Brave New World of Evidence-based Maternity Care for the 21st Century: Chapter One (2013)

by faithgibson on September 8, 2013

Unpublished manuscript, originally written in the early 1990s, 
revised and updated in 1997, 2002 & 2013

By Faith Gibson, LM, CPM

Chapter One

This chapter is actually a combination “preface” and “introduction”. Usually these are published separately in the very front of the book, but mostly people don’t actually read them.

However, this information is vital to understanding all that comes next, so I have simply incorporated it into the first chapter.  I hope the reader will bear with me, as answering questions that haven’t yet been asked is always risky business.

The big question in any potential reader’s mind is usually ‘what’s in it for me? Is the topic interesting? is the material entertaining or edifying? For “current event” topics, relevancy is a central question. Does the writer knew his/her subject, how well researched is the topic, and what’s value to society?

In the post-911 era, one of the big considerations would be “does it offer insight and a plan for realistic workable for action?” Does it provided realistic and workable answers to the problems it reveals, or does it merely burden us further by giving us yet another potential horror-story to worry about?

Let me assure you that the following material has all the “right stuff”  – relevancy, political intrigue, sex and violence, money and power and incidentally, it’s historically accurate. Furthermore, it is interesting, explores a problem that is genuinely worthy of our time and attention, and is one that already has a proven solution.

But before going any deeper into the subject, let me give you some background information and a brief overview of the problem.

Who I am, why am I writing this?

I am a community midwife who has been providing home-based birth services to healthy women with normal pregnancies for almost 2 decades. I am also a former L&D nurse (about 3,000 hospital deliveries), mother of 3 (all spontaneous vaginal births) and now grandmother of two, one born by Cesarean (1993) one a VBAC at home (1997). I practiced lawfully as a Mennonite midwife under the religious exemptions clause for more than a decade before licensing for non-nurse or ‘direct-entry’ midwifery was available in California. Since 1997, I have been Ca LM #041.

My Life of Crime

However, I am getting a bit ahead of my story. On August 9th, 1991, in a politically orchestrated attempt by organized medicine to nullify the religious exemptions clause as it applied to non-nurse midwifery, I was arrested in my home in the presence of my youngest daughter by agents of the Medical Board of California, and criminally prosecuted over the course of 21 months. There was no ‘precipitating’ event, such as a complaint by a childbearing family, or from a hospital based on a ‘bad outcome’. Nope, it was pure politics and I unfortunately was (an still am!) on the wrong side of that power struggle.

Thankfully the charges against me were dropped after 20 months (and 16 court appearances),when the religious exemptions clause of our state’s Medical Practice Act as it is applied to the non-medical, non-nurse practice of midwifery was validated in court on April 29th, 1993. This little exercise in democracy cost $30,000 in legal fees for which I was never reimbursed (nor the expense of therapy to recover from pre-9/11 post-traumatic stress syndrome!) But ultimately my arrest and the legal research i did initially in my own behalf convinced both the judge and organized medicine that it was time to change the law by  passing a direct-entry-midwifery licensing law in California — the Licensed Midwifery Practice Act of 1993 (LMPA).

In that sense, I suppose it was worth it. I’d like to think I would be brave enough do it again, given that my arrest and the circumstances that eventually forced the “powers-that-be” to drop the charges were directly responsible for the enormous gains in California midwifery laws and practice. But I’m not at all sure that I’d let something like this happen to me again, even if i was sure it would turn out wonderfully.

BC/AC ~ i.e. Before and After my Life of Crime

Before being thrown into the world of criminal prosecution, my life was significantly less stressful. I was a childbirth educator (Lamaze) for families planning home and hospital births. I attended planned home births as a Mennonite midwife providing care to healthy women under Section 2063 (religious exemptions clause). As a previous L&D nurse I understood the ‘system’ (not the same thing as being able to control it), but believed I could round-off a few of its sharp edges by providing social and psychological support to women planning hospital labors and births.

I was administrator for a professional liability plan (i.e. malpractice insurance) for 55 community midwives in three states, an expert witness in midwifery-related criminal and administrative court cases, and founder/executive director of the American College of Community Midwives. Currently I am the chief “web wife” and bottle washer for the ACCM internet site (www.collegeofmidwives.org), as well as several sister sites {footnote w/ URLs).

I wrote an extensively researched historical account of the politics of medicine and midwifery, entitled “The Official Plan to Eliminate the Midwife – 1899 to 1999, that was published in 2002 in a feminist anthology edited by Wendy McElroy called “Liberty for Women” (www.independent.org ). In September 2011 the professional Journal BIRTH published an essay of mine called “Time Travelers’ Perspective on Normal CB”. elected chair first 3 yrs, served 2007 to 2013

Between the time the criminal charges against me was dropped (April 1993) and now I have been doing my best to see that the professional practice of direct-entry midwifery goes as smoothly as possible for California licensed midwives and childbearing families, while also serving the general interests of society. That’s a long (not always so interesting) story that will gets its own chapter later on.

But it goes without saying that I believe healthy childbearing women have an ethical and constitutional right to choose the manner and circumstance for normal or ‘physiologically-managed’ childbirth. This includes a non-medical setting – home and independent birth centers under the care of skilled and experienced midwives.  But the bigger and more important issue is that no healthy CB woman should ever be forced to choose between a midwife and a physician, or btw a home and a hospital birth in order to have a physiologically-managed normal birth.

In support of those rights I have been politically active for three decades in various aspects of obstetrical nursing and community-based midwifery, particularly the issue of midwifery licensing. I am most proud of my work to get legislation passed that legally reversed important aspects the Bowland Decision and established the right of healthy women to have control over the manner and circumstances of their normal birth (SB 1479 by Senator Liz Figueroa), including the right to give birth at home with a professionally-licensed midwife.

The care that I, and other midwives like me, provide to healthy mothers with low and moderate risk pregnancies is as safe (often safer) as hospital-based birth services provided by obstetricians to the same cohort of healthy childbearing women. These facts are acknowledged in the direct-entry midwifery licensing law in California.

 Overview of 21st Century Maternity Care — Statement of Problem

However I have come to believe that, politically speaking, the issue of “home birth” is a really red herring — that is, a topic that distracts us from the more important and more obvious issue which is the quality of care received by the 99% of women who choose to labor and give birth in hospitals or, due to medical circumstances, must labor and give birth in hospitals. This is where the rubber meets the road for the vast majority of mothers-to-be and newly delivered  women and their newborn babies.

Hospital-based maternity care must work for all its “stakeholder” – mothers, babies, fathers, families, hospital personal, doctors and nurse, HMOs and even for health insurance companies, malpractice carriers, government-sponsored Medicaid program and for the taxpayers who foot the bill.

At present, the cost of maternity care accounts for slightly more than 25% of our entire healthy care budget, which itself is 1/6th of our GNP. Two-thirds of this money goes to provide birth-related services to healthy women with normal pregnancies and normal births, over 70% of the childbearing population (cite P. Schlenzka, 1999). The US spends more money on childbirth services than any other country in the world, yet we have next to the lowest vaginal birth rate (i.e. highest Cesarean section rate,  after Brazil). We rank 39th in perinatal mortality out of developed countries. In addition to its expense, there are other glaring problems with the current system that beg for correction.

Unfortunately for midwives like myself, the answer to this dilemma is not home birth midwifery. Where CB women themselves want or need to be for childbirth is where the corrections must be made and 99% of the time that is a hospital.

The challenge is to improve our hospital-based maternity care system in conjunction with necessary changes in our national maternity care policies that underlie the provision of these services and the reimbursement of its care providers.

The following material is designed to elevate our understanding of healthy childbearing and explore the problems facing us as individual women and families and as reflected out into society. This includes the excesses that at present dominate obstetrical medicine, coupled with the total failure of the public press and broadcast media to adequately report on the iatrogenic complications that the “standard” interventive model of obstetrical care for healthy women introduces into normal birth.

Last but not least, I will recommend realistic, achievable remedies and present a plan and a process — an “exit strategy”, to put it in the military-speak of our day — to end the Hundred Years War between medicine and midwifery.

This gender-based conflict is a complicated story of political intrigue, natural and unnatural tensions between “art” and “science” and the frequent confusion of superstition and junk science for valid scientific facts. More than any other aspects of medicine (with the possible exception of psychiatry), the lack of a solid scientific foundation has plagued the field of obstetrics for at least a hundred and fifty years. [link to “Story I hate to tell and no one should every have to hear“]

For those who want well-referenced on-line sources on the political history of midwifery and medicine, I suggest starting with “The Official Plan to Eliminate the Midwife ~ 1899 to 1999”. If you are looking for formally published background information, I refer you to my essay as published in “Liberty for Women”. The story of contemporary medical and midwifery politics and the criminal case against me in 1991 are contained in Jessica Mitford’s book “The American Way of Birth”, John Robbins’ book “Reclaiming Our Health” and Penfield Chester’s book “Sisters On A Journey”. All are available online.

I maintain an extensive library of historical and contemporary textbooks that includes carefully labeled three-ring binders containing indexed articles from professional peer-review journals and other sources. These contain the material referred to by the citations provided for the factual statements contained in this book. At last count these documents filled 43 notebooks. This material is available to anyone who wishes to take up the challenge to actually become familiar the scientific basis for appropriate maternity care as provided to healthy women and to identify those areas of contemporary medical practice that fail to live up to that minimum standard.

Target Audience — Birth Professionals, Lawyers, Legislators, 
Journalists and Professional Writers for the Broadcast Media

My target audience is birth professionals of all backgrounds, lawyers, legislators, journalists and professional writers for the broadcast media.

In particular, this material is not designed for pregnant women, either as information on maternity care choices or in preparation for childbirth. My strong advise — do not read this if you are pregnant or plan to get pregnant in the near future. Just as you would avoid certain foods and toxic substances, I urge you to fast from negative descriptions of all kinds. Keep your mind peaceful and be happy. There is plenty of time later in your life to research the politics of obstetrical care and become a birth activist. If you are pregnant (or planning) and looking for the best reading material I hardily recommend the following four books: The Baby Catcher by Peggy Vincent, Misconceptions by Naomi Wolf, Expecting Trouble by Dr. Thomas Strong and The Thinking Woman’s Guide to a Better Birth by Henci Goer. They can all be ordered from Amazon.com or other on line book dealer.

Lets Start with the Good News

The American public has, with good reason (especially in the shadow of September 11th, 2001), become tired of being bombarded by the “crisis” of the month. This is some individual or group who are either creating or exploiting hysteria. The topics for this include (more timely examples à toxic dumps, bad schools, defective tires, dishonest accounting methods or over-stated corporate earnings). The list is just endless and grows daily. We don’t want to hear that there is yet another reason to worry about something that no one knows what to do about. Or worse yet, someone is proposing the expenditure of huge sums of money researching a solution that will, no doubt, take decades to find and include some painful or far-fetched remedy or expensive drug with horrible side-effects.

But unlike global warming and bio-terrorism, we know what to do about the “problem” generated by the obstetrical profession’s ignorance (or rejection) of science-based management as it applies to healthy women with normal pregnancies. The solution to this problem is no secret. There are lots of resources – sound scientific evidence, textbooks and knowledgeable, experienced people (midwives and midwifery-friendly doctors) who can teach the principles and demonstrate skills of physiological management.

This will reduce our Cesarean rate by 50% while making for happier mothers and healthier babies and freeing up an additional 10% of the health care budget to spend on people who are genuinely ill or injured.

In the long run it is a win-win solution, as obstetricians will get to do what they are trained for — focus care on those suffering from the diseases and dysfunctions of fertility and childbearing.

And should a terrorism event (biological or otherwise) occur and hospitals become overwhelmed with the injured or ill (perhaps with contagious diseases), we will have midwives available to provide safe, community-based maternity care without having to waste the precious medical resources of doctors and hospital beds on the care of healthy mothers and babies in the midst of a life/death national emergency .

Continue to Chapter 2