Topic link 3 ~ Identifying the Essential Qualities of Maternity Care +?+?+

by faithgibson on January 24, 2024

Part II:

Safety & the maternity-care continuum
in an essentially healthy population 

Two kinds of data are required to intelligently determine if the current configuration of medical and midwifery care is making the kind of cost-effective contribution that economists refer to as ‘value added’. In order to identify “value-added”, we must first identify the innate riskiness of normal childbearing and directly quantify the relative benefits of each category of maternity care. This requires baseline data for “no care” in an essentially healthy US population, as well as outcome statistics for each type of birth attendant. Having done that, the essential qualities of maternity care can be distinguished from customary practices not directly associated with better outcomes for mothers and babies.

The ultimate goal is to test the validity of all current maternity care policies, protocols and practices in regard to safety, cost-effectiveness and patient satisfaction and to arrive at ‘standard care’ characteristics. This would integrate the principles of physiological management with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies, with obstetric interventions reserved for those with complications or if requested by the mother. Having scientifically identified ‘standard care’ characteristics, this model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.

Childbirth risks in healthy women & policies that reduce them

In searching for the essential qualities of safe and cost-effective maternity care, I have identified 5 useful sources – 4 published studies in combination with a consensus of the research literature for hospital-based maternity services in the US. These included:

(1) a contemporary study of purposefully unattended births & rejection of necessary emergent care
(2) a retrospective study of lay midwife-attended OOH w/ access to comprehensive medical service
(3) a prospective study of professional midwife-attended OOH w/ access to comprehensive medical services
(4) a prospective Canadian study that contrasted outcomes for a select groups of low-risk women that gave birth under three different circumstances (a) OOH setting under the care of direct-entry midwives, (b) in hospital under the same category of midwives and (c) in hospital by MDs
(5) a configuration of hospital-based obstetrical studies of medically-managed hospital births in low and moderate risk women by obstetricians, FP physicians and certified nurse- midwives.

CONTROL GROUP: The study of unattended birth functions as a ‘control group’ that allows comparison of ‘care’ versus ‘no care’. Then we can compare the 3 major groups of birth attendants to one another and to the ‘no care’ cohort.

Taken together these studies provide information on the biological background rate of maternal and perinatal mortality and morbidity when all the benefits of modern biological sciences are absent, inaccessible or rejected by a childbearing population due to cultural traditions or religious beliefs.

The poor outcomes for purposefully unattended birth in the US in an educated and essentially healthy population are consistent with available statistics for maternal-infant mortality in the late 19th and early 20th century in the US, and the current high maternal mortality rates in developing countries such as Afghanistan, Ethiopia and the Gambia. The major cause of MM in this first-world cohort was hemorrhage and infection and establishes a background rate of biological risk that is independent from poverty, malnutrition and other factors specific to deprivation.

CONVENTIONAL OBSTETRICS: At the other end of the scientific continuum, this collection of studies also helps us to distinguish between maternity care policies and practices that benefit healthy women and those non-productive traditions, customs and provider preferences that increase the economic cost, but do not directly contribute to improved maternal-infant outcomes.

Five Models, Five Perspectives, Five Insights

Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care – Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:

This control group consists of women with the same general health and demographic characteristics that are seen in the CDC birth registration data. This is predominately healthy, white, middle-class women who had economic access to all categories of maternity care providers and settings, but in this case, purposefully choose unattended births. Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that rejected all forms of medical care under all circumstances – no prior diagnosis or treatment of chronic medical problems, no risk-screening of mothers during pregnancy, no prenatal care, no trained attendant during childbirth and no emergency transfer of mother or baby with life-threatening complications to a medical facility – a situation similar to rural parts of the developing world.

Out of 344 births, the unattended group had 6 maternal deaths and 21 perinatal losses. The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live births (92 times higher than Indiana’s MMR for the same period) and one perinatal loss for every 16 births or PNM rate of approximately 45 per 1,000.

Study #2: “Home Delivery & Neonatal Mortality in North Carolina”, Claude Burnett, Judith Rooks; JAMA, Dec 19, 1980, Vol. 244, No. 24, p. 2741-2745:

Planned home birth (PHB) in an impoverished and medically-indigent minority population attended by experienced lay midwives. These demographically high-risk maternity patients were risk-screened one time by a public health officer prior to being approved for PHB under the care of a lay midwife. However, state laws did not authorized non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears. These county-registered midwives were required to transfer patients with complications to a local hospital in an appropriate and timely manner. The lay midwife-attended group had no maternal deaths and 4 neonatal losses per 1,000 (including 2 fatal birth defects).

Note: This study also reported the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended, often because local hospitals turned away laboring women who did not have the prescribed ‘cash in hand’. These unattended births had a dramatically increased perinatal mortality rate ranging from 30 to 120 stillbirth and neonatal deaths per 1,000, a perinatal mortality rate consistent with 3rd world countries and unattended births among the religious group in Indian.

This highlights the preventive value of physiologically-based pregnancy and childbirth services and the equally important access to medicalized maternity care during pregnancy as indicated and the ability to call on comprehensive medical services during the intrapartum and immediate postpartum-neonatal period whenever necessary. Compared to the combined mortality statistics for the control group, the care of these lay midwives saved the lives of 14 mothers and 58 babies. If their care were a drug or medical device, it would be illegal for every childbearing women not to have one of them.

Study #3: Outcomes of planned home births with certified professional midwives: large prospective study in North America; Kenneth C Johnson, senior epidemiologist; BMJ 2005;330:1416 (18 June 2005)

Planned home birth (PHB) in a generally healthy population as attended by nationally-certified direct-entry (non-nurse) midwives in the year 2000. All clients were risked-screened and received prenatal care and those with medical or pregnancy complications were referred to medical services. Professional midwives monitored maternal vital signs and fetal heart tones during labor and were authorized to carry emergency supplies such oxytocin (Pitocin + Methergine), IV fluids, oxygen, neonatal resuscitation equipment and also to suture perineal lacerations. Twelve percent of PHB patients were transferred to the hospital during labor or after birth, the majority of
 whom were first-time mothers. Cesarean rate was < 4% for PHB women hospitalized during labor. This group had no maternal deaths and 2.6 neonatal losses per 1,000 (including lethal birth defects).

Study #4: Outcomes of planned home birth with midwives versus planned hospital birth with midwife or physician; Janssen PA, Saxell L, Page LA, et al. CMAJ 2009;181:377-383:

A 5-year Canadian  prospective study published in 2009 compared the outcomes of PHB in British Columbia attended by professional direct-entry midwives btw 2000 and 2004. It compared planned hospital births also attended by this same category of professional midwives and a matched low-risk cohort of physician-attended hospital births. They found that the risk of perinatal death associated with PHB attended by midwives did not differ significantly from the low rate associated with planned hospital birth. The study also found that women who planned a home birth had a reduced number of obstetric interventions and adverse maternal outcomes.

The neonatal death rates per 1,000 births were 0.35 for midwife-attended planned OOH birth, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births. Maternal mortality for all three groups was zero. Inclusion in the two hospital categories required the childbearing women to have the same low risk-based characteristics as those who were planning to labor at home. These finding echoed a Dutch study published in July that also found a planned home birth to be as safe as a planned hospital birth, provided that a well-trained midwife is available, transportation and medical referral system is in place, and the mother is at low risk of developing any complications.

The authors concluded: “… (the) study showed that planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and adverse maternal outcomes compared with planned hospital birth attended by a midwife or physician”.

#5 Neonatal mortality rates for planned hospital birth as reflected in a consensus of scientific literature, plus CDC birth registration stats for birth after 37 completed wks and data on obstetrical intervention levels in general population from the “Listening To Mothers” survey, Childbirth Connection; 2002 and 2006:

Planned hospital services for low and moderate risk women — labor attended by a professional nursing staff, routine intrapartum use of continuous electronic fetal monitoring (93%), IVs (86%) and epidurals (63%); birth conducted as a surgical procedure by a physician or certified nurse midwife. Medical intervention rate for this group was 99%; aggregate surgical intervention rate was 70% (episiotomy, forceps, vacuum extraction and Cesarean section). The CS rate was approximately 25% in 2002 (now 32%). The scientific literature reported neonatal mortality for obstetrically-managed hospital birth for low-risk women to range from a low of 0.79 to 4.1, with an average NNM rate of 1.5 per 1,000. 

The patient-choice issue of genetic testing & termination 

The routine use of ultrasound and prenatal genetic screening in the hospital cohort, in conjunction with termination of affected pregnancies during the pre-viable state, slightly lowers the rate of perinatal and neonatal mortality when compared to the sub-set of families who choose OOH birth. This is due to a reduced number of babies in the hospital cohort with lethal anomalies who are carried to term.

Families that choose non-medical maternity care are statistically less likely to utilize prenatal genetic and ultrasound screening or to terminate affected pregnancies when indicated. One study in PHB in Washington State (1996) documented a disproportionate increase NNM due to congenital anomalies, not all of which were incompatible with life. Among this specific sub-set of non-testing parents, prenatal diagnosis and planned hospital care would have reduced (but not eliminated) the incidence of neonatal mortality. However, this is a patient choice and is not a provider or place-of-birth issue.

In regard to the great debate about safety, it is useful to realize that birth-related morbidity and mortality can be time-shifted, place-shifted and practitioner-shifted, but they cannot be eliminated. In other words, increasing rates of pregnancy termination reduces neonatal mortality rates but obviously does not reduce over all perinatal mortality.  There is nothing that birth attendants can do or not do that reliably, and with economically sustainability, can create a condition of zero risk for both mother and baby 100% of the time.

The risk-benefit continuum among the 4 responses to normal childbirth and the 3 types of birth attendants:

Simple access to prenatal care, on-going risk-screening and physiological management of active labor, birth and immediate postpartum-neonatal period by experienced birth attendants of all categories improved outcomes by orders of magnitude. Here is the breakdown for each type of birth attendant and both in and out-of-hospital settings.

NO CARE: The most startling conclusion is the consequences of “no care”. Lack of prenatal care, no skilled birth attendant present during labor and birth and not having or not using emergency care when indicated is unconscionably dangerous and represents a failure of society at some level. The total absence of medical and maternity services, whether by religious or personal choice, due to poverty or cultural beliefs, can turn the otherwise normal biology of pregnancy and childbirth into a lethal condition.

LAY MIDWIVES: Many people would have assumed that the care of lay midwives would have been little better than unattended births but they would have been very mistaken. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to the control group.

When it comes to ‘value-added’ above the background biological hazard, lay midwives added the most value of any category of birth attendant.  These good outcomes were achieved by providing childbearing women with prenatal care, on-going risk-screening and referring those with serious medical or pregnancy complications to obstetrical services. Mothers and their unborn babies were monitored during active labor by capable midwives who recognized medical problems and arranged timely transfer of patients with complications to the obstetrical service at the county hospital.

This straight-forward access to prenatal care, risk screening, transfer as indicated and physiological management during labor, birth and postpartum-neonatal period as provide by lay midwives was able to reduce perinatal mortality by 20 to 40 times compared to the mortality statistics for control group. This substantial feat was accomplished at a small fraction of the expense and was able to lower neonatal mortality to a rate similar to that of professional midwives and a maternal mortality rate equivalent to hospital-based-obstetrical care.

Within the structured healthcare systems of North American and the formal reimbursement scheme by governments and insurance carriers, expansion of services by lay birth attendants would not be a viable option. Our educated population rightfully expects their healthcare providers to be professionally trained, regulated by the state, able to carry emergency drugs and equipment and to repair simply perineal lacerations as a part of their normal scope of practice.

Nonetheless, lay midwives are an eager and reliable group that should not be overlooked. They are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries and among groups that are for any reason excluded from the official healthcare system in developed countries. It is illogical and unwise to criminalize this group.

PROFESSIONAL MIDWIVES: In study #3 state-regulated direct-entry midwives had no maternal mortality and a neonatal mortality rate of 2.6 per 1,000 (including fatal birth defects), which was ever-so slightly better that the lay midwives and in the same general range as hospital-based obstetrical care for low and moderate-risk women. However, childbearing women cared for by professional midwives had 2 to 10 times less obstetrical intervention than medicalized hospital care and a 6-fold decrease in Cesarean section (under 4%). All of these good outcomes were achieved at a small fraction of the expense of orthodox obstetrical care.

In study #4, the Canadian direct-entry midwives were fortunate to be providing care in a providence that had an integrated model of care with generally cooperative and complimentary relationships between midwives and physicians. Midwives in several parts of Canada have hospital admitting and practice privileges, so healthy women have the option of a planning a midwife-attended hospital birth. This also allows for continuity of  care for transfers from home to hospital when the mother-to-be does not require obstetrical management or operative delivery. When the services of an obstetrician are needed, this articulated system provides for a seamless transfer of care and ‘no-fault’ receptions.

Last but not least, these statistics are for a sub-set of childbearing women — the lowest of low risk women. This is a patient population with good access to and use of prenatal screening and for whom all diagnosable congenital anomalies have been eliminated from this cohort. Neonatal deaths for midwife attended PHB in this population are the very lowest of all stats for normal birth in any setting — NNM per 1,000 of 0.35 for births planned home births, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births.

These are ideal circumstances and while we all aspire to them, they cannot be replicated 100% of the time by 100% of the childbearing populations. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare.

With the rarest of exceptions, this general principle applies to healthy childbearing women. Assuming that the mother-to-be is fully informed by her birth attendants, she has the right to decline prophylactic medicalization and choose instead (or accept) the increase risk of a specific pregnancy or intrapartum circumstances that puts her into a moderate risk category  — for example, a small fibroid, a large baby, vaginal birth after a Cesarean, prolonged rupture of membranes, meconium, or a post-dates baby with reactive NST.  It is necessary for the maternity care system to acknowledge the constitutional right of adult women to continue receiving birth-related services even when they are not totally ‘ideal’ candidates for OOH care.

The alternative is to put many women between the Devil and Deep Blue Sea by denying access to professional OOH care. This forces them to choose between medicalization they do not want, and in actual fact may not benefit from, or having unattended births (the risks of which have already been identified). The other problematic possibility is that women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives her of access to adequately trained attendants and medical back-up arrangements, but also creates another group of unregulated lay midwives, which is both unnecessary and unwise.

The better strategy is to acknowledge that moderate risk women have a constitutional right to have professional services for an OOH birth. The statistical record of a mixed-risk population (low plus moderate-risk women) consistently demonstrates a NNM rate between 1.5 and 2.6 per 1,000, irrespective of birth attendant or birth setting.

HOSPITAL-BASED CARE: Institutionally-based obstetrical care appeared to have improved neonatal mortality ever so slightly (approximately 1.5 per 1,000) as compared to the lay attended group (3:1,000) and professional midwives (2.6:1,000, but this small gain was offset by a dramatically increasedCesarean section rate of 32% and drastically increased cost of care. This escalating CS rate has been associated with the current upward trend in maternal mortality (MM) by other researchers.

In that regard, physiologically-based forms of care, which lower the incidence of Cesarean, also reduce rates of maternal mortality. While no family or birth attendant should ever be forced to choice between the life of the baby and that of the mother, we also must be sure that enthusiasm for the lowest possible neonatal mortality statistics does not increase the risk to the childbearing woman and result in avoidable maternal mortality.

High-tech, high-cost, highly interventionist obstetrical care for healthy women does not appear to improve combined mortality rates for mothers and unborn or newborn babies. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of surgical delivery.

Bottom Line: Hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.

As measured by the outcome statistics for the 3 categories of birth attendants: lay midwife-attended, professional midwife-attended and hospital-based, medically attended — the most efficacious strategy for preventing maternal and perinatal mortality and morbidity consists of the three simple already identified aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth. This was associated with  prenatal care, risk-screening, transfer to medical services as indicated, birth attendant skilled in physiologic care present during the intrapartum, postpartum-neonatal period and appropriate use of emergent and comprehensive medical services as necessary.

Evidence-based maternity care by birth attendants trained in physiological (non-interventive) management achieved “maximal results with minimal interventions” by a wide margin. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.

To paraphrase the popular African saying, it takes a village of skilled and knowledgeable people to support the safe passage of mother and baby thru pregnancy and birth.


Unfortunately, the current legal ‘standard’ for the surgical specialty of obstetrics is a medical-surgical model of care. Physiologically-based principles of care have not been a legitimate part of obstetrical practice since being defined as medically inferior in 1910. At that time, Dr. J. Whitridge Williams gave voice to the low esteem that physiological care had in the scheme of obstetrical practice when he said; “That word ‘physiological’ has all along stood as a barrier in the way of progress.” [Twilight Sleep: Simple Discoveries in Painless Childbirth, Dr. H. Smith Williams; 1914, p. 90]  The theory and skills of physiologically-based care were never incorporated into the 20th century medical curriculum and are not taught in 21st century medical schools.

Practically speaking, this means the use of physiological management, which is primarily non-medical in nature, is legally a ‘substandard’ form of care when provided by an surgically-trained specialist such as an obstetrician. Currently, the principles and practices of physiological management are only taught in midwifery training programs. Until that changes, midwives will continue to be the sole providers of maternity care based on physiological principles.

In far too many places, PHB is the only situation where true physiological management is legally able to be employed. This artificially forces us into a proxy state of mind that appears to pit hospital against PHB. But in a rational evidence-based system, no healthy women should ever have to choose between a midwife and a physician or between home and hospital in order to receive physiologically-based care for a normal birth.

In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the birth attendant or the planned location of care.

Responsible Midwifery for the 21st Century 

Responsible midwifery is an integrated model of care. It is able to meet its social obligation to serve and protect mothers and babies while simultaneously protecting the professional capacity of midwives and preserving the reputation of midwifery. In order to meet the biological, psychological, educational and social needs of childbearing families, excellent maternity care needs to be based on the highest level of art and the most comprehensive level of science. It must also be an ever-evolving discipline as new knowledge, new technologies and new thinking come to the healthcare field.

Physiological care as a ‘subtle’ system and independent form of ‘expertise’: Regardless of a midwife’s formal education, responsible midwifery for healthy women rests on the incontrovertible principles of physiological management as the universal standard of care. This ‘whole cloth’ model is organized around pregnancy and birth as a healthy function of normal biology. Obviously, this designation includes ‘first-responder’ emergency skills and equipment, as well as timely access to comprehensive medical care as the back-up plan (Plan B), However, the foundation of physiologically-based, non-medical care –“Plan A”, if you like — is  best understood as a ‘subtle’ system.

In regard to healthcare, the word ‘subtle’ describes a supportive  structure of normal (non-medical) care. Subtle systems are at one end of the healthcare continuum, while the pathology-focused, macro-level of intervention that defines the practice of medicine are at the other end. In the middle of this caregiver spectrum are integrated types of care and different types of careproviders who creatively  blend the best of both (the subtle and the interventive) to suit the circumstances.

The practice of medicine is organized around diagnosing pathology in physical or biological function and implementing a predetermined set of interventions. There is nothing ‘subtle’ about a patient who is unconsciousness, in a coma, hemorrhaging or having seizures. Nor is there anything subtle in the treatment of these dramatic physical symptoms and other evident pathologies, all of which requires the use of diagnostic procedures, medical treatments, drugs or surgery.

This is not to say that some level of subtly is not an aspect of the diagnostic process or provision of good medical care — such subtly is often the mark of  true expertise and makes one an “expert” in his or her field. Its just that subtle observations and subtle responses are not the core of the medical process. They are a minor part, or an expression of extraordinary fineness, but not the macro or basic unit of activity.

In direct contrast to the medical model of care, normal physiologic needs are typically detected and responded to via a subtle or ‘micro’ level of patient indicators and caregiver reactions. Physical and psychological needs are, for the most part, detected  by subtle visual or auditory clues — the fleeting look of  anxiety, pain or surprise that momentarily passes over the mother’s face, a faint hint of perspiration on her upper lip, her hands gripping the bedstead, a moan or low grunty sound that escapes her lips. Depending on the stage of labor, these subtle clues are likely to indicate the beginning of painful contractions in early active labor, the onset of transition labor accompanied by the mother’s feeling of panic or the very first urge to push early in 2nd stage.

A word picture for the subtle nature of supportive care comes from the world of parenting. The mothers and fathers of infants and small children naturally develop the ability to detect the smallest tell-tale sign that a child is about the up-chuck. Since the beginning of time, parents (and nurses) all over the world over have instantly responded by quickly moving the child or turning the baby’s head so it won’t choke and the mess will be easier to clean up. Breastfeeding mothers also respond to a variety of subtle clues that their babies is are either hungry or ready to quit nursing because they are full.

It’s this kind of watchfulness that is at the heart of physiological management as a subtle, non-medical system of care for an essentially healthy population of childbearing women and their newborns. As with parenting and the profession of nursing (as well as driving a car or piloting a plane), one must be present and paying attention in order to see and hear and respond to these subtle indicators — hence the descriptive (as well as legal implications) in the word “birth attendant”. Older medical and midwifery textbooks  refer to this quality of waiting and watching as “patience with nature”.

Birth attendants and other caregivers respond to the subtle physiological and psychological needs of the laboring woman by watching carefully, asking the mother about her sensations (what are you feeling now?) and how she feels about what is happening (her emotions). After assessing the situation to be within the normal range for the stage or phase of labor, caregivers provide practical, non-medical support (physical or psychological) as appropriate. Often this nothing more than an a hand laid reassuringly on her shoulder, a word or two of encouragement or explanation, a suggestion that she change positions, get up or move around. These subtle reactions communicate  that she and her baby are OK, that she is making progress and it won’t be too much longer before her baby is born.

The temperament required for this kind of ‘patience with nature’ is a large part of what makes a birth attendant good at providing normal care for normal childbirth. Unfortunately, these characteristics are the opposite of the personality traits associated with surgical specialties. Surgeons are trained and paid to make split-second decisions, take quick decisive action, finish up as efficiently as possible and move on to the next most urgent need. If surgery had an unofficial motto, it would be “lickity-split”. In addition, surgery is such a highly specialized field that most of us do not even have a right to voice an opinion about how its practiced. As a result surgeons do not take kindly to having their understanding or judgment questioned.

For professionals who spent hundreds of thousands of dollars and 12-15 years training in the surgical specialty of obstetrics, the idea of sitting in the room with a laboring woman and just watching and waiting for hours and hours is met with the same enthusiasm as watching paint dry. For this reason, physiologic care will likely remain the purvey of non-obstetricians for the foreseeable future.

The role of the midwife is to provide a supportive structure for the physical, mental, emotional, and social needs that accompany this normal (but extremely intense) aspect of reproduction. The goal of this integrated model is to serve the full spectrum of practical needs experienced by childbearing women. This includes guidance and counseling, as well as one-on-one, hands-on support and encouragement and spans the most mundane issues of newborn behavior and breastfeeding at one end to the appropriate utilization of obstetrical or neonatal services as desired by the mother or required by baby. 

It should be noted here that community midwifery has far more in common with general practitioners than the specialty of obstetrics. The midwife who provides care in non-institutional setting is generally responsible for the entire ante-, intra-, and postpartum period as well as the immediate and on-going care of the newborn baby and all the issues this entails such as breastfeeding, weight gain, colic and concerns about newborn behavior for the first 6 weeks.

Reproductive biology not perfect: For healthy women with normal pregnancies, absolutely no routine medical or surgical treatment, drug, protocol or procedure can make normal labor and birth better than the process already provided by the normal biology of human reproduction. But reproductive biology is no more perfect that any other aspect of our physical body, which means the risk of complication and emergencies must remain ever-present in the minds and plans of all birth attendants. The incontrovertible principle of responsible midwifery is right relationship between midwives, mothers and the biological sciences, with critical thinking skills at the heart of it all. The invaluable contributions of modern medicine in responding to complications must be enthusiastically acknowledged, which includes appreciation for the vital role of obstetricians, perinatologists and hospital-based care.

To achieve a high level of preparedness, midwifery educators need to intellectually prepare their students to be fully competent in both the art and the science of midwifery. This includes adequate clinical experience in manual dexterity skills, development of clinical judgment skills and the mental toughness to make right use of appropriate interventions or initiate a timely transfer of care when indicated. There is no shame or blame for either mother or midwife in necessary hospitalizations, but rather a recognition that each person involved in the situation has to deal, as best they can, with the cards dealt by Mother Nature. This is often the opposite of what the parents expected and the midwife hoped for. Nonetheless, a timely hospital transfer and use of comprehensive obstetrical services is not a “failed home birth” or failure of other aspects of the care-giving process. An appropriately timed hospital transfer is a marker of responsible midwifery, to be applauded and appreciated.

Since the birth attendants who provide normal care for normal birth are primarily midwives, the hundred-year history of prejudice by the medical community against physiological management is a burdensome legacy. Unfair as this hard-wired prejudice has been, non-nurse or direct-entry midwifery is sometimes endangered from within by a ‘soft prejudice’ of its own low expectations. This describes a well-meaning but inappropriately defined role of intrapartum management that is a combination of ‘do-nothing’ and ‘feel-good’ care that parrots platitudes and responds to everything that happens with comments like “that’s normal” and “it’s OK”. But childbirth is no place for magical thinking. This idea of ‘midwifery-lite’ completely misses the crucial role that midwives take on as primary caregivers for childbearing women and their newborns.

Regrettably, Mother Nature presents us with potentially life-threatening situations in 1 out of 10 pregnancies. This number includes the entire spectrum of childbearing women, even those who are healthy and have low- and moderate-risk pregnancies. Like the lifeguard at the pool, the mandate is eternal vigilance. A midwife is an educated observer with emergency response capacity. Watchfulness and well-timed access to intervention can make a huge difference for mothers or babies who need help. In the majority of cases, small well-timed actions will correct the problem and successfully circumvent the danger. That is not a place-of-birth issue, nor does it normally depend on high-end technology. But someone must be present and paying attention (hence the original of the phrase “birth attendant”).

In any labor, the midwife must be continually aware of the mother’s childbearing history, current pregnancy status, the size, position and gestational age of her baby, the psychological status of the parents, their religious beliefs, goals and values, as well as the real-time characteristics of her labor, the critical facts of the mother and baby’s immediate biological situation and any diminution of wellbeing for either mother or unborn baby. This is particularly an issue in planned home birth where transfer time must be factored in. This requires consideration of the geography, weather, traffic, distance, financial impact on the family and the level of cooperation (or lack thereof) that can be expected from the staff of the receiving hospital.

This sobering reality requires that all OOH birth attendants be smart and capable – smart to recognize situations which have the potential to develop into a complication and capable of dealing with unusual or abnormal circumstances in ways that dramatically reduces the likelihood that a low level problem will become a complication that escalates into life-threatening emergency.

Part III:  Developing “Standard Characteristics” for OOH Studies of Intrapartum Care