Physiological principles provide
the safest and most cost-effective form of maternity care. According
to the World Health Organization,
it is
the preferred standard for healthy women.
W.H.O. refers to this as the
"social" model of childbirth; most
countries depend on these low-tech / high-touch methods
to provide cost-effective care. In the US, this known as "family-centered"
or "mother/ baby/ father-friendly" maternity care.
Approximately 70% of pregnant women in the United States are healthy and have
normal pregnancies. That is approximately three millions normal births
annually.
"In the first place, Do No Harm" ~ putting the
Hippocratic Oath into practice
True mastery in normal childbirth services
means bringing about a good outcome without introducing any unnecessary
harm. Our present system of obstetrics for normal childbirth does not do
well in this regard. In spite of spending more money than any other country
in the world, the United States is 30th in maternal mortality and 22nd (3rd
from bottom) in perinatal mortality. The five countries with the best
outcomes spend only a fraction of the money we do. They all have national
maternity care systems that depend on physiological management as provided by
professional midwives to healthy populations.
Our maternal-infant mortality record is dismal
because obstetrical interventions, originally developed for complications, are
inappropriately used on healthy women. This introduces unnatural risk and
unnecessary complications. Avoidable
problems are the
result of disturbing the normal biology of labor and birth by routinely
applying medical and surgical interventions to nearly 100% of the
childbearing population.
|
Textbook
pictures instructing medical students in the surgical technique of
Episiotomy -- an incision
into the vagina during the pushing phase of childbirth. It is never
medically necessary unless the
unborn baby is distressed or if the
mother is exhausted and asks for an
episiotomy. |
|
 |
 |
|
blades of the surgical
scissors
inserted into vagina |
surgical scissors
closed so as to
create a 2-3 inch incision |
The Maternity
Center Association of NYC recent surveyed healthy women with normal term
pregnancies who gave
birth in the previous 24 months. This was done in an effort to track
contemporary obstetrical trends and the quality of care received by healthy
childbearing women. The 'Listening to Mothers' survey revealed that 99% of healthy pregnant women do not
receive science-based maternity care from their obstetrical providers. An average of seven or more
serious medical or surgical procedures were performed on each laboring woman.
As reflected in this study, there were virtually no spontaneous, unmedicated births (i.e., without
medical or surgical interference) in institutional settings.
[Listening
to Mothers by the
Maternity Center Association
of NYC, October 2003].
That means nearly three million healthy childbearing
women are exposed each year to unnecessary obstetrical interventions. Without truly informed consent, healthy childbearing women have been unwitting
subjects in an unregulated medical experiment for more than a century. Non-consensual medical treatments
are routinely forced on competent adults.
A healthcare system that over treats
three-quarters of its patients (3 million each year) is both expensive and
dangerous. It exposes mothers and babies to unnecessary physical and mental
suffering and increased rates of preventable death and disability. Recently
the obstetrical profession has upped the ante by promoting the strange idea
that an 'elective', or medically unnecessary, 'maternal choice'
cesarean is safer than normal childbirth. Many in the obstetrical
profession predict that cesarean delivery will completely replace normal birth
within the next decade or so to become the obstetrical "standard of care".
For society, this irrational and unscientific
system misdirects scarce economic and human resources that could more properly
be used to treat the ill, the injured, and the elderly. Healthcare
expenditures account for 17% of the Gross National Product. Obstetrical care
accounts in the US for 20% (1/5th) of our entire healthcare budget (equal to
3.4% of our GNP). Seventy percent of those maternity care expenses (2.4% of
the GNP) are inflated by unneeded medicalization, which generates additional
(and expensive!) complications.
The bill for this failed medical experiment
is being passed on to the public and to employers through the Medicaid tax
burden and the increased cost of health insurance. In order to remain
competitive in a tight global economy, many industries are outsourcing
manufactured goods and replacing service jobs with offshore workers.
Economists have identified our inflated health care costs (compared to other
countries) as a major factor in the choice of cost-cutting measures that
depress our economy and deprive Americans of employment opportunities.
To remain competitive in a global free market, the US must
utilize more efficacious forms of maternity care to meet the practical needs
of healthy families. Worldwide, the global economy depends on
the use of physiological principles and low-tech, inexpensive methods of midwifery care for normal birth
services to retain its competitive edge. The US must also utilize these safe
and cost-effective forms of care in order to compete in a global
economy.
A rehabilitated policy would integrate the classic principles
of physiological management with the best advances in obstetrical
medicine. This would create a single,
evidence-based standard for all
healthy women used by all maternity care providers. Under a rehabilitated system, management strategies would be
determined by the health status of the childbearing woman and her
unborn baby in conjunction with the mother’s stated preferences, rather than
by the occupational status of the care
provider (family practice physician, obstetrician or midwife). At present, who the
woman seeks care from (obstetrician vs. FP physician or midwife) determines how she is
cared for.
Our tort laws currently force most doctors to provide interventionist
care irrespective of the health status of the mother or her wishes. It
should be noted that this creates an
asymmetrical burden of risk that falls
unfairly on the childbearing woman. The mother /baby couple is exposed to the
actual pain and potential harm of medical and surgical interventions in order
to reduce the risk of lawsuits for the obstetrician. This is deeply
offensive and must be corrected.
Medical
journals, textbooks and scientific sources all make it clear that routine obstetrical
intervention and normal birth conducted as a surgical procedure are always more dangerous
for healthy women than the use of
physiological principles, in conjunction with appropriate social and psychological
support. Scientifically speaking, this is not a controversial finding.
Reliable scientific evidence is neither lacking nor incomplete, nor is this
data the subject
of methodological disputes.
Consider this: If planes landing at US airports crashed
five times more often than when they landed at airports in England
or Japan,
we would demand an inquiry of our air traffic control system, since the laws
of aerodynamics are the same worldwide. Each year in the US about 8 million mothers and
babies 'fly' the united service of interventionist obstetrics.
Only a fraction -- under 30% -- need and benefit from this type of medicalized treatment. Isn't it time to inquire why the universal 'laws
of normal childbirth,' which are the same worldwide, are being routinely
suspended by American obstetricians and, as a result, American mothers
and babies are crash landing at an alarming rate.
====================================================================================
Problems
and Proposed Solutions
The following goals can
be achieved by demanding that our national maternity care policy
recognize the "social" model of maternity care for healthy women as the
preferred standard for healthy women.
1.
Recovering
Institutional memory within the obstetrical profession and re-establishing
physician expertise in physiological
management and socially based childbirth services:
Prejudice against
'natural' birth methods and a century of routine hospitalization for all normal
childbirth displaced important opportunities for doctors to learn and use
physiological methods for supporting labor and spontaneous birth. In the last three
decades the standard medicalization of childbearing has been greatly expanded.
High-tech surveillance during the prenatal period now exposes every normal
pregnancy to repetitive ultrasounds and non-stress testing and other
diagnostic procedures. Premature and/or artificial termination of normal
pregnancy by induction, instruments, surgical incision, or cesarean section is
now the statistical norm. Childbirth for healthy women is typically
accompanied by the routine use of continuous electronic monitoring (93%), inducing,
or speeding up labor with artificial hormones (63%), epidural anesthesia (63%),
episiotomy, instrumental delivery, and/or cesarean surgery (72%).
As a result medical educators have no
knowledge or understanding of the social model of childbirth. Most
hospital-based care providers have no experience in or respect for the
principles of physiological management. Institutions such as hospitals and
health insurance companies have no identified mechanism to authorize the use
of physiological management or to economically compensate practitioners who
bill for professional services associated with the "social" model of care.
The institutional memory of "normal" childbirth is now totally absent for most
obstetrical units and virtually all obstetrical providers. In order to
rehabilitate institutional memory, medical educators, medical students, and
practicing physicians all need to be exposed to the theory and the practice of
physiological management. This requires that medical educators and
obstetricians familiarize themselves with physiologic principles through textbooks and other sources of information and
gain hands-on experience by working with
practitioners (primarily professional midwives) who are experts in physiologic
management.
In a rehabilitated maternity care system, physicians who
provide care to a healthy population would be required to either:
-
utilize the successful strategies
of physiological management themselves
-
cede the care of healthy women to
those who do,
-
or obtain truly informed consent for substituting medicalized
obstetrical care with its well-documented dangers
2. Hospital labor & delivery units
to 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:
Midwives have been the preferred provider for normal
maternity care for millennia. In the history of western culture, midwives have
been an autonomous profession in Europe for many centuries. There are formal
training programs in Scandinavia that have been teaching midwifery to
both doctors and midwives for more than 200 years. Midwife-graduates of these
programs currently staff hospital labor and delivery units of all over Europe.
It is a cost-effective system that works for mothers, for midwives, and for
taxpayers. It appropriately utilizes the lengthy education and highly
technical skills of obstetricians, who are called in when complications develop during labor and birth.
This European system, which depends on professional
midwives to staff their maternity units, assures that physiological management
is taught to medical students and remains the standard used by all
practitioners. This system frees obstetricians from many "routine" duties,
thus permitting them to be the highly trained experts their education prepared
them to be.
In order to develop to this system in the US, it is
important that educational "bridge" programs be developed for L&D nurses, so
that any who wish may evolve into hospital-based practitioners.
3.
Fully Informed
consent for medicalized care -- especially for labor induction, augmentation,
anesthesia, instrumental and operative delivery:
Fully informed consent would require true informational transparency
relative to the documented consequences of medicalized labor and normal birth
conducted as a
surgical procedure.
Scientifically correct
information must be routinely provided to healthy women on the short and long-term limitations and
complications resulting from the medicalization of
labor – i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed.
This severely limits or eliminates access to time-tested strategies of
physiological management and right use of gravity, thus increasing artificial
stimulation of labor and operative delivery and all their associated
complications.
Obstetricians must provide valid information during the last
trimester of pregnancy that includes the short and long
term complications
associated with major medical and surgical procedures performed
during the labor – continuous electronic fetal monitoring, restriction of oral nourishment,
IVs, labor stimulating/inducing drugs, off-label use of Cytotec/misoprostol, narcotics, epidural anesthesia, indwelling bladder catheters, episiotomy, vacuum extraction, forceps and a
27% cesarean section rate.
In particular, obstetricians must identify
the lavishly documented failure of continuous electronic fetal monitoring and
liberal use of cesarean section to reduce the rate of cerebral palsy and other
neurological disabilities. For example, a July of 2003 report by
In particular, obstetricians must identify the
lavishly documented failure of continuous electronic fetal monitoring and
liberal use of cesarean section to reduce the rate of cerebral palsy and other
neurological disabilities. For example, a July of 2003 report
by the
ACOG Task Force on Neonatal Encephalopathy & Cerebral Palsy
stated that:
|
"Since the advent of fetal heart rate monitoring, there has
been no change in the incidence of cerebral palsy." "... The
majority of newborn brain injury does not occur during labor and delivery.
Instead, most instances of neonatal encephalopathy and cerebral palsy are
attributed to events that occur prior to the onset of labor."
Textbook picture ~
EFM
Scalp electrode screwed
into skin of baby's head .... |
 |
An August 15, 2002 report on this topic in Ob.Gyn.News stated that
"performing cesarean section for abnormal fetal heart rate pattern in an
effort to prevent cerebral palsy is likely to
cause as least as many bad
outcomes as it prevents." "... A physician would have to
perform 500
C-sections for multiple late decelerations or reduced beat-to-beat
variability to prevent a single case of cerebral palsy."
The
September 15, 2003 edition of Ob.Gyn.News stated
that:
"The
increasing cesarean delivery rate that occurred in conjunction with fetal
monitoring has not been shown to be associated with any reduction
in the CP rate..." " ... Only 0.19% of all those in the study
had a non-reassuring fetal heart rate pattern.... If used for identifying
CP risk, a non-reassuring heart rate pattern would have had a
99.8% false
positive rate...."
The benchmark for informed consent transparency should be this same
information about complications that is reported to physicians in the
scientific literature and obstetrical trade papers, such as the excerpts from Ob.Gyn.News
included in this document, only restated
for childbearing parents in
lay terms that are appropriate for their
concerns.
Legislation mandating fully informed consent (or
decline) of all major obstetrical interventions, based on a true
transparency model of information, in particular for continuous EFM, labor
stimulating drugs, anesthetics, episiotomy, forceps, vacuum extraction and
cesarean surgery may be necessary.
4.
Tort
Reform:
Currently our tort laws force doctors to provide interventionist
care irrespective of the health status of the mother, or of her
wishes. It should be noted that this creates an
asymmetrical burden of risk that falls
unfairly on the childbearing woman, in which the mother is exposed to the
actual pain and potential harm of medical and surgical interventions in order
to reduce the risk of lawsuits for the obstetrician. This is
unacceptable.
The unexamined theory of our tort laws induces physicians to
protect themselves by 'cost-shifting', 'risk-shifting' and 'blame
shifting'. This is particularly pernicious when obstetrician implement surgical "solutions"
in order to reduce the legal culpability to
themselves, as physicians are not legally responsible for post operative
complications. For instance, they are expressly exonerated from "downstream"
sequelae or time-delayed complications such as incontinence or uterine
prolapse (the sequelae of forceps delivery) or placenta previa, p. percreta or
stillbirth in a future pregnancy (the sequelae of Cesarean section) .
Obstetrician Peter Bernstein noted this in his
essay (Elective
Cesarean Section: An Acceptable Alternative to Vaginal Delivery?) which noted that the law (and at present the ethical designation by society)
inappropriately
protects the physician who chooses to reduce the litigious risk to
himself by shifting it forward to the mother and/or baby in a future
pregnancy. According to Dr. Bernstein:
There may be
no legal
liability to the physician who performed the patient's first cesarean section
when the patient winds up with a hysterectomy or worse, but that does not clear
that physician of responsibility for performing a surgical procedure of
unclear benefit....
In the short term, the most direct remedy to this
problem is truly transparent informed consent for the use of interventive and
operative obstetrics. In the long term it requires the rehabilitation of two
important areas of modern life --our tort laws and of our maternity care
system.
5.
Reassessment of policies severely restricting or denying
obstetrical care for normal labor and vaginal birth after a cesarean (VBAC):
#1Excellent
supportive study Vaginal Birth After Cesarean and
Uterine Rupture Rates in California
for 1995;
#2 Quotes
from additional supportive study on VBAC safety
If one counts the full spectrum of risks associated with delivery by
cesarean section -- intra-operative, post-operative, delayed and downstream
complications for both mother and baby, including complications arising in
post-cesarean pregnancies -- the evidence is overwhelmingly in favor
of spontaneous labor and normal birth. A consensus of VBAC studies published
over the last 20 years has repeatedly confirmed this. A recently published
California study found the very safest category (aside from women with no uterine surgery) was spontaneous vaginal
birth after cesarean, which was even
safer than elective repeat CS.
However,
"faith-based" reporting by the news media has poisoned the issue of VBAC safety
in the public mind. Aggressive coverage of the VBAC topic by the press was
precipitated by a study in the
New England Journal of Medicine
in June of 2000. Unfortunately, the
blind faith of the press disarmed the natural inquisitiveness of responsible
reporting.
According to this research,
there was a 5 to 15-fold increase in
uterine rupture in post-cesarean labors when powerful uterine stimulants
(especially prostaglandin drugs such as
Cytotec) were used to induce
or augment labor in women with a surgically scarred uterus. However,
the press got the story backwards. Spoon-fed a physician-friendly "spin"
with a hidden agenda, the press acted as a conveyor belt for obstetrical propaganda.
Instead on focusing
on the real danger -- the use of powerful artificial hormones to induce
labor -- newspaper stories
wrongly identified the primary danger for VBAC mothers to be normal
(spontaneous) labor and spontaneous birth. This story was spread across the
entire country by the Associated Press and even carried by National Public
Radio. The syndicated news coverage precipitated a crisis of gigantic
proportions for post-cesarean families all across the country as newspaper
stories urged the complete and immediate abandonment of post-cesarean labor
based on safety.
The media
claimed that new research identified great danger in spontaneous labor
(i.e., not induced, no artificial hormones to speed it up) that
had gone unnoticed until now. Obstetrical spokespersons interviewed for these stories resurrected the 1930s axiom
that "once a
cesarean, always a cesarean", as these doctors assured everyone that 'elective'
repeat cesarean was so much "safer for the baby". However,
the scientific literature on VBAC has not changed at all in the last 20
years, except to identify the added risk of labor-inducing or accelerating
drugs in post-cesarean pregnancies. The consensus of VBAC research continues
to find the incidence of uterine rupture associated with labor to be low --
approximately .05% -- and to identify spontaneous labor as safer than
repeat cesarean surgery and anesthesia.
In combination with the skewed reports of this study, the American College of
Obstetricians and Gynecologists' (ACOG) changed their 1985 practice guidelines
by re-defining normal VBAC labors as extremely high risk. They generated
protocols that make VBAC more expensive for hospitals and extremely inconvenient
for physicians. As a result, most obstetricians are unwilling/unable to provide
VBAC care. For example, the new ACOG protocols require the obstetrician,
anesthesiologist and surgical scrub team be all present in the hospital for the
entire time that VBAC mothers are in active labor. Smaller hospitals cannot
provide this kind of coverage. Many other simply refuse, since repeat cesareans
are more profitable.
Then malpractice carriers began to charge higher insurance premiums if
doctors and hospitals 'allowed' post-cesarean women to labor naturally. Many
obstetricians and hospitals eliminated the option of a VBAC in order to save
money on malpractice premiums. In large geographical areas of California,
previous CS mothers must drive over 100 miles to find a hospital that will
'permit' them to labor spontaneously. In large areas of the state, there are
NO hospitals or doctors that will attend a VBAC.
Unfortunately, the misrepresentation of the NEJM study propelled the already
excessive use of cesareans to even greater heights. Rather than protect women,
it only exposed even more childbearing women to the many hazards of abdominal
surgery. Today, women are routinely forced to schedule medically unnecessary
cesareans, as more and more doctors and hospitals cop out with a policy of "we
don't labor sit, we don't do VBAC’s". Saddest of all, these self-serving
policies replace the small theoretical risk of a spontaneous birth (no labor
inducing drugs) for the greater hazards of abdominal surgery.
Make no mistake about it --
it is the use of prostaglandin and other labor inducing drugs on VBAC women that should be abandoned
– not normal labor.
The true risks of "elective" cesarean: Cesarean surgery carries
added dangers not
associated with normal
birth. This fact has always been well known by doctors but rarely admitted to the public.
(ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD).
The incredibly high Cesarean rate in the US is fueled by the mistaken notion that it does not matter how the baby is born “as long as it is
healthy”. This discounts or ignores the risks of
elective surgery to the childbearing women at the time of the operation and
complications in future pregnancies, including an increase in postpartum
depression.
Cesarean surgery
increases maternal
deaths by 2 to 4 times compared to normal vaginal birth. Maternal mortality
rate associated with vaginal birth is only 1 out of 16,666. It jumps way up to 1
out of 3,225 after a Cesarean.
(Lilford, 1997 et el) One popular obstetrical text
reports Cesarean-related maternal deaths to be as high as one out of
thousand.
(
Gabbe Obstetrics, 1991) In spite of these known dangers the US
has a higher CS rate than any other country except for Brazil.
In addition, there are serious health problems for
post-cesarean babies not accounted for by the NEJM study, such as iatrogenic
prematurity and respiratory distress. Elective repeat
Cesareans have a fetal mortality of 2 to 3 per 1000 operations.
(Obstetrics:
Normal and Problem Pregnancies Gabbe,
1991)
The May 2004 edition of Ob.Gyn.News noted that elective
cesarean is riskier to the newborn baby than vaginal birth. It stated:
"Neonates born by elective cesarean section are at greater
risk of poor outcomes than those born vaginally.... 14% of those
from the elective cesarean group (relative risk 3.58) were admitted to an
advanced care nursery [in contrast with only
5% of vaginal delivery] ....oxygen was used ...
in 73% of those in the elective cesarean group
[compared to only 23% in vaginal delivery group]...
The difference may be
due to beneficial effects of the process of labor and delivery on infants
and their ability to transition following delivery. Clinicians should
consider neonatal effects, as well as maternal well-being, when discussing
the possibility of elective cesarean delivery in patients with uncomplicated
pregnancies, he said."
[emphasis added]
(Ob.Gyn.News May 1, 2004, Vol 39
An example of long-term health
hazards was found in a recent study done in the UK, which identified that
being born by Cesarean triples the risk of adult asthma.
(Journal of Allergy & Clinical Immunology 107[4[:732-33, 2001)
Another factor is the detrimental impact on the mother-child relationship
from an increase in postpartum depression (PPD) and post-traumatic stress
symptoms (PTSD) associated with operative deliveries. Postpartum depression
is more common and more sever after the added stress of a Cesarean or other
operative delivery and if the baby is premature or must be in the intensive care nursery after the
birth. (Predictors, prodromes and incidence of postpartum depression.
Obstet Gynaecol 2001 Jun)
Political strategy for change:
The need to rehabilitate these inappropriate and detrimental policies by
doctors, hospitals and malpractice carriers is obvious. A particularly useful
strategy,
that would also reduce the number of primary (original) surgeries, is requiring
physicians to obtained truly informed consent before any non-emergent cesarean can be
performed. Legislation that prohibits the medical profession
from denying normal birth services to healthy VBAC women who wish to labor
spontaneously (i.e., no labor stimulating drugs or instrumental delivery) may
also be necessary.
6.
Recognizing and protecting the ethical and constitutional
rights of competent adult women to have control over the manner and
circumstances of pregnancy and normal birth.
7. Midwifery as an
autonomous profession.
Historically and globally, the discipline of midwifery functions to guard
normal childbearing and to restrain the excesses of the high tech medical model.
To do this effectively, professional midwifery must be an autonomous
profession in its own right.
For the last 100 years, organized medicine has
used unethical and unconstitutional practices to unfairly burdened the midwifery
profession. Unworkable licensing laws is one example. Written by organized
medicine, these laws inappropriately place the control of the
profession of midwifery into the hands of an entirely different and competing profession
-- obstetricians. The obstetrical profession then use that illegitimate
control to strangle midwifery by keeping it marginalized, criminalized or in a
legal limbo. This directly harms the profession of midwifery and individual
midwives. It also limits or eliminates access to midwifery services by childbearing
women. This political situation is the political backdrop for "flat earth
obstetrics". The excesses of obstetrics are the predictable consequence of
preventing the corrective and humanizing influence of midwifery from being
applied to the field of normal maternity care. Absolute power circumvents
accountability and public oversight. Power plus secrecy corrupts
absolutely.
In California, the 'physician supervision clause' in both the certified
nurse-midwife and licensed midwifery acts, must be repealed. It creates
unnatural and unnecessary vicarious liability for physicians, which totally blocks the ability of
midwife-friendly physicians to consult with midwives or midwifery clients. Both CNM
and LM licensing statutes were originally written by organized medicine.
Lobbyists promised the Legislature that a law requiring
physician supervision would promote public safety by guaranteeing appropriate
access to medical services by pregnant women. Instead of the promised stepping
stone, this provision turned out to be a stumbling block.
Midwifery must be an autonomous profession. The law must be
changed. The unworkable relationship between physicians and midwives must be
replaced with a voluntary one defined as 'collaborative', in which midwives
consult with physicians as needed and are respected by medical and obstetrical providers as
colleagues.
8. Interdisciplinary process
of reform that includes parents /
consumers & midwives as a central part of reformulation:
In order to create a single, evidence-based
standard for all healthy women, to be used by all maternity care providers, a process of negotiation that draws on the best of scientific resources
and the best of human resources will be necessary. The hundred-year old, authoritarian standard must be
transformed, based on
criteria arrived at via an egalitarian & interdisciplinary process.
This must
include the wide spectrum of "stakeholders" -- interested parties,
practitioners and
experts in related scientific disciplines.
As an interdisciplinary process, the tradition of midwifery as an independent profession is central to the
development of a "social" model of maternity care. Equally
central to the process is the participation of childbearing women and their
families. In fact, childbearing families must be acknowledged as
a class of experts in the maternity experience. It is particularly
important to receive Input from women who had complications
following induction, episiotomy, instrumental delivery, cesarean surgery or who found it impossible to
arrange for a subsequent normal labor and birth after a cesarean (VBAC).
==================================================================================================
Conclusions
The main and the plain reading of the scientific literature
brings one to the logical conclusion that physiological management is a safer
and more cost-effective form of care for a healthy population. In a reformed
maternity care system the social model of childbirth, which depends on
physiological principles, would be the preeminent standard of care for all
healthy women with normal pregnancies. This leads us to the natural and
compelling conclusion that our current
medically dominated system of maternity care must be rehabilitated.
This
reformed standard must be based on
criteria arrived at through an interdisciplinary process that
includes the tradition of midwifery as an independent
profession and
integrates the input of childbearing women and their families into the
process.
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 the current reimbursement 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 the
reformed or social model of 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.
One way to
develop an effective rehabilitative process would be to convene a
blue-ribbon panel – experts from the disciplines of public health, sociology, anthropology, psychology, biology, child development, law, economics, midwifery, perinatalogy
and obstetrics. This public exploration must include listening to childbearing women and their families as
a class of experts in the maternity experience. Such a respected forum
could study the scientific literature and provide unbiased, fact-based news
for the press and broadcast media to report. Another suggestion is a
commission appointed by the California state legislature or a public policy
organization such as the Pew Charitable Trust.
