Apgar Wars ~ 6th in series: Effects of repeated negative reports on attitudes of medical professionals & the public

by faithgibson on September 24, 2013

in Contemporary Childbirth Politics

I am sad to report that the vast majority of medical professionals  have moved past questioning the verasity of ACOG’s high-profile anti-PHB studies.

Regrettably, this includes the many physicians who are directly knowledgable about midwifery in general, supportive of both nurse-midwives and “other” midwives and OOH childbirth services, and also sympathetic to a childbearing woman’s right to make informed decisions about her maternity care (including medically unpopular choices such as place-of-birth).

The consensus of opinion in the professional world is that the accuracy of data and the methodologies of these particular studies are not in question.

Such a constant drum-beat of doom, which only gets louder and louder, has finally gotten under everyone’s skin; and leaves even sympathetic professionals feeling that  “where there is SO much smoke, there MUST be fire!“. Surely these highly educated obstetricians with impeccable credentials would never misrepresent the facts and they would never make a mistake. The inescapable conclusion based on ‘common-sense’ and this data is that PHB is even more dangerous than they thought and if ‘we’ midwives expect them to continue being supportive, the we’d better clean up our act.

The general conclusion (with a few important exceptions) is that reliable scientific proof has finally been able to established the facts: that intrapartum care by non-nurse midwives in the US is associated with an orders-of-magnitude increase in NNM and neurologically damaged babies. These preventable bad outcomes ranges from doubling the the neonatal mortality, to 19 times greater incidence of zero Apgars in first time mothers who labor and/or give birth at home under the care of a non-nurse midwife.

From this perspective, it is quite understandable that the medical profession wonders why — what are community midwives doing wrong that causes so many preventable deaths and problematic outcomes?. According to the recent “zero 5-min Apgar” article, the number are one horrible neonatal outcome out of every 615 live births for PHB/other-midwives, compared to one out of 6,500 for MD-attended hospital births and one out of 11,775 for nurse-midwives in the hospital.

Personally I have to say that if these numbers prove true, hospital obstetricians and OOH ‘other’ midwives should both throw in the towel and just let hospital nurse midwives attend every healthy woman’s labor and birth.

What are nurse-midwives in the hospital doing right that hospital obstetricians and “other” midwives in non-institutional settings are doing wrong?

Maybe concluding that there is 2 to 4-fold increase in bad outcomes will clear the way to focus on what this group of “other” (or non-nurse) midwives are doing wrong (or not doing) that results in such harm and preventable bad outcomes to their unborn and newborn patients. More to the point, what should (or can) the ‘system’ do to change the circumstances under which this amorphous group of non-CNM midwives provides care?

So I decided to address such questions from that perspective — one that doesn’t argue the accuracy of the data or the reasonableness of their conclusions. Maybe it will offer an opportunity to move the dialogue in a more positive direction.

Irrespective of this data — good, bad or ugly — what childbearing families and government healthcare officials want the public and medical profession to return its attention to the critical need to reform the system that currently provides maternity care to healthy women with normal pregnancies. This is particularly important to tax-payer who bear the economic burden required of government-financed childbirth services, since 49% of all births in the US are reimbursed by Medicaid.

So here is what i see as the nugget of truth in this undulating sea of confusion:

Relative to the care of CNMs versus that of ‘non-nurse’ midwives in the US, the biggest difference and most persistent ‘problem’ is not actually the characteristics of ‘other’ midwife, but the big differences in the childbearing family who chooses such care.

While patient-choice was casually mentioned in some of these studies, it certainly was not seen as the most important or most central question. Self-selection and associated informed-consent patient choice that may or may not bear on events as reported in AJOG fall into two broad groups:

1. Families who for cultural, religious or philosophical reasons do not want, or are actively resistant and even rejecting of ‘standard’ medical care. These families often refuse under the religious exemptions clause ALL medical testing.

For Christian Scientist families, this includes the most simple lab work — CBC and maternal Rh determination. And you can forget early ultrasound for dating pregnancies and genetic testing when such a family does not show up until 32 wks.

I also see women that had a previous pregnancy under the care of an CNM who could no longer attend the mother-to-be due post-dates, even though her bio-physical profiles and NSTS were both normal. To be sure that the pregnant woman will not be again forced into unwanted and unnecessary medicalization again, she is looking for a non-nurse midwife this time.  If ‘other’ midwives are not available, many of these mothers will just labor out of the hospital until the birth is imminent.

2. The second issue is the sad but true fact that physiologically-normal intrapartum care is generally NOT available in hospitals but specifically prohibited for that subset of childbearing women who have a breech, twins, or post-dates pregnancies, or a previous Cesarean.

A significant number of the women who seek out the services of non-nurse midwives do because these same childbearing women have already been told by the ‘system’ (or know they will be told) that a Cesarean section will be performed on them if they show up at the hospital in labor. This is based not on the mother’s current medical condition, but protocols that promote medicalization and discourage or prohibit the use of physiological management relative to a long list of conditions defined by the medical profession as ‘high risk — LGA, high or low amniotic fluid, DGM, PROM, post-dates, breech and twin pregnancies, VBAC, etc — to name but a few. Once any of these conditions are identified,  hospital-based CNMs will not be allowed to provide physiological care to these women, and of course, the doctors are trained, interested nor have the temperament to provide physiological management, while planning a normal vaginal birth for  breeches, twins, or VBAC is often prohibited by due to the hospital’s mal-practice contract.

When we make mothers-to-be choose btw the Devil and the Deep Blue Sea — unwanted, medically-unnecesary scheduled C-section, or an ”other’ midwife, or an unattended OOH birth, we are not problem-solving but merely engaged in risk-shifting and blame-shifting.

Doctors and hospitals shift the risk from themselves to the mother and baby by refusing to provide VBAC and other vaginal birth services, and when there is an adverse event OOH in these instances, they get to blame the midwife.

It seem that the focus on “other-midwife” outcomes — whether they are (or aren’t) accurate — is irrelevant.

It is a red herring that distracts us all from ever talking about the real issue in the US (and maybe Canada), which is a medical-obstetrical profession that should — but at present does NOT — routinely provide normal (non-medicalized, physiologic) care for normal childbirth in healthy women. A previous CS mom is still healthy and her pregnancy is still normal, as is also true of most breech babies and dyzigotic twins.

I’m personally not yet convinced that the numbers being used actually represents accurate data, or the way in which this data is being used is an accurate reflection of the core problem. That ‘core’ problem — at least in the US — is an institutionally dysfunctional system.

In response to that ‘fact’ of life, some mothers and many midwives are personally trying to ‘fix’ the problem one pregnancy at a time by sidestepping the system. My son in the military tells me these temporary fixes are officially called a “work around” in the bureaucratic world.

Everyday that the public discourse centers on the obstetrically-fueled food-fight over this necessary ‘work-around’ — should they or shouldn’t they — it is one day longer before we address to the root of the problem and actually turn our attention to making the system functional. That would be affordable, cost-effective maternity care for the 85% of healthy women with normal pregnancies (and who currently have a 33% C-secton rate and increasing MMR).

In 1964, I had an unattended labor and gave birth (unplanned by me) in the back seat of our family car in the driveway of the hospital where i worked as an L&D nurse. This was the only choice available to me in what science now proves was an evidence-based attempt to avoid the mandatory administration during labor of Twilight Sleep drugs, and gen. ames. a ‘generous’ episiotomy, outlet forceps, manual removal of the placenta and perineal suturing which included “the husband stitch”, described as restoring the vagina of a childbearing woman to its former virginal ‘tightness’.

In 1964, there were no midwives of any kind available, which is to say, no other choice.

Now I provide care to women who for good, bad and indifferent reasons want to avoid what they see as ‘excessive’ medicalization and/or the depersonalization of institutional care. They and their babies are safer with me and “other” midwives being present during labor than they would be having unattended births, which is associated with a 20 to 40 times greater NMR. However, AJOG has not published anything about these realities.

This a big improvement over giving birth unattended in the backseat of a car, but I continue to pray for day when the care offered to healthy women by the ‘system’ begins by taking them into account — the childbearing woman and her family and what they believe, what they want, how the feel about the care being offered and how that care might be personalized rather than depersonalized.

Then no healthy women will ever again have to choose btw a midwife or a doctor, or btw home or hospital, in order to have a physiologically-managed normal birth and appropriate use of intervention if Mother Nature fails her. That should be a very attractive idea to ACOG.

And those of us interested in make our maternity care system work better can something other than obstetrically-sourced articles trashing PHB and ‘other’ midwives whose real purpose was to distract everyone from the real problems.


Apgar Wars series ends with part 7. After examining the cumulative effect on medical professionals & the public of endlessly repeated negative reports in the news media about community midwives/PHB.

Good evidence suggests that the anti-PHB public relations campaign being waged by ACOG and other groups of obstetricians is working.  And while AOCG really does not like the idea of PHB, this official campaign is not actually about the anti-PHB side of the issue but rather the pro-medicalization side of the coin.

The continued ‘elective’  hospitalization of healthy women is extremely expensive and would be extremely hard to perpetuation based sole on it own merits — the simple presence of laboring women in a an acute care location but without any regular use of such medicalized services. To justify its  Highly medicalized childbirth, which quite obviously  as an  entire house of ca By frequently using the standard PR techniques such as calling press conferences and providing press-releases about newly published articles and papers, they have convinced even the most friendly of medical profession that: “Where there’s smoke, there must be fire”.

In this instance is a general acceptance of the notions that PHB & “other ” midwives are indeed responsible for high rate of baby deaths. Don’t miss the last in this series and some suggestions about what can be done to correct these false impressions.

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