"Medwife" and Proud of It

Midwife is a generic word for a person who attends a woman in labor and delivers the baby (do NOT ever use the word "birth" as a transitive verb around me. It is a noun). Roughly speaking, midwives come in two varieties in the US: "direct entry" midwives and Certified Nurse Midwives. "Direct entry" midwifery can mean just about anything: any woman who is either apprenticed to someone who calls herself a midwife, or who does a "course" (which may be anything at all --there is no governing body -- ranging from hippie nonsense to basic obstetrics). She may never have had to pass any examination, either theoretical or practical to demonstrate that she has a requisite level of knowledge and ability.

At the time I studied midwifery in the UK (1974-75), there were no accredited or licensed midwives in the US except for graduates of two institutions, one of which was the Frontier Nursing School in Kentucky. It was a post-graduate school for those who were holders of certificates from 3 year diploma nursing courses (academic degrees in nursing having only begun a few years previously; the vast majority of registered nurses were diploma holders) and who were licensed, after examination, as Registered Nurses in one or more states. (When I finished nursing school in 1967, there weren't any accredited midwives at all in New York and most other states). The Frontier Nursing School provided midwives originally to remote, rural regions like Appalachia where women had no access to doctors at all. Even as late as the 1940s they made their rounds on horseback in some places.

The reason I chose Cambridge in the UK was because the British had a reputation for a very high level of excellence in their midwives. One of the texts I used, the classic "Maggie Myles" (Textbook of Midwifery by Margaret Myles, 8th edition) actually stated that trained midwives were one of the UK's "major exports", especially to the Commonwealth countries and former colonies of the now-defunct British Empire. It was a year course, 9 months in hospital, three months "on the district" (i.e. doing home visits and home births), open only to those who had the British equivalent (SRN) of the American RN. A State Certified Midwife had certain legal obligations, her code of practice was extremely clear and precise, so that we worked with, not for, doctors, and had considerable autonomy about giving medications, etc. Once, however, certain parameters had been crossed, we could no longer be the main care provider. When I returned to the US, my SCM was the full equivalent of a CNM. Now, with all nurses being required to be the holders of at least a BA, courses to become a Certified Nurse Midwife in the US is a Masters' degree program. My British SCM was accepted unconditionally in Israel and I was granted a license by reciprocity; since I came to live in Israel in 1976, I've never practiced as a midwife in the US, although I worked as an RN in Labor and Delivery from nursing school graduation until 1974, so that I've never worked outside of maternity nursing in 44 years.

The current situation in the US is a mess. Some states do not permit midwives of any type to attend births; some define anyone attending a birth as a midwife even if she has had no education of any variety, some states allow CNMs, and lastly there are states which grant privileges to holders of a bewildering assortment of qualifications and licenses: CM, CPM, PM, LM, etc. Unlike the UK, there is no national professional body which sets curricula, or registers, or supervises midwifery practice.

Why do I bother to delineate the various categories of midwifery in a country I will never live in, God willing, again? Why should it matter, especially as I am coming to the end of my career? Because there are great misconceptions about midwifery, and the role a midwife plays in the care of women.

I tend all sorts of women, in all stages of pregnancy, whether they are high risk or low risk, whether they want medication in labor or do not. (For me, the issue of home birth does not exist: I do not think it is safe under existing conditions, in the US. The trend, in those European countries where it is permitted, under strict regulation, is away from home birth -- but that is another topic, which I hope to deal with in a separate post). Direct entry midwives lack the knowledge to care for any but the simplest, low-risk situation. They certainly do not have the requisite knowledge to safely deliver at home, and no hospital will employ them. The fact that some women do successfully deliver at home is sheer luck. In point of fact, it isn't very many. Less than 1% of births in the US are at home. But the biggest problem with direct entry midwives, as opposed to CNMs lies in the fact that, for the untrained midwife, ideology plays a much larger role than for a CNM. This ideology can be regarded as either inspiring or ominous.

It goes something like this: hospitals have medicalized what is a normal, uncomplicated biological phenomenon; have turned pregnancy and labor into a form of illness from which the average woman needs to be rescued. That pregnant women have been brainwashed into believing that they need medical and/or surgical intervention in order to deliver their babies; that doctors won't allow them to have the "glorious", spontaneous, uncomplicated "birth experience" that women are entitled to have. Usually some reference is made to how simple it all was "back in the good old days" before "medicalization" of labor. As evidence, the ever-rising incidence of Caesarean Section is referred to, called the "unnecessarean", often performed by the "slice and dice" doctor in order to free him to get to his dinner or the golf course. "Trust birth" is one mantra, and much too often, "female empowerment". The term "birth rape" has been coined by radical women who complain of being powerless in the labor room, as if they had more knowledge than the professionals who tend them.

An old, very experienced OB/GYN once said to me that one could only claim that a birth was complicated or uncomplicated in retrospect, and he was right. Things can, and do, go wrong in even the lowest of low-risk births. (This is one of the reasons I like obstetrics: while the vast majority of births will go as expected, when the axe falls, it falls fast and everyone has to be instantly ready; anyone working in midwifery has to wear multiple hats) The stakes are high: women do still die in childbirth, although the numbers are miniscule from the second half of the 20th century onwards, compared to the period before that. Babies die, or are damaged in birth, women may survive but lose their ability to ever become pregnant again. Birth is a kind of Russian Roulette and anyone who does not respect birth's negative potential is an idiot, or willfully blind.

Prior to about 1920 there were few statistics. Birth was indeed thought of as so normal as not to require research or record keeping, beyond the legal requirement for a birth certificate and perhaps a parish register. In the 18th century, it has been noted, the average marriage in certain British parishes lasted for 17 years -- men died from illness or accident, women died in childbirth. It wasn't uncommon for men to marry as many as three times with two wives dying in childbirth, but death in childbirth was regarded as fate, not pathology. These are the wonderful "old days" today's super-natural birth advocates refer back to. I've got a host of stories of deaths and traumatic deliveries, some of which changed the course of history, that simply wouldn't happen today.

Along with better record-keeping, and advances in medical knowledge, came two very important technological improvements: the advent of general anesthesia in the mid-1850s, and antibiotics, namely Penicillin, in the 1940s. Until then, while obstetric forceps had been around since the 18th century (and were often used in extremely traumatic ways in situations that otherwise would have called for intrauterine destruction of the fetus as the only way to get it out), Caesarean Section was virtually impossible unless one was willing to sacrifice the mother to hemorrhage, shock, and/or infection. Suddenly, both the woman and her baby were likely to survive. Maternal deaths plummetted; so did the mortality and morbidity statistics for the baby, although not by such a large amount. Women came to believe that every birth would result in a perfect outcome. And that birth could be painless.

In the 1960s the concept of "natural childbirth" came into being. The drawback of the combination of medications (Demerol --pethidine, scopolamine, and phenergan), given intravenously, called "Twilight Sleep", was that the baby was often born very depressed and needed resuscitation; the medication crossed the placental barrier and into the baby very rapidly. Research claimed that the first half hour after birth was an essential "bonding" time for mother and infant, and with a mother doped up, she was deprived of this (how nearly all of us, born to mothers during the era of heavy medication, ever bonded with our mothers and they with us, was ignored -- just as the generation of bottle-fed infants, often on strict schedules, ever grew up normal is another question). Various techniques, such as Lamaze, were developed to assist the woman to cope with her contractions without getting medication. Up to a point, they worked. A lot depended on the kind of labor the woman was experiencing, and her pain threshold.

It was now known, through statistics, that women having certain kinds of labor had the best outcomes. Contractions and cervical dilatation could be plotted on a graph (the Friedman curve) and if a woman's labor deviated radically, it was shown that medical intervention such as pitocin augmentation, increased the chance of good outcomes. Prolonged labor resulted in a substantial number of cases in increased fetal morbidity and lasting disabilities. The March of Dimes, which originally was set up to deal with cerebral palsy sufferers, which was most often a consequence of prolonged labor, changed its target to birth defects as the number of CP kids declined. The ability to resort to C/S also decreased maternal and fetal mortality and morbidity. Earlier generations simply did not have the technology, or they would have availed themselves of it. Along with improvements in obstetrics came the idea that any bad outcome must be someone's -- usually the doctor's -- fault, and Americans, in general, are very litigious. I can remember when the tools of fetal monitoring and ultrasound were introduced (early 1970s). It was a mixed blessing. It could give warning of impending complications; it could also lead a doctor to the OR faster than he might otherwise have gone -- and if the baby was born pink and screaming, the parents often felt that the operation had been unnecessary. Epidurals, pioneered in the Vietnam War, brought the concept of "painless birth" much closer, too.

And suddenly, what I can only call the "Luddite response" to childbirth came into being. "Natural" childbirth became "childbirth without any medical intervention whatsoever" and appealed to women who had never seen the pre-modern carnage that attended childbirth before modern techniques. To be fair, both doctors and hospitals had managed, by now, to alienate many women, through poor communication and an emphasis on sterility and technology. Delivery rooms which had white-tiled walls had a tough time even admitting that pastel colors might be preferable. Delivery positions other than lithotomy were regarded as primitive. And a husband who wanted to be with his wife in labor was thought very odd indeed, not to mention probably a potential contaminant of the aseptic atmosphere. This is still going on, in places. It's no wonder home birth looks attractive to someone who has no knowledge of the potential dangers of giving birth where there is no instant availability of emergency care. It's no wonder a woman resents a doctor who uses a line like "don't worry your pretty little head" or a variant thereof since the rise of feminism. I've never understood the attraction of suffering unnecessary pain as being "empowering", but I do know there are many women who do so. Sometimes I think it is just to make the doctor, especially if male, uncomfortable.

The history of obstetrics in the US is a very interesting subject. Doctors -- accoucheurs -- were first gaining a foothold among aristocratic women in Europe when America was in its infancy. Wanting only the "best", American women demanded obstetricians to the exclusion of midwives and it's been that way ever since. Indeed, in the 1930s, the only midwives licensed to practice in Louisiana, for example, were black women who tended other poor black women who could not afford a (white) doctor. We were shown a film about one of these when I was in nursing school ("All My Children") and it was appalling.

The super-"natural" school of thought regards persons like myself, who think there is a middle-of-the-road approach to pregnancy and labor not as "midwives" -- that title being reserved for those who eschew all modern advances in medicine -- but as "medwives", midwives who are in thrall to the hated medical establishment. My philosophy is simple: my goal is a healthy mother and baby. Whatever it takes, I'll do. When I can act in accordance with the mother's wishes, I am happy to do so, but my responsibility as a professional will not allow for undue risk to either patient. In my experience, when patients are properly informed, there usually is little opposition to my suggestions. In situations where I am caring for a patient in conjunction with a doctor because of some high-risk condition, I usually find that the doctor and I have a good working relationship; we respect each other's boundaries. The patient benefits from a joint approach. Communication, trust, and respect are of the utmost importance. The practice of obstetrics is both an art and a science. The knack is knowing which to employ in any given situation.

Much has been made of midwives --almost always the direct entry variety -- who accept patients who are patently unsuitable for exclusive midwife care. Right now there is a huge hullabaloo about Karen Carr, who accepted a woman after more responsible midwives refused to take her as a client, due to more than one high-risk condition that made home birth extremely dangerous. In the event, Ms. Carr actually delivered the baby, who died, in a state where she is not licensed to practice, yet she has aroused a surprising degree of support for her action, and the woman's right to take a course of action which caused her baby's death. (The mother, btw, is not being prosecuted for manslaughter, since an unborn fetus has no legal rights. I find this also reprehensible) Due to a plea bargain, Ms. Carr is now able to wreak havoc on more babies and mothers, btw. This is one of the reasons that there should be nationwide licensing, nationwide supervision, nationwide standards of practice. In European countries this is so. But non-CNM midwives in the US resent having any restrictions put on their method of working, and as I stated at the beginning, the US is a patchwork of regulations, or lack of them, for midwifery practice.

So I stand by the title of this post: the term "medwife" is not a negative term, in spite of attempts to make it so. With the increasing shortage of doctors specializing in obstetrics, midwifery will become more common. I only hope that the practitioners are Certified Nurse Midwives, who are real professionals, and that the incompetent, under-educated, unsupervised, "cowboy" midwives are relegated to history.