Twenty-first century maternity care as a cooperative adventure btw medicine and midwifery

What’s the problem with what we are doing now?

According to a consensus of the scientific literature physiological management is the safer and most cost-effective form of maternity care for a healthy population. The natural and compelling conclusion that our current hospital-based maternity care — a system based on obstetrics as a surgical specialty that has over the last 100 years become the customary form of care for healthy women — must be rehabilitated.

As an allopathic surgical discipline, 93% of laboring women women have from seven or more medical interventions and 70% of them have one of more a surgical procedures performed (episiotomy, vacuum, forceps or Cesarean).

In the last 40 years, the number of interventions and surgical deliveries has aways and only gone up. While this is explained as necessary ‘improvements’  to make childbirth safer, the maternal mortality statistics more than doubled over this same period of time, with an all-time high in 2007 (?) of 17 maternal deaths per 100,000 live-births.

While being poor or non-white, extremely young or old, as well as multiple gestations and obesity are all factors, the biggest issue is that highly medicalized intrapartum care and a surgical delivery that is triple who is recognized as “optimal” is risker and results in more, and more expensive complications, while not making any improvement in the outcomes for new babies.

Like Big Oil and Big Pharma, we now have a ‘Big Obstetrics’. Big Obstetrics has an enormous number of economic incentives to continue spending, spending and spending, and virtually no reason to reason change course. Nonetheless, the tsunami of obstetrical excesses has peaked, governments and other third party payers have increasingly realized they are not getting their money’s worth.

Many childbearing women don’t have a single contemporary friend who didn’t have a C-section and so are seeking midwifery care, with a Cesarean rate under 10%, as an alternative hospital-based obstetrics.

How to Make the System work for everyone?

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).

Such a 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 procedure.
• 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.