Born in the USA (19 page)

Litigation can also have an effect on the Cytotec problem, but almost all Cytotec cases are settled out of court and the settlements include gag orders, so the public never hears about them. Of course, insurance companies, hospitals, and pharmaceutical companies do hear about the big settlements. Their initial response is to rush to their political friends and try to lobby the government to cap malpractice awards or limit the right of patients and families to sue. But it is only a matter of time before hospitals and insurance companies will begin to put pressure on doctors not to use a drug that is not approved by the FDA and could end up costing them lots of money in litigation. In
chapter 7
we will look further at the important role “drug regulation by litigation” plays in our society.

In the United States, many obstetricians have no faith in democratic institutions such as the FDA. They express disdain for the public realm and contempt for any attempts to monitor, much less regulate, their practices. Their attitude reveals a desire to go it alone that, when combined with decades of a reactionary approach to medical care, undermines the social contract between doctor and patient. It is an underlying problem that touches many areas of American reproductive life.

Most obstetricians are also gynecologists, and the hot new field in gynecology—artificial reproduction (in vitro fertilization, etc.)—is also full of hype, false promises, and malpractice.
³⁷
Every other industrialized country has found it necessary to develop government regulations around artificial reproductive services. But in the United States, after congressional hearings, regulations were adopted for the laboratories used by the reproductive services, but the clinical part of the practice, the part that involves gynecologists, was left unregulated, even though that is where malpractice is rampant.

American medical practice overall has far and away the least amount of regulation of any country in the world—making it fertile ground for vigilante practice. Not only do many of our doctors lack faith in democratic institutions, so do many of their patients—the American public. Health care consumers in the United States are generally timid and have been quick to acquiesce to doctors' complaints of encroachment by HMOs and government, allowing the tyranny of an obstetric monopoly to continue. They put physicians on a pedestal because they need to believe that doctors can
help them when they're sick, and as a result, doctors believe that they are above the law. These attitudes create an environment where vigilante practice is possible, and nowhere is this more apparent than in the use of drugs and technology by American obstetricians.

In the United States, the obstetric establishment is powerful and the government regulatory bureaucracy is too weak to stand up to pressure from the pharmaceutical industry, the insurance industry, and the medical industry (doctors and hospitals). The results are underregulated drugs, a lack of safety studies and studies of questionable quality, seduced or sleepy media, and underinformed women and families. We must do all we can to turn this around. On a grassroots level, there are encouraging signs, such as several Internet support groups formed by women who have suffered from uterine rupture and survived. One has more than 350 members.
³⁸
The question now is: How many women and babies will have to die or be damaged before the tragic practice of inducing labor unnecessarily is ended?

Because the midwives feared God, they did not do as commanded by the king.

EXODUS 1:17

A midwife is lectured at by committees, scolded by matrons, sworn at by surgeons, bullied by surgical dressers, talked flippantly to if middle aged and good humored, seduced if young.

“THE TIMES,” LONDON, 1857

After working as a practicing physician for several years, I became a perinatologist and perinatal scientist, as well as a full-time faculty member at the Schools of Medicine and Public Health at UCLA. Then I became a director of maternal and child health for the California State Health Department. In that capacity, I learned that in the rural town of Madera, California, doctors had decided that they no longer wanted to attend births in the Madera County hospital. They complained that it took too much of their time and didn't pay enough. So in 1968, two out-of-state midwives were recruited by the county to fill the gap. After two years of midwifery practice at the hospital, the rate of babies dying around the time of birth in the Madera County hospital was cut in half. Alarmed that their style of maternity care was being made to look bad, the doctors in town agreed that they would once again attend births in the hospital if the two midwives were fired. The hospital fired the midwives, the doctors returned, and soon the rate of babies dying around birth rose to its earlier higher levels.
¹

This natural experiment comparing the safety of doctors and midwives left me confused and full of questions, because, in spite of my years of experience as a physician, I had no real knowledge of midwifery. Who are these
midwives? How are they trained? Could it be that, as seen in Madera County, they are generally safer birth attendants than doctors? Through no fault of their own, Americans, including obstetricians, have little understanding of midwifery. In the early years of the twentieth century, a witch-hunt against midwives in the United States and Canada resulted in the elimination of midwifery as a legitimate health profession. The profession has gained ground in the last two decades, but most people today have no personal experience with midwives and have been exposed to considerable misinformation about midwifery.

From California I left for Europe, where I joined the staff of the World Health Organization (WHO). There I was exposed to the essential role midwives play in maternity care in other highly industrialized countries and in developing countries. I also learned much about the profession, including the fact that in every other highly industrialized country, midwives are highly valued health care professionals.

Throughout history, there have always been women in the community to whom other women can turn for support with women's concerns—not just reproductive health care but also issues such as spousal abuse. The word
midwife
is early English for “with woman.” The French word for midwife,
sage femme
(wise woman), goes back thousands of years, as do the words in Danish,
jordmor
(earth mother), and in Icelandic,
ljosmodir
(mother of light).

Hippocrates formalized a midwifery training program in Greece in the fifth century
B.C.
Phaenarete, the mother of Socrates, was a midwife. In the Bible, the Book of Exodus recognized the strength and independence of midwives who defied the Pharaoh's command that they kill all sons born to Hebrew women. The first law to regulate midwifery in Europe was passed in Germany in 1452 and required a midwife to be in attendance at all births. Since then, every little girl in Europe has grown up with the understanding that if she has a baby, she will have a midwife to assist her.

When Europeans migrated to the New World, midwives were among them. In the mid-1600s, the king of France commissioned midwives and sent them to practice in New France (now Canada). The British government also paid for the services of midwives in the New World, including in the American colonies. Midwives were a valued part of the developing health care system in colonial times and by the mid-1880s they were teaching medical students in at least one university.
²

As the number of physicians increased in the United States, medical doctors attempted to monopolize health care through state medical practice acts that defined health care parameters, including who can practice.
By the end of the nineteenth century, it was common for midwives to be accused of witchcraft and tried in court, and midwifery practice began to disappear. The case of Hanna Porn was one of the most famous and had far-reaching consequences. In Gardner, Massachusetts, in 1909, a judge sentenced forty-eight-year-old Hanna to three months in the House of Corrections. Her crime? She was a practicing midwife.
³
An immigrant from Finland, Hanna Porn served primarily Finnish and Swedish laborers' wives. Fewer than half as many of the babies whose births she attended died as babies whose births were attended by local physicians. But the Massachusetts Supreme Judicial Court used her case to rule that midwifery was illegal in Massachusetts, based on the testimony of physicians who said that midwives were incompetent. In 1910, an attempt was made to reestablish midwifery by opening a school of midwifery in Massachusetts, but the idea was defeated by opposition from nurses as well as physicians. Other states quickly followed suit and made midwifery illegal, and it remained illegal in nearly all states for more than fifty years, until nurse-midwifery began to be legalized.

What is it about the practice of midwifery that attracts so much hostility and criticism? There are several excellent books that explore this question.
⁴
The overarching issue is simply that midwives have always been at the center of the “woman's world”—that part of life and society that women have some control over, and from which men tend to be excluded, including, until recently, pregnancy and childbirth. The profession has always attracted strong, independent women in the community, woman who are difficult for men to control and whom some men come to fear. If men wish to control their women, they must find a way to control midwives. When physicians (who until fifty years ago were almost all men) began to practice maternity care, they found themselves competing directly with midwives for pregnant clients. Even nurses (who until recently were all women) supported the medical domination of maternity care, because nurses have always been controlled by doctors and they believed that their jobs depended on keeping doctors happy.

Despite this attempt to dismantle the profession in the United States and Canada, midwifery continued to thrive in Europe and other parts of the world. And while the profession was severely hampered in the United States for decades, it was not stamped out. Throughout history, every attempt at ending the practice of midwifery has failed. It seems that there will always be women who want to be midwives and women who want midwives to attend them when they give birth.

When officially sanctioned midwifery was attacked in the United States, midwives went underground. Women who became known as “granny midwives” (because they tended to be older) continued to practice, especially in poor communities. In the 1920s, Mary Breckenridge, a public health nurse, decided first to get training in midwifery and then to form the Frontier Nursing Service to serve families in the Appalachian region of Eastern Kentucky. She wanted to improve the lives of poor children by providing maternity care to families in rural areas where there were no doctors. The organization included a central hospital with one physician and several nursing outposts and featured nurses on horseback, who were able to reach remote locations in all kinds of weather. Within five years, the Frontier Nursing Service provided care to more than one thousand families over seven hundred square miles. The staff formed the organization that later became the American Association of Nurse-Midwives, as well as the Frontier School of Midwifery and Family Nursing, which trained hundreds of women in what became a new profession in America, nurse-midwifery.

The number of nurse-midwives grew slowly but surely, and by 1977 the profession was licensed in every state. After nursing school, a nurse can elect to go on to midwifery school, a kind of graduate school, for about two years and become a nurse-midwife. This is not the same as becoming a labor and delivery nurse, a nursing specialization that has no training requirement and usually involves about six weeks of on-the-job training.

Women who want to be midwives and do not want to become nurses first can train as “direct-entry” midwives—that is, women who go directly to midwifery school without training first in nursing—a group that has also grown steadily in numbers and recognition. In 2006, the practice of direct-entry midwifery was legal in twenty-four states, “alegal” (that is, direct-entry midwives were allowed to practice without legal interference) in seventeen states, and explicitly illegal in only nine states. In the last decade, more and more states have been legalizing direct-entry midwifery, so the number of states in which direct-entry midwifery is legal can be expected to increase. The U.S. federal government recognizes the training for both nurse-midwives and direct-entry midwives and has authorized the Midwifery Education Accreditation Council to accredit midwifery schools and programs.

Despite the current renaissance of midwifery in the United States, the fact that midwives were harshly persecuted for more than a century has left the profession with a legacy of public reticence and confusion that must be overcome. Many myths surround midwives, myths that are often reinforced
by obstetricians who view them as competition. One is that midwives are not trained but are “hippy-dippy” lay women who attend only home births. Another is that midwives are religious zealots or witches who use magical potions. That nurse-midwives attend births only in hospitals is a common misconception, as is the idea that a midwife is a second-class doctor for women who can't afford a real obstetrician. None of these ideas is remotely true. There are two excellent books by nurse-midwives that describe their home birth practices, and several organizations are working to educate the public about midwifery practice.
⁵
Scientific data (which will be discussed later in this chapter) have proven that for attending low-risk births (that is, births without complications), midwives are not second-class obstetricians, but rather obstetricians are second-class midwives.

Many American obstetricians are confused about midwives, as I was before I joined the WHO. During a recent panel discussion on a popular American television talk show, a practicing obstetrician said, “Midwives are obstetrician's assistants,” another common myth. As a fellow panel member, I tried to correct his misperception. Because American obstetricians have always had nurses to do their bidding, including labor and delivery nurses, many of them believe that midwives are working for them. Even today, many obstetricians just don't get it. They try to boss midwives around, inviting them to join their practices and then cavalierly firing them, pushing them off of hospital staffs, accusing them of practicing medicine without a license, and so on. To avoid getting in the middle of this professional turf struggle, a pregnant woman must be prepared to do her own research, ask questions, and form her own opinions. One way to measure a particular doctor's openness and attitude toward women in general is simply to ask about the doctor's opinion of midwifery.