Dear MCDG Listers:
Thanks to so many of you who sent me lovely notes on my role as founding Listmaster of MCDG.
It has been one of the most satisfying roles in my career—bringing me close to all of you caring for mothers and newborns. Your support has encouraged me to keep posting on MCDG.
During the 48 years that I have been catching babies and the 37 years as Listmaster, I have witnessed so many changes in maternity care. As a neonatologist from the late 60s, I was present at hundreds of births in that role. At the beginning, partners were excluded from the birth of their partners. When Bonnie and I had Seth, born in 1968, I was excluded from the birth, even though I was chief resident in neonatology at McGill—and no pictures were allowed. But 2 years later, when Nomi was born, partners were accepted, pictures and all.
As a family physician concerned about the practice of full-service family practice, I have seen the gradual withdrawal from birth by family physicians, due to limited training in birth and political pressure from the obstetrical community.
But these are not the only reasons for avoiding maternity care. Family physicians had trouble integrating birth into their office practice—especially as it was expected that continuity as a principle, demanded that the physician of record be present for the birth (soft call). This meant being perpetually on call.
Fortunately, group family practice maternity services have developed to promote a system of hard call, in which one takes a turn being on call for the group, and all women and their partners get to meet all who might attend the birth. This has stabilized family practice maternity care, as we have demonstrated that family doctors can do this work, while still having a life.
It has been my pleasure to witness the growth of midwifery from a not legal profession to a respected part of the maternal/newborn health community, to see physician midwifery skeptics become supporters/collaborators.
Murray Enkin was a role model for me in both midwifery support and evidence-based research. I expressed my appreciation in a piece I wrote about him in BIRTH. Birth. 2023;00:1-3. doi:10.1111/ birt.12723
In the early days, when the new midwifery was becoming re-established, the grandmothers believed in continuity until death or divorce. Now group midwifery practice with hard-call is the norm, and there are even some groups of family physicians and midwives working in a single group, covering both practice models with hard-call. In BC ¼ of all births are now under midwifery care.
I have been able to witness and support the development and recognition of doulas. In that endeavor, Marshall and Phyllis Klaus and Penny Simkin were my mentors. Marshall began his impact on me way back to the 60s when he was an attending in the newborn nurseries at Stanford Medical School, where I was a student.
Marshall wrote few papers and did a limited amount of research, but every study and paper was a gem—from his early bonding studies to the role of doulas. His research paved the way for the elimination of newborn warehousing and rooming-in to single-room
maternity care.
I wrote my appreciation in a piece for BIRTH. doi.org/10.1111/birt.12332
Since our work on episiotomy, still the only RCT in North America, there has been a drop in episiotomy in the US and Canada from 64% and 55% in the US and Canada to 40% and 25% by 1998 and falling still. Thus by 1998 in the US to a 3rd/4th degree tear rate from 4.2—1.5% and falling. I will f/u with some results from the RCT of episiotomy in another post.
During my time practicing and witnessing birth, there have been changes that are not so wonderful.
§ Caesarean section has moved from an emergency procedure to just another way of having a baby.
§ So-called natural Caesareans, in which the mother watches the surgery and is able to reach for and sort of “deliver” her own baby is cute but might be aiding in the push for more Caesareans.
§ Endless pelvic floor studies, some of questionable methodology, have discouraged women from vaginal birth, based on fear of urinary and bowel incontinence and sexual dysfunction.
§ There is pushback from some who feel that our episiotomy rate with instrumentation is too low. I will f/u with some results from the RCT of episiotomy in another post.
§ The revolutionary women in the 70s and 80s who spearheaded the successful elimination of routine episiotomies, enemas, shaving, IVs, and promoted partners in birth and re-introduction of midwifery, are now grandmothers. They seem to be silent on the many new technologies that their daughters are experiencing, including early induction, almost routine epidurals and the overall industrialization of birth.
There were many reasons behind my decision to step down as Listmaster—including mainly my age and my belief that it was time for the new generation to take over. Also there have been some health reasons that some of you are asking about.
The short version is that I have had a severe progressive peripheral neuropathy, resistant to many treatments, for 30 years. A year ago, I had a near death experience with a dissected aortic arch. And very recently, I self-diagnosed with myasthenia—confirmed by neurology. It only took me 20 years to make the diagnosis. I am responding to treatment, but it is a slog. I
If any of you want to see the dramatic story of the aortic dissection, coming out in January 2024 in the Canadian Family Physician of my hovercraft rescue in the middle of the snowstorm that we never have on the Sunshine Coast, send me an email off list.
Enjoy to holiday season and stay well
Michael
Dr. Michael Klein C Klein CM, MD, FCFP CCFP FAAP (neonatal-perinatal)Emeritus Professor
Family Practice & Pediatrics
University of British Columbia
Sr. Scientist Emeritus
BC Children’s Hospital Research Institute, Vancouver
www.michaelcklein.ca
Author Dissident Doctor—catching babies and challenging the medical status quo
“It is much more important to know what sort of patient has a disease than what sort of disease a patient has.”
Sir William Osler (1849-1919)
To view this discussion on the web visit https://groups.google.com/d/msgid/mcdg/354A2D7A-F5BE-4B3B-A748-59E501220255%40mail.ubc.ca.
