Ch. 13 ~ The Obstetrical Franchise In America: The 20th century Gender War btw Midwifery and Obstetrics (spoiler alert – obstetricans won, midwives and childbearing women lost!)

by faithgibson on January 21, 2025

in Contemporary Childbirth Politics

Chapter 13 ~ Putting Humpty-Dumpty Back Together Again

The theme of this chapter is to reunite the story that was split asunder in the first 10 chapters. At issue is the rehabilitation of the maternity care system, that is, science-based birth care as the foremost standard for healthy women with physiological management, regardless of the status of the caregiver (physician or midwife) and regardless of the location of the labor (home, hospital or birth center).

As a standard, physiological management includes social and psychological support and the big question is how one does that in a system currently organized around high-end, very profitable technologically-based care.

It is also necessary to describe what it looks like (how a physician would conduct him or herself) and how one bills for birth as a biologically event supported physiologically and managed under the rules of aseptic technique, instead of conditions of “surgical” sterility.

And finally, how does one end the political and social controversy and leave us a stable condition that empowers consumers, midwives and socially conscious citizens to make the necessary changes?

Simplifying the Situation by Simplifying Language

{Maybe should be moved to ???}

Obviously one does not have to be a midwife to use the principles of midwifery – anyone, male or female, physician, nurse or midwife may employ these sound strategies. In the 20th century the false association of ‘midwifery’, that is, the discipline of physiological management, with the person of the midwife as an enemy of the medical profession, continues to cause mischief even today. Most obstetricians don’t want to be thought of as practicing ‘midwifery’, but they can operate out of the principles of physiological process, and use physiological management for normal labor and birth. A simple vocabulary correction would permit us to disengage the type of care from the type of caregiver, which would make the conversation about 21st century science-based birth services more effective.

From Time Immemorial, the word ‘midwifery’ referred to that entire spectrum of care for normal pregnancy and childbirth, and those who provided that type of care were either ‘midwives’ or man-midwives. Mothers-to-be considered themselves to be ‘maternity’ patients who received ‘maternity’ care. The idea of obstetrics as a medical and surgical practice was first introduced to provide care in abnormal situations only. As providers of medical services, doctors no longer referred to themselves as ‘man-midwives’ but rather as obstetricians.

By the 1930s, all care for pregnancy and childbirth, whether for normal or abnormal circumstances, was called ‘obstetrical care’. By this time the idea of midwifery and midwives had been erased from the medical profession’s vocabulary. Until the last few decades, hospital accommodations for all categories of childbearing women were called “maternity wards”. Now days all childbirth related services have been subsumed into the idea of “obstetrical”, with no one speaking of ‘maternity care’, maternity patients or maternity wards.

I suggest that the category of care to healthy women with normal pregnancies should properly be called maternity care and provided to maternity patients. The proper care for healthy women is physiologic. In this model, it would be the status of the mother  — healthy vs. states of disease or complications – that organizes the type of care provided, rather than the status of the care provider. It is not logical for obstetricians to provide ‘obstetrical’, ie. medically/surgically interventive, care to healthy women.

Maternity care, whether it is offered by a male or female, physician, nurse or midwife, would still be physiological management because that is the foremost standard of care for healthy woman. With this new vocabulary, an obstetrician could provide maternity care to healthy women and obstetrical care to those with complex situations or complications.

Safe Maternity Practices for the 21st Century

The challenge for the 21st century is to bring about a fundamental restructuring of maternity care in the United States. This is an economic as well as a humanitarian issue, as only the ‘social’ model of maternity care is designed to address the social, psychological, educational and developmental needs of new mothers and their families. Worldwide, the global economy depends on the use of physiological principles and low-tech, inexpensive methods of midwifery care for normal birth services to retain its competitive edge. The US must also utilize these safe and cost-effective forms of care in order to compete in a global economy.  In the US the social model of childbirth, which depends squarely on physiological management for its success in providing care to healthy women with normal pregnancies, must become the foremost standard of care. At least 70% of the childbearing population is healthy and have normal pregnancies.

Under this system, management strategies would be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife). At present, who the woman seeks care from (doctor vs. midwife) determines how she is cared for. In a rehabilitated maternity care system, physiological management for healthy women would be the foremost standard, regardless of the status of the caregiver (physician or midwife) and regardless of the location of the labor (home, hospital or birth center).

A Win-Win System and the Rise of Personal Preference of Individual OBs

After obstetrical education is freed from the need to think of birth as always and only a surgical procedure, a spectrum of opportunities will open up.  If obstetrics were an integrated, holistic discipline, the principles of physiological management would be part of the bedrock of its practice. This would not only include the physical aspects (right use of gravity) but also the psychological and social, thereby creating a ‘new frontier’ of practice options. Depending on personal temperament, obstetricians would get to choose between the obstetrical complication end of the spectrum or the ‘people part’.  Many OBs like developing one-on-one social relationships with the patients they see and are even somewhat envious of the relaxed schedule that midwives enjoy. These physicians like providing ‘maternity’ care and the opportunity to develop a genuine relationship with their maternity patients, provide care at a slower gentler pace, without all the stress and malpractice anxiety typically associated with a busy obstetrical practice.

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What Healthy Woman Maternity Care in a Hospital Setting Would Look Like

To Midwife, the Verb

This describes the active ‘verbs’ of maternity care based on the theory of simple kindness, which propagates ‘omni-directional’ verbs. This is a personal construct of mine based on the idea that “love does not kill to save”, and observes that kind verbs are omni-directional or reversible. For example, if we say “I help you” OR “you help me”, as the object of that verb’s action, my ‘safety’ is the same at either end – one of us helps, the other is helped, and all is well. However, if we use the example of “I cut you” (as in episiotomy or C-section), I really will not want you to cut me as a casual act. It will NOT be OK with me to be cut, while it may be OK with me do the cutting.

If you examine the customary “verbs” of midwifery – support, care, treat with respect, etc — they are fundamentally omni-directional, where as many routine interventions of “usual and customary” obstetrical practices entail the use of forcible means or surgical penetration. They seek to protect the doctor and hospital at the expense of the mother and baby. That is fundamentally unethical and must be addressed.

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How to Make the System work for everyone Re-write for “Voice” i.e., tone of reconciliation

The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is the safer and most cost-effective form of care for a healthy population. This leads us to the natural and compelling conclusion that our current hospital-based maternity care system must be rehabilitated.

A newly formulated national health care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. That standard must be based on criteria arrived at through an interdisciplinary process that INCLUDES the traditional discipline of midwifery as an independent profession and integrates the input of childbearing women and their families into the process.

It is especially important to include testimony from those families who had complications following cesarean surgery or who found it virtually impossible to arrange for a subsequent normal labor and birth after a cesarean (VBAC).

Obviously changes in medical education and obstetrical practice will both be necessary, as well as changes in the way compensation for maternity care is calculated. Physicians who provide maternity care to a healthy population would be required to either utilize the successful strategies of physiological management themselves, cede the care of healthy women to those who do, or obtain truly informed consent for substituting medicalized obstetrical care with its well-documented dangers. Fully informed consent would require true informational transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedure.

Scientifically correct information must be routinely provided on the limitations and problems associated with the medicalization of labor – i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed.  This severely limits or eliminates access to time-tested strategies of physiological management and right use of gravity, thus increasing artificial stimulation of labor and operative delivery and all their associated complications.

Obstetricians must provide valid information during the last trimester of pregnancy that includes the short and long term complications associated with major medical and surgical procedures performed during the labor – continuous electronic fetal monitoring, restriction of oral nourishment, IVs, labor stimulating/inducing drugs, off-label use of drugs (ex. Cytotec), narcotic medication, epidural anesthesia, indwelling bladder catheters, episiotomy, vacuum extraction, forceps and a 27% cesarean section rate. The benchmark for this transparency should be the same information about complications that is reported to physicians in the scientific literature and obstetrical trade papers, such as Ob.Gyn.News. This should be faithfully restated for childbearing parents in lay terms that are appropriate for their concerns.

Transformation in our national maternity care policy would require that:

  • Medical educators learn and teach the principles of physiological management to medical students, interns and residents
  • Practicing physicians learn and utilize these same skills
  • Fully informed consent for obstetrical management of healthy women be provided that includes true informational transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedur.
  • Hospital labor & delivery units be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain for hospital-based midwifery practice to do so at minimal expense to themselves
  • Third party payers fairly reimburse all practitioners for the professional’s time spent facilitating normal childbirth, which helps avoid the need for medical and surgical intervention, as well as reimbursing for medical and surgical procedures
  • Tort law (medical malpractice) reform be enacted so that doctors are not inappropriately judged by outdated medical criteria that are not evidence-based

In a rehabilitated maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship. Appropriate maternity care would be provided by all three categories of professionals in all three birth settings as appropriate – hospital, home and birth center – without prejudice, controversy or retaliation against the childbearing family or against other care providers. By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs or that waste our economic resources.

This rehabilitative process could be launched by the California state legislature or a public policy organization such as the Pew Charitable Trust which could convene a blue-ribbon panel consisting of scientists from all the pertinent disciplines – public health, epidemiology, sociology, anthropology, psychology, biology, child development, law, economics, midwifery, perinatalogy and obstetrics. Such a highly respected forum would study these problems and provide unbiased, fact-based news for the press and broadcast media to report.  This public exploration must include listening to childbearing women and their families as a class of experts in the maternity experience.

Such a panel would produce interdisciplinary recommendations for a reformed national maternity care policy. This would include methods to reintegrate midwifery principles and practice into this expanded system of maternity care.

Ultimately such exploration and recommendations would result in legal and legislative changes affecting doctors, hospitals, midwives and the health insurance industry. Such a system would then be respected and used equally by all maternity care providers with the backing of hospitals, health insurance and medical malpractice carriers, and state and federal reimbursement systems (Medicaid / MediCal) etc.    

Unfinished Draft  /// End Section Conclusion / wrap-up of political controversy

Midwives and Obstetricians — Enemy or Friend of The State?

In a democratic society the function of government is determined by consent of the governed. Sanctity of life and protection of vulnerable populations– infants and children, pregnant women, the ill, injured, disabled, the mentally incompetent — are all considered to be the legitimate duty of The State. At our insistence, elected representatives pass laws authorizing public agencies to do this – law enforcement, child protective services, medical boards to name a but a few — and we hold agents of the government responsible for achieving those goals.

In the early part of the 20th century, the obstetrical profession considered its care of childbearing women to be an extension of the State’s obligation to protect the vulnerable. This perspective was originally based on the notion that epidemics of puerperal sepsis and maternal deaths were inevitable occurrences (since the needs of medical education required that childbearing women be aggregated in institutions). Given that as the background, puerperal sepsis had to be vigorously controlled via the conduct of childbirth by under surgically-sterile conditions. The two US titans of the 20th century obstetrical profession – Drs DeLee and Williams — were personally convinced that normally childbirth was inherently pathological.

This conclusion was fueled by their observations that even (read ‘especially’) when childbirth was conducted as a sterile surgical procedure by trained obstetricians on women under general anesthesia, complications still abounded. According to their theories, the doctors were not at fault (!), so it must be the women themselves or the nature of their biology that was to blame.  Given this as a starting point, it was only logical for the obstetrical profession to conclude that their profession was an extension of the government’s role of beneficent to and protection of vulnerable populations. By that definition, the physiological principles of midwifery was assumed to be a deficient and old-fashioned form of care, an ‘enemy of the state’ no longer to be tolerated by ‘modern’ society.

In this equation, the natural conclusion is simple. If the obstetrical profession is a ‘friend’ of the State, helping to carry out its functions, then the entire midwifery profession (and all its practitioners) must be an enemy of the state. This describes the present-day relationship of organized medicine, state legislatures, court systems, state medical board and society in general to the principles of physiological care, midwifery as a discipline and midwives as providers of maternity care.

Its assumed that the obstetrical profession saves babies, thus the failure to use the care of the obstetrician is to risk the unnecessary or ‘preventable’ death or disability of vulnerable women and their unborn/newborn babies. What this adds up to is a ‘crime’ on the part of the parents and malpractice on the part of the practitioner for any failure to make liberal use of electronic fetal monitoring, labor stimulating drugs, conduct of birth as a surgical procedure, instrumental or operative delivery, etc. Under this system of medicalization, physiological process and midwives are both enemies of the state.

However, when this odd and unexamined assumption – an unproven hypothesis — is opened up to the rigors of unbiased scientific inquiry, the conclusions arrived at are dramatically, startlingly different. In fact, they are the opposite. Scientific sources make it clear that routine obstetrical interventions and birth as a surgical procedure for healthy women are always more dangerous than the use of physiological principles, conjunction with traditional social and psychological support and appropriate access to obstetrical services for complications.

The science-based standard of care for healthy women is physiological management.

Period.

Physicians who provide maternity care to a healthy population are required to either utilize the successful strategies of physiological management themselves, cede the care of healthy women to those who do, or obtain truly informed consent for substituting medicalized obstetrical care.

Period.

The obstetrical profession became a prisoner of their own project when it set up this extreme contrast, one that identified itself as a ‘friend’ of the State, based on its potential for protecting mothers and babies. Since institutionalized medicalization and obstetrical intervention for a healthy population isn’t able to deliver on that promise, it is another example of the double barreled shot gun with one bore twisted back and aiming straight at the conventional practice of obstetrics. Defined by its own criteria, the judgment is harsh.

The Real Enemies of the State Are Ignorance, Prejudice and Disease States

However, nothing is to be gained by simply making obstetrics the bad guy. First, it’s not true. Second, generating new controversies and hard feelings would be a stumbling block, preventing the achievement of very worthy goals. So lets wipe the slate clean and just start over. The real enemies are neither doctors nor midwives. They are ignorance, prejudice, disease states and medical complications, congenital anomalies, lack of access to appropriate medical services and a tort law system that holds us all hostage to unnecessary medicalization and particularly victimizes the obstetrical profession, and indirectly, the rest of society.

Physiological Management for Healthy Women –

The Bell that Can’t Be Unrung…

Obstetrics as a scientific discipline must once again learn, teach and utilize physiological management for healthy women. To do that, midwives are suggesting, in the strongest of terms, that an exchange of expertise is in order. It is as much the responsibility of physicians to be familiar with the time-honored philosophy, principles and skills of midwifery as it is the duty of midwives to know the principles of anatomy and asepsis. Midwives are in agreement that modern obstetrics has much to teach and much to contribute to the wellbeing of the families it serves.

The Late Dr. Galba Araujo, formally professor of obstetrics from Brazil, in an article urging an “articulated model of midwifery” into contemporary obstetrics stated:

“We have learned much from the traditional (midwife) and respect is mutual between our parallel groups. We have learned to teach our (obstetrical) students less invasive delivery and above all, to use the vertical position for the mother. Perhaps this is the most valuable lesson among the many we have learned.”

Midwives have availed themselves of both formal and informal study of obstetrical science. Likewise, the honorable but unassuming traditions midwifery — the art of being “with women” — the quietness of spirit, the patience with nature, the intimacy skills which serve childbearing families so well are also of great value to the bio-medical sciences. We believe that physicians cannot begin to examine their prejudices without specific information on the nature of these principles and the opportunity to build personal and professional relationships with those who practice physiological management of normal birth.

In spite of the fears of many within the obstetrical community, midwives do not represent a feminist conspiracy to eliminate the obstetrician. Quite the obverse — midwives seek to augment, supplement and complement the contemporary medical model of care. The jewel in the crown of independent midwifery is that it 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. The immutable standard of maternity care is the same the world over and through out history, it is the same in every language — the goal is and will remain the practical wellbeing of the mothers and babies it serves. Here on the brink of the 21st century, the first duty of maternity caregivers of every educational and experiential background must be to bring about a cooperative and complimentary system that truly functions in the best interest of childbearing families.

????? missing paragraph???

The time to eliminate prejudice is upon us.

This philosophy of reconciliation is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was the mother of young children as well as First Lady.

When asked what she put first in her life, her husband (who was President of the United States), or their children, she replied:

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 the mother and baby first.

WE, the People, came together to form a more perfect union.

WE, the People, cannot stop perfecting that union until it includes science-based birth care for all healthy women with normal pregnancies.

?? Draft material from other sources ??

Link to Chapter 14

 

 

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