pregnancy, she actually chuckled and said ‘oh, that doesn’t count’!! What?? It bloody well counted to me!!
My UK midwife care was amazing! I saw the same woman at every appointment vs whoever was there as with my US prenatal care and although my midwife was out of town when I delivered, I had an amazing midwife step in and make herself familiar with my notes (I had to take them with me for each appointment and to the hospital!), she read my birth plan, my past birth history, etc, and did everything she could to help me achieve my preferred birth. She stayed in my room throughout labor, only popping out to update the board no doubt and make some notes. She believed in me when she saw I wanted a drug free delivery, rather than laughing at the idea. Although I had a slight ‘complication’ of a swollen cervix, she went above and beyond to try to help correct the problem with positions, etc, rather than rushing me to an OR which most Obs would likely do to prevent a problem. I ended up using a spinal to stop me pushing long enough for my cervix to correct itself and I went on to deliver without drugs after the spinal wore off. It was AMAZING!!
I definitely support midwifery care!! There is certainly a place for doctors, but I personally feel that in most cases, only after midwife support is exhausted! Not all midwives are created equal, but that needs to be fixed too!
Seriously, you folks don’t like to be corrected, and you don’t like spreading accurate information! Most readers are intellectually advanced enough to ignore any ‘tone’ they don’t like and can see facts for what they are. These facts are incredibly easily verifiable. What is your agenda? Why are you so invested in passing on this particular bit of information that isn’t true? It makes no sense. I am disgusted with the internet and how false information gets passed around. It causes babies to die, as another poster mentioned. Misinformation, just like what you promote, kills babies. Why are you invested in that? What is your medical background? You childbirth background? (not talking about your own births?). Why should anyone listen to you on anything, really? Furthermore, why can your readers not smell BS when they come across it, and proudly rail behind the wrong info?
Monika– I had read that the European country with the highest c-section rate, Italy, had much better maternal and neonatal rates than America.
Basically– if you want prenatal/birth care to be CHEAPER, yes, forcing patients to midwives would work. If you want it to be NICER, I’ve heard that midwives are very sweet people and take lots of time talking to their patients. If you want it to be SAFER, pushing women off on midwives is not the way to go. It may be cheaper and nicer, but it is more dangerous.
The option should be there, but encouraging it / forcing it on “low-risk” women is not going to increase safety, if the stats from other countries mean anything.
I certainly don’t think it should be FORCED on women at all!! I do, however, think it is wrong to not offer choices of midwives, less intervention (when it’s not needed! If it IS needed, by all means…use it!!!), home births and/or birth centers, etc, to those who would prefer it in their low risk pregnancy!
Not all midwives are wonderful people, but any well trained midwife should be an advocate for doing what is best for the mother and baby…the key phrases are WELL TRAINED and SHOULD BE!! For example, a well trained midwife will know the signs that you could be a bleeder and prepare for it rather than automatically taking steps to avoid bleeding by giving drugs when you don’t need them, especially if you would prefer not to have them if it’s not needed. Doctors don’t like giving you the actual option…they like to make it sound like they are sving your life or the life of your baby (even if they aren’t or even if what they are saving you from is something they caused, therefore could have been prevented!!)
If you don’t wanrt a midwife, don’t have one…but don’t try to keep them from people who do want them!
And BTW, the UK is highly midwife led!
@Ceridwen – I’m just wondering why you don’t want to talk about the Netherlands? Is it because the research about the Netherlands doesn’t support YOUR agenda? You can’t pick and choose your facts. You need to look at the whole picture before coming to your conclusions about the safety of midwives and home birth.
Here is Dr. Amy’s response to you on her blog by the way http://skepticalob.blogspot.com/2011/03/dr-amy-is-mean-to-me.html
Kearsten–
The thing is, Midwives ARE available. Maybe not in some very remote areas of the country, but elsewhere CNMs are all over the place and women are welcome to solicit their services.
The reason that OBs are the norm for pregnancy is not because there are no midwives. It’s because women WANT OBs.
The only way that I can see to make more women see Midwives instead of OBs would be to 1) make it compulsory for low-risk women to see Midwives– “forcing” them, AND 2) promote midwives as being better/safer. However, the latter is a lie, and I can understand women who have lost babies due to incompetent midwifery (CPMs) are pretty pissed off that the NCB community lied to them about the safety of homebirth midwives.
As far as non-homebirth midwives (CNMs), again, they are all over the place. Women who want to go to them, go to them.
I guess I don’t understand the article, unless it IS talking about forcing low-risk women to see midwives.
@Ceridwen – I KNOW that there are different types of midwives, and the homebirth doesn’t necessarily = natural childbirth. I gave birth in a hospital with a CNM, totally unmedicated. My issue is that there’s a huge difference between a CNM and a direct-entry midwife. Have you looked at the credentials for a direct-entry midwife? If you have, how can you possibly believe that they should be allowed to practice, particularly if you believe in the midwife model of care?
I didn’t find my natural birth experience to be transcendant or blissful – it was a nightmare of pain that ended with an obstetric emergency that would have killed me had I been at home. I am tired of hearing labor pain valorized as some badge of honor. It’s not.
@Monica,
That is my experience too. I have lived in more than one European country most of my life, and when I first heard the claim that Midwife maternal care is the norm, my first reaction was “that cannot be right”, then “maybe I am missing something”, but still I am waiting to see data to support this claim, even though I have seen it being claimed more than once.
Either a statement is true or it is not, this has nothing to do with being mean really.
I love Dr. Amy. She’s not often nice, but she’s right. And you aren’t.
Don’t promote midwives with medwives. This is a bait and switch.
When midwives “lead” that often means that they are rejecting medical care and not bothering to inform their prospective patients.
Most nurse-midwives in the US have to abandon strict adherence to the Midwives Model of Care to get jobs. They are derided as “Medwives” for effectively practicing under OB directed protocols. They function as advanced practice OB nurses, not actual midwives. Lay midwives don’t have a nursing degree in the place, so they can’t do this.
If midwives “lead” that means they would get to do things their way. The Midwives Model of Care is a do-nothing strategy embraced by those who do-nothing because they know almost nothing. It is simply a way for Birth Junkies to get their fix and get paid for it to boot! They try to demonize medical help and safety measures because they don’t know how to do them, but they just want to be around birth. They glorify natural more because all they know how to do is catch, rather than any benefit to you.
The Midwives Model of Care causes nothing but pain and death in women and babies for the benefit of the career ambitions and profits of midwives. They value a vaginal birth more than a live baby! All the moms and families get IF they are lucky enough to have no complications is horribly painful “birth experience” that they are supposed to treasure just because midwifery says so.
Since few women will willingly sign up for this non-sense, it has to be spun.
1) Now midwives are supposedly just the same as doctors for low-risk women….but you are only low risk in retrospect when everything turns out….all the ones that die really weren’t, they say….and some don’t know they are high risk, because the midwife discourages evil medical testing without telling women the risks of that, because the midwife might find out something that would loose her some business.
2) Midwives do all the things doctors do in the same situations. They refer you when needed an avoid all those unnecessareans. Except they don’t. There’s way more to treating bleeding than a shot of pit. Many referrals from homebirths are too little too late.
2) Low risk women must be believed to never have any problems and if they do, they can all survive a trip to the hospital. The reality is even nurse midwives have very little training in labor problems and hardly any in fetal monitoring and don’t save many who could have survived the trip let alone sudden emergencies. Their temporizing measures don’t work on anything but common simple problems.
3) It is the medical systems’ fault. When the problem the midwife was too untrained to recognize and ideological to seek help for can’t be denied, she goes to the hospital. The fact that an entire surgical/ICU/neonatal team isn’t waiting at the door at every remote community hospital for her and can’t bring back to life a baby smothered in utero long ago, is the failure of the medical system — not midwifery.
4) Medicine doesn’t fix any of the problems in labor, it actually causes all of them. Pain is because of lying in a bed, shoulder dystocia – ditto. Induction and epidurals? The former caused the earthquake in Japan, and the latter caused the tsunami. Ok, but at least they cause all the c-sections. I wonder why so many had these problems and died at much higher rates before modern medicine?
5) And anyone who dies would have died anyway or the parents did something wrong.
6) Any place where midwives are common has low maternal and neonatal death rates — except really they don’t.
This greedy, selfish cult is pushed by its fanantical Mean Girl driven culture — berate anyone who questions the doctrine, bully grieving parents or even c-section moms through faux-sympathetic posts, and delete anything contradictory on the web you have control over.
Who needs this?
“A recent Cochrane Review of the literature (Hatem et al, 2008), which included 11 trials and 12, 276 women, concluded that, “Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects” (p. 2)”
If you had actually read it you would see they didn’t have a very good definition or demarcation of what was “midwifery-led” and what wasn’t. And, as always, they came up with excuses (as opposed to legit selection criteria) to include what they wanted and what they didn’t.
Cochrane reviews are amateurish, cookbook junk science that agenda-promoting groups like midwives produce. No one in science takes them seriously.
Why are people making this article about something that it is not? The point is to save as many women and children’s lives as possible. The author suggests OB’s should stick to what they are trained to do which is life saving surgery, and CNM’s should do what they are trained to do, deliver babies. If these two professions can meet in the middle and put the health of women and their babies first, instead of their own egotistical desires we would all be better off. Midwives don’t always kill babies, and OB’s don’t always save them. Get a grip people.
Once again, I apologize for losing my cool with Dr. Tuteur. It’s really frustrating when you try, as I do, to propose something that’s really an attempt to bring together all that midwifery AND medicine have to offer, to find that the conversation so quickly gets really radically polarized. It’s like going to a town meeting to introduce an idea and then having one person screaming into the microphone so no one else can think straight and they all leave the discussion very rattled with little idea about how to move forward. To reiterate: Wouldn’t it be great if women could labor with a midwife in a hospital with ample support for whatever kind of birth she A) wanted and B) needed — there would be a tub AND an epidural. A midwife AND a high-risk OB. I think that this kind of care would answer problems brought up by the radical opposition. I am not proposing that we all leave the hospitals for home births, nor that we all get c-sections. Nor am I proposing we labor with untrained assistants! I really want to look at the hospitals and see how we can make changes there so that the majority of women are served.
Where does normalizing midwife-led care leave low-risk women (like me) who just prefer to be under the care of a doctor for pregnancy and birth? I have been with my doctor a long time and have a good relationship with him; why would I want to transfer to the care of someone I don’t know just because I am pregnant? You argue that midwives in Britain are “very respectful of each woman’s individual circumstances,” but what about when those circumstances include wanting pain medication during labour? From what I’ve heard about British midwives, they can be extremely nasty and condescending to women who ask for epidurals. Childbirth may not be a sickness, but that doesn’t mean it doesn’t ^&%$ing hurt for many women.
The recommendation for an increase in midwife-led care seems to me like a cynical attempt to save money by limiting the choices available to pregnant and labouring women.
“I apologize for losing my cool with Dr. Tuteur.”
Your apology is not accepted.
You are still trying to change the subject. Your entire post rests on a claim that is false. You need to change the claim that the countries in Western Europe that have a greater role for midwives have great mortality statistics. They don’t. The Netherlands has the worst perinatal mortality in Western Europe and the midwives in The Netherlands caring for low risk women have higher perinatal mortality rates that the obstetricians caring for high risk women.
Please, please, please correct your post so that it is factually accurate!
Sara–Thank you for your comment. I would definitely not propose that we not have midwife-led care that is ruled by agenda-pushing bullies who refuse to allow for pain-medication. Epidurals should always be a choice for women in birth– I have written several times about how useful and effective they can be. And I would like to see if we can’t find a way for them to be available to women AND have other options, too.
“The point is to save as many women and children’s lives as possible. The author suggests OB’s should stick to what they are trained to do which is life saving surgery, and CNM’s should do what they are trained to do, deliver babies.”
The reason so many of us object is because midwifery doesn’t save lives. It kills people. It sacrifices women and babies’ lives to line the pockets of midwives, doulas, a childbirth educators. And it makes more money for guys who run health care.
The evidence shows that when midwives are allowed to practice as they wish, they have much higher death rates.
Nurse-midwives in the U.S. have twice the death rates in home birth as they do in hospitals. Do they have twice as many unpreventable deaths? twice as sudden emergencies? No, when they are out of hospital they don’t have to be medwives, follow the medical model, any more. They do as they wish, which is catch the baby and little else. People die.
In the Netherlands, high risk hospitals births with doctors had lower death rates than supposedly low risk home births with midwives.
And it doesn’t even save money. Midwives charge about the same as insurance pays for a hospital delivery. And no, c-sections do not get paid substantially more. Again, the Netherlands, where midwives are prevalent, has studies that show midwifery did not cost less when you added in the all the neonatal intensive care and such from taking in their mistakes, oh I mean, trying to avoid the unnecessarean.
“Wouldn’t it be great if women could labor with a midwife in a hospital with ample support for whatever kind of birth she A) wanted and B) needed — there would be a tub AND an epidural. A midwife AND a high-risk OB.”
What if the kind of birth we want doesn’t involve a midwife? What if we don’t trust them? What if we don’t think they are any good at monitoring the health of our babies in labor and calling for help in time? What if we don’t believe they can handle a sudden emergency? What about us?
You have a rather skewed idea of what the “majority of women” want. It’s more like what you want.
And BTW, if birth is such a normal event, one where we don’t need a doctor, why do we need a midwife?
What on earth is going on here??? Amy Tuteur and her army of sockpuppets have taken an extremely reasonable, middle-of-the-road article and made it into some sort of epic battle.
Also, Dr. Amy: your meanspirited blog post about Ceridwen made it pretty clear that regardless of who is correct on the issue (and I have no particular agenda myself), you are an extremely nasty person. You make your side of the argument look very, very ugly, which does not help your agenda one whit. Nobody likes a bully.
“Nobody likes a bully.”
I’m not sure why natural childbirth and homebirth advocates think that it is “mean” to point out when someone makes a medical claim that is flat out false. All journalists have a responsibility to make sure their articles are accurate.
This is an example of a problem that poisons the natural childbirth blogosphere. Natural childbirth advocates believe any challenge is “mean.” They blithely write and post complete falsehoods and rather than regretting the misinformation they spread, they resent the people who point out the lies.
In REAL professions, accuracy and honesty are crucial. Evidently in the world of natural childbirth and homebirth advocacy “being nice” is more important than being factually correct. This should serve as an object lesson for anyone who thinks she can get “educated” by reading natural childbirth or homebirth websites.
Natural childbirth and homebirth advocates don’t merely print falsehoods as facts, but even after they are forced to ACKNOWLEDGE (as Ceridwen has been forced to do) that they have included incorrect information, they refuse to correct it.
Amy, it’s not your claims that make you a bully, it’s your behavior.
In other words: unless you behave in a civil manner, which you don’t, you will be dismissed as a hostile wingnut, which is your reputation across the internet. I mean, heck, I’m not anyone’s mom, I just read momblogs because I’m involved with parenting publications, and *I* know your reputation inside out. And nearly everyone thinks you’re a hostile wingnut.
If your claims are true, and if you truly believe that you have a message that will save babies’ lives, then change your tone. Otherwise, nobody will listen to you. At this point, hardly anyone does.
“Amy, it’s not your claims that make you a bully, it’s your behavior.”
Is it my behavior or is it the fact that I am a woman who behaves in exactly the same way as any man might do? It seems to me that the issue of “meanness” says much more about stereotypes of how woman are supposed to behave than about anything else.
When was the last time you called a male writer “mean” when he pointed out inaccuracies?
I argue with male trolls all the time, Amy. I’m an active, organized feminist who marched for women’s rights just earlier this month. Your Sarah Palin-esque “anyone who objects to me must be sexist!” nonsense won’t fly with me.
And I’m aware that I’m not being very nice here either. But hey, I’m not the one who claims to be providing people with information that saves lives – that’s your game. The fact remains: if you care as much about saving babies as you claim you do, you will only have credibility if you change your tone. Do you care about saving kids, or just winning an argument or preaching to people who already agree with you?
“I argue with male trolls all the time, Amy.”
I didn’t ask you if you argued with men. I asked you whether you called them “mean” when you disagreed with what they said.
Of course I call men mean when they’re being mean. Your gender has nothing to do with the argument. You ARE, objectively speaking, unkind to people. You call well-meaning people liars (when, at worst, they may simply have different facts at their disposal, or different beliefs than yours). You flood blogs with attacks. And you created an entire blog post attacking Ceridwen for no reason that I could ascertain, other than to be nasty.
I’ll ask you again: do you care about saving lives? Then you need to change people’s minds, and your approach does not change people’s minds.
I’m very curious about some of the actual fact seeking/stating/checking in this thread.
“Midwife-led care is the norm in most of Western Europe where statistics for maternal and fetal health are excellent.”
Can you cite your source for me please? That it’s the norm? What percentage means the norm?
… sorry, just to add, because I thought the Netherlands was the top at 30% which doesn’t to me seem to be “the norm” with other countries lower. But I would be interested in being proven wrong.
“You call well-meaning people liars (when, at worst, they may simply have different facts at their disposal, or different beliefs than yours).”
1.) Well-meaning people ARE liars if they disseminate information that simply isn’t true. If someone points that out and backs it up with correct information in a straight-forward way and wants the lie corrected…well, I just don’t see that as being “mean” or “nasty.”
2.) What do you mean “different facts?” Do you mean “not all the facts,” “facts read on a blog somewhere on the internet so it must be true.” or “facts that I haven’t personally checked out but are possibly true?” The only reasonable thing to do when confronted with additional facts that show the inaccuracy of the statement is to retract and/or correct the LIE!
3.) “different beliefs.” Oh, well as long as two people have different beliefs the facts don’t matter. Right? We aren’t talking about religion here. We are talking about matters of life and death of mothers and babies!!! Who cares about whether or not I believe in midwives or OBs or epidurals or homebirths or aliens or unicorns? I want the FACTS before I make a decision.
By the way, I don’t get a mean or nasty tone from Dr. Amy. But I’m a person that appreciates a calm, straight-forward manner rather than a labile emotional and hysterical outburst. If only I could get my toddler to grasp this concept.
@Shandra — the 30% in relation to the Netherlands is the rate of homebirths. It is the highest rate of homebirths in any western developed (e.g., OECD) country. No one else is even close.
However, in the Netherlands, ALL maternity care is channeled through midwives, which is what the author of this blog is proposing. When a woman is pregnant, she goes to a midwifery practice. If the midwives determine that she has any sort of complicating factors, she is risked out of their practice and referred to an OB. A woman cannot self-refer to an OB. Thus, it is a midwifery-led system.
This is not the case in any other system (although in the UK an expectant mother would generally see midwives unless referred to an OB for special concerns as part of the NHS system, she could always go private, and see an OB directly).
How about New Zealand? About 80% of births are are managed by midwives (CNM-equivalent, integrated to healthcare system), and the homebirth rate is close to 10%. It’s exactly the kind of system Ceridwen is advocating. (Notably, it is also a country with a national healthcare system, which is often cited as a cause of the “bad” U.S. statistics.)
Yet perinatal mortality is 10/1000, substantially higher than US. Maternal mortality is about 14/100,000 (compared to US 17/100,000), but the small absolute numbers mean that it’s probably very close to equivalent — it bounced between 25/100,000 in 2006, 17/100,000 in 2007, and 14/100,000 in 2008 . That report also states, “The intrapartum stillbirth rate (0.49/1000) continues to be of concern as the majority of these babies are term and not small for gestational age and therefore may have been preventable deaths”.
It’s a direct contradiction of the assertion that midwifery-led care produces better statistics than the U.S. system.
Thanks for clarifying Monika; I hadn’t realized that was the system. So are midwives the default in other western european countries?
I’m still trying to figure out why it would be even ethical to force women to see midwives rather than doctors.
Because, yes, under this you would be forcing them.
We already have midwives in America. CNMs are all over the place. Women have that option. Many women exercise it, but most would rather see a doctor.
So what is the point of this post, other than saying that it would be safer to force women to see midwives instead (which the facts do not support– actually it would be more dangerous), and that it would be cheaper (which is likely, but at the cost of the lives of women and babies).
@KEARSTEN “BTW, the UK is highly midwife-lead”
Incorrect, given that less than 1 in 10 women will delivery in a midwifery-led ward, according to the King’s Fund study.
The misinformation and generalizations about childbirth are exhausting. Women deserve facts. Real facts, not stuff you heard somewhere on some other web site or in passing on the news, or from your friend the midwife. And when there is real evidence around, not the “my labour went badly because of the evil doctor”, or “my baby died because of my stupid midwife” anecdotes, THEN women will actually be able to inform themselves correctly. Real evidence has already started amassing, including excellent data from the Netherlands (which keeps coming up simply because it’s so unique, comprehensive, and well-studied), and the Wax (2010) study (which is in fact about homebirth more than midwifery, although there is a distinct relationship.) It is criminal that this information exists for CPMs in the US but MANA has declined to make their database available (except to researches looking to promote MANA).
If a woman wants to choose a particular model for care, and particular place for birth, I think that is her absolute right, and responsibility. But to do so without correct information, by relying on unverified and fallacy-containing posts like this one is inappropriate.
Ceridwen isn’t talking about forcing women to do anything — her post is clearly about the opposite: allowing women to have more, and better, choices. It’s true that there are midwives in the US, but women often *don’t* have that option. In fact, in NY we’ve seen that when enough women choose midwifery care over OB for their intrapartum care (and “enough” is still under 10%), the physicians of the hospital vote to deny midwives hospital privileges AT ALL. Which means that as a trade group, it’s physicians who work to “force” women no option but OB care unless they want to do a homebirth.
This whole thread has gotten off the point Ceridwen is trying to make: improved care for women means we need to think about how to *change* things to provide more options and more individualized options.
I think this article is right on.
I am not hippie dippie. I didnt have incense burning in my birthing suite. there was no whale music playing. I worked in the corporate health care consulting field for a decade. I love science. I love data. I respect clinical trials. My husband actually wrote a major report on C-section rates in the US. We did our research and concluded that having an OB for standard prenatal and delivery management was not necessary or preferred. Instead we chose to go the midwife route. It made the most sense; it was lovely; it was safe; it was cheap and it was appropriate care.
I gave birth in Australia five years ago in a model I think should be replicated here. I opted for a midwife-led “birthing center”, which was housed within a full service tertiary hospital, replete with labor ward and NICU. Anyone who was deemed low-risk (which is most of us) could chose the birthing center. The OB was only brought in for a consultation at the beginning of prenatal care and if there were any major complications during pregnancy. Otherwise all prenatal care was provided by the team of midwives.
When it came to the day of delivery I went to the birthing center and went through an agonizing drug-free labor with these lovely, competent midwives helping me through the experience. Because there are no unnecessary machines beeping away (most of those monitoring machines have been proven in trials to be unnecessary for low-risk births) the rooms werre spacious and calming. I could wander around as I needed because there were no wires or IVs. After a very intense transition (I went from 2 to 8 cms dilation in 40 minutes!) I begged for an epidural. So GUESS WHAT HAPPENED? I got walked down the hall (about 15 PACES) into the hospital’s traditional medical labor/delivery ward. They hooked me up with all the bells andf whistles and got the epidural going (but it was too late and I “pushed thru the pain.”)
Bottom line is this: Midwifes are just as capable as OBs of handling the majority of births. This is a proven fact. They are much cheaper and their outcomes just as good. We need this model in a country so overwhelmed by health care costs.
If you are nervous about being far from an OB and/or a NICU then the birthing center model is terrific. The medical establishment is right there down the hall should you need/want it.
“This is a proven fact.”
Great! The it ought to be easy for you to provide the proof. Let’s see it.
If you want some citations:
1) Ceridwen’s entire post was based on a study arguing for midwife care. There’s a reference point right there.
2) http://linkinghub.elsevier.com/retrieve/pii/S0140673695112073
3) http://www.bmj.com/content/312/7030/554.abstract
4) http://www.bmj.com/content/309/6966/1400.abstract
From my research on this I concluded that for LOW RISK women midwife care is as safe as specialist-driven care. I believe in a model where midwife-led birthing centers are housed WITHIN hospitals. I am not (and nor is Ceridwen) launching a campaign to abolish choice for women. We are not saying there should be no OB care. We are not anti-epidural or anti-intervention.
My argument and the argument put forth in this post is a very MIDDLE GROUND approach. Midwives provide care for low risk women but WITHIN a framework that provides immediate access to specialty care and intervention should it be NECESSARY.
And this from the NEw England Journal of MEdicine:
We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections ( http://www.nejm.org/doi/full/10.1056/NEJM198912283212606 )
Some more studies:
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb09969.x/abstract
http://journals.lww.com/lww-medicalcare/Abstract/1979/05000/Perinatal_Care_and_Cost_Effectiveness__Changes_in.4.aspx
Have you read those papers, Catrin? Not the abstracts, but the papers themselves? If you haven’t read a paper then you are not entitled to cite it.
When you do read them, please get back to us on where they took place, when they took place, how many women did they involve (was there enough statistical power?), what was the education level of the midwives (master’s, university degree, post high school certificate), who were the midwives being compared to (obstetricians or family practice doctors), were they randomized, if not how was risk adjusted, actual findings, and statistical significance. Oh, and don’t forget to tell us how each paper compares with the many other papers in the field that look at the same thing.
Lay people generally do not realize that the publication of a scientific paper does NOT mean that it is true. It merely means that the paper is qualified to be included in a discussion of the literature. In order to determine if the paper “proves” anything, you MUST read the paper, you MUST analyze the results, and YOU must compare it to the rest of the literature on the topic.
That’s what doctors and scientists do.
Amy, I agree with the above. You are right and I know all of that. No longer at my consulting firm so don’t have access to the full papers. So, NO, I do not have the full studies at my fingertips. But I know many physicians, both personally and through my work. For every one of you (and I think you may be one of a kind!) there is another doc who is willing to accept that this country indeed needs an overhaul in the way it approaches birth.
I am not a doc myself so I have to take a leap of faith and put trust in some of my friends and colleagues here. They are willing to concede that the US model of care, which is specialist driven (therefore high cost), is not ideal in every situation. The top-heavy system in the US is largely a function of our reimbursement model, our risk-averse litigious culture and the resulting malpractice insurance costs. Not to mention how expensive a medical degree is. If I were an OB I may be reluctant to give up care to midwives! Hell, you are saddled with huge med school debts, you pay massive malpractice insurance fees and your reimbursement is stagnant at best!
BUT, even with all those caveats, my OB friends concede that midwife care for LOW risk women (WITHIN a framework of specialty care as needed) is just as good. I can only assume that these docs, like you, like to use randomized double-blind controlled trials to back up their beliefs.
I love specialty care and am proud to live in a country with the Mayo clinic, Hopkins, the Cleveland clinic, etc at my disposal. I am relieved that I have top OBs at my disposal should I ever need them. I am glad that interventions are readily available to me should I ever need them. But until I need them I would prefer to see a GP or a midwife for my standard care.
The reason I asked those questions, Catrin, is because anyone who provides medical information has an obligation to be both accurate and precise.
It is true to say that there is considerable scientific evidence to show that low risk patients managed by midwives who have an undergraduate +/- master’s degree in midwifery (European, Canadian and Australian midwives as well as CNMs, but NOT CPMs) comprehensively regulated, working within a highly integrated system, having access to an excellent transport system have outcomes equivalent to comparable risk patients managed by doctors in hospitals.
But that does NOT mean that there is any evidence to support a midwife LED system where midwives are the caregivers who determine who and when patients will be triaged to doctors. In fact there is no evidence to show that midwife led systems have better outcomes and the existing evidence suggests that the outcomes are worse. That’s why Ceridwen’s claim is flat out false and she ought to change it to reflect the existing scientific evidence.
Being precise is critical because:
American homebirth midwives (CPMs) have terrible outcomes.
When midwives work outside the hospital, outcomes are not equivalent to the hospital unless there is a dedicated transport system in place and the distance to the hospital is short.
Midwives only have good outcomes when they work with planned physician backup, and that back up must be easily accessible.
Midwives MUST consult with physicians regularly through pregnancy and during labor for ANY deviation from the norm.
All standard testing must be done.
Ceridwen’s claim about midwifery led care is neither accurate nor precise. In fact, it isn’t even true.
Here’s what I’m getting. I read and re-read Dr. Amy’s original post. She’s blunt, yes, but other than using the words “that is flat-out false” her original post really just cites studies and statistics. I don’t see how that makes her mean or a bully. I don’t see how this makes her side of the argument look negative to anyone who reads it. It’s just facts. They don’t support your agenda, so I guess that makes you mad. I suppose she could have taken out the words “flat-out,” which would have been a little gentler, but all those annoying facts would have still been there.
Dr. Amy’s tone only got a little “nastier” when all of you started accusing her of being “mean” and a “bully” and of “falsifying everything without a shred of evidence” (wow, it’s so easy to say that about facts that don’t validate your own personal opinion, isn’t it?) With all those insults flying around I’m not at all surprised to hear her defending herself and becoming a little abrasive in the process. Frankly I’m impressed that she’s kept as cool as she has. I’m not sure I could have.
Dr. Amy: people with the facts on their sides don’t need sockpuppets. Nice try, though.
There’s lots of evidence supporting midwife care for low risk women and lots of evidence for the prevalence of midwives in western Europe, though clearly things can improve per the King’s Trust analysis. A report was issued today from The Association Of Reproductive Health Professionals.(http://www.arhp.org/publications-and-resources/contraception-journal/march-2011) It’s heavily footnoted, in case anyone cares to check out the references, but here’s an interesting quote, “This overuse of medical procedures increases injuries as well as costs. Indeed, we are unaware of any study indicating that the 56% increase in the rate of surgical births from 1996 to 200827 as improved outcomes. However, there are data to show that the overuse of medical procedures has increased both infant28 and maternal morbidity.11, 29…. Countries such as the United Kingdom and the Netherlands, where women have routine access to woman-centered care and where there is better match between medical need and the number of medical interventions performed, have fewer deaths and lower health care costs.” It’s always interesting to look at other examples from other countries, it’s never as simple as grafting one healthcare model onto another country. But I do think the main point remains that women should not have to choose between a home birth and a hospital birth in which medical interventions are overused and the doctor does not show up until the end of labor. It’s more than reasonable to think that a combination of very well-trained and amply supported midwives and obstetricians would provide the best care for women in pregnancy and birth. As has been pointed out in this comment thread, often the first line of “care” a woman receives when she arrives at the hospital in triage is a resident or labor and delivery nurse not a well-trained midwife familiar with her medical history. The system is not set up to make it possible for doctors to support women in labor continuously.
Midwife care is readily available across the USA to those who choose it. Fortunately we also have the option of OBs if we choose unlike the UK where women have less choice. Further, midwives do stop stay with one laboring woman throughout her entire labor. They have multiple patients and sometimes do not make it until the end of labor or pop in and out occasionally then return at the end.
” As has been pointed out in this comment thread, often the first line of “care” a woman receives when she arrives at the hospital in triage is a resident or labor and delivery nurse not a well-trained midwife familiar with her medical history.”
Do you have stats for how “often this happens? I doubt it is all that common for most women who got prenatal care and formed a relationship with a CNM or OB
Maura, you make a great point that midwives aren’t always with women either and I’d love to see your stats about that. Perhaps another reason to really look at our system and see how we can change it! Maybe we should make it so that we do have well-trained midwives *and* specialist obstetricians readily available to pregnant and laboring women.
This may be helpful to some of you unfamiliar with scientific studies:
- Determining whether midwifery care (home birth or hospital birth) is extremely difficult to do, because women would not agree to be randomly assigned to a home birth or a hospital birth. The same goes for pain relief during labor. Without random assignment of subjects, it is impossible to know what the true outcomes are without confounding factors.
- Studies that involve 100, 200, 300 subjects are not reliable when it comes to determining safety in terms of maternal mortality or perinatal mortality. Since mothers and babies die in childbirth so rarely in developed countries, the number of subjects would need to be much higher in order to be an accurate reflection of the population.
One more tip:
1. It is good to keep in mind that much of Western Europe (the UK, Germany, Italy, France, etc) have universal health care coverage. This potentially translates into earlier prenatal care, which has been shown to greatly affect the outcomes for mother and baby. C sections are NOT the only reason the US has higher rates of maternal mortality than many other developed countries.
Beth (Epidemiologist)
*Determining whether midwifery care (home birth or hospital birth) is safe is extremely difficult to do…
That’s what I mean to say!
I live in Germany. And while we certainly have midwives, they are HIGHLY trained (unlike those “certified midwives” you have”) and as a rule, they attend births AT THE HOSPITAL where they work together with the OBs and where it’s possible to do a cesarean at the snap of a finger if it should become necessary.
And as for interventions like epidurals, fetal heart monitoring, etc.? The midwives I know and who I have met while being pregnant / giving birth where pretty much in favour of it.
And my birth experience? It was great ^_^ Very relaxed, very comfortable and a totally joyous thing.
Danielle I’m so glad that you’ve found Tracy and that she is ceptlemoly your style! That’s why I specified that I was comparing my midwife to my doctor. Your doctor sounds like “The Awesome!”