Born in the USA (20 page)

In reality, a nurse-midwife or direct-entry midwife transferring a laboring woman to an obstetrician is analogous to a family physician referring a patient to a specialist, such as a cardiologist. It does not mean that the family physician is the cardiologist's assistant or somehow less competent, only that the cardiologist has a different expertise than the family physician—an expertise in handling certain complications. It is no more appropriate for an obstetrician to give orders to a midwife than it is for a cardiologist to give orders to a family physician. The relationship should be an active collaboration based on mutual respect between health professionals of equal standing. In New Zealand, a midwife has the same rights and privileges as a family physician and receives the same flat fee for attending a birth that a doctor receives.

Though styles of practice vary among individuals, there are several general differences among the practices of nursing, midwifery, and medicine. Nursing means assisting doctors (and taking orders from doctors), though a nurse's focus is on caring for the needs of the patient rather than on medical diagnosis and treatment.

The scope of a midwife's practice is often defined by the setting or institution in which she practices. Midwifery can be limited to maternity care or it can be practiced more broadly as primary health care for women—that is, providing all basic health services related to a woman's gender, such as family planning, screening for cervical cancer, and treatment of reproductive tract infections.

That midwifery is much more than just catching babies was brought home to me when I visited Povungnituk, a tiny Inuit village on the far northern shore of Hudson Bay in Canada. For many years, the government of Canada had flown pregnant Inuit women a thousand miles south to give birth in a large hospital. This practice was destroying the Inuit culture, as it meant that the role of Inuit midwives was severely reduced and no babies were born on Inuit land. The Inuit people demanded to have their babies born in the far north, and finally their demand was met. The government sent two direct-entry midwives to Povungnituk to train Inuit women as midwives. When I visited a year later, the training midwives told me that although they were teaching only care during pregnancy and birth, the women of the village were spontaneously seeking out the Inuit midwives for help with all kinds of “women's problems,” such as abusive husbands. They were once more the “wise women” of the village.

Generally speaking, a fundamental difference between midwifery care and physician care at birth has to do with control. Childbirth is a complicated physiological process regulated by the woman's nervous system. Childbirth is not under the conscious control of the woman giving birth, but rather is directed by hormones and neurological feedback systems that neither the woman nor someone assisting her can control. Labor is controlled by the parasympathetic portion of the autonomic nervous system, which is not under conscious control (intestinal mobility and sexual orgasm are other examples of physiological functions controlled by the parasympathetic nervous system). Anything that causes fear or alarm shuts down the parasympathetic system and fires up the sympathetic nervous system (adrenalin). Fear and anxiety stop intestinal mobility, stop any chance of orgasm, and stop labor. Any intervention that increases a laboring woman's fear or anxiety will interfere with, slow down, or even stop the birth processes.
A wise birth assistant, be it midwife, nurse, or doctor, knows how to facilitate these autonomic responses and not interfere with them. The key elements in the midwifery model of birth are normality, facilitation of natural processes (with minimal intervention, all evidence-based), and the empowerment of the birthing woman. Taking on the role of facilitator, midwives will typically reassure, calm, and encourage birthing women. Obstetricians, on the other hand, typically try to get the birth under their own control by overriding the natural processes with drugs and medical procedures and giving orders. The medical model and the midwifery model are essentially different paradigms or ways of looking at women and birth. Doctors “deliver” babies and believe that having a baby is something that
happens to
a woman. Midwives assist at birth and believe that giving birth is something that a woman
does
.

Midwives tend to believe that a woman giving birth needs to be the one making decisions about her birth experience. The woman giving birth needs to believe in her own body and feel responsible for her body, while at the same time letting go of the need to control what is happening, since she cannot. However, though a woman has decision-making authority when she hires a midwife, her authority may be challenged within a hospital setting. I know a midwife who puts a doorstop under the door when she is attending a client in a hospital. When a member of the hospital staff comes to the door, they find that the door won't open. The midwife calls, “Who is it?” and when the person outside the door—be it doctor, nurse, medical student, nursing student, or lab tech—identifies him- or herself, the midwife asks the birthing woman if she wants the person to come in. It is interesting that a two-dollar rubber doorstop can change who is in control of the situation, at least temporarily.

In reality, I have never seen a hospital where, on a day-to-day basis, the patient is truly “in control” or has final decision-making authority. At the end of the day, the doctor and the hospital will decide what will happen to the woman unless the woman is willing to insist on having some control and is willing to fight for it. (See
chapter 7
for a discussion of patient rights.) Yes, by law, doctors must get their patients' informed consent before doing procedures, but there is a difference between giving consent and having control. Consent means that the patient accedes to what the doctor wants. That is not control. If an obstetrician tells a woman that, if she chooses, she may walk around early in her labor, that is not putting the woman in control, it is simply giving the woman permission to do what the doctor chooses. The doctor remains in control. A hospital is doctor territory
and doctors will always fight to be in control, regardless of what they may tell their patients.

Another fundamental difference between midwives and doctors is how they view pregnancy and birth. Midwives understand that pregnancy is not an illness. They typically call the women in their care “clients,” not “patients,” since they are not sick and are not getting medical treatment. Though midwives know what can go wrong during pregnancy and birth and know how to identify problems early and to cooperate with doctors in managing complications, their focus is on birth as a life-enhancing experience. Although they believe it is essential to have medical assistance available when needed, they are trained to go beyond medical care and empower women to achieve their goals for themselves and their babies.

Obstetricians, on the other hand, tend to focus on what can go wrong during pregnancy and birth. All doctors have been trained to look for trouble (diagnose a problem) and decide what to do about it (decide on a treatment), and that is what comes naturally to obstetricians. In prenatal care they take the same approach, focusing on what can go wrong and ordering numerous testing and screening procedures. This attitude casts a shadow over the maternity care a woman receives. When an obstetrician runs a test or gives a preemptive treatment, it is an unspoken vote of no confidence in the woman's body. Although the occasional test is a good idea and sometimes a treatment is necessary, we've seen in earlier chapters that much of what obstetricians do to pregnant and birthing women is unnecessary and serves only to calm the doctor's own fears.

Midwives trust in women's bodies and their capacity to give birth successfully with little or no intervention in most cases. They are trained to express confidence in every way possible, thus modeling a positive attitude that is passed on to the woman herself and often results in an empowering birth experience. Since a birthing woman will be faced with the daunting task of rearing a child for the next twenty years, having confidence in herself and her abilities is vital.

Another important difference between midwife-attended low-risk birth and obstetrician-attended low-risk birth is the quality of the experience for the woman. Many surveys have shown that women who have midwives as their attendants have far higher levels of satisfaction with their birth experience than women who have obstetricians attending their births.
⁶
This is not hard to understand. Midwives give great attention to building close relationships with their clients and their clients' families. They spend an average of twenty-four minutes with a woman during each prenatal visit,
compared with obstetricians, who spend ten minutes per visit on average.
⁷
If a woman decides to have a midwife as her birth attendant at a planned out-of-hospital birth, or selects one of the unusual midwives who works in the hospital but is not on an eight-hour shift, her attendant will probably be there continuously from the beginning of her labor until after the birth. If she has an obstetrician as her primary attendant, the doctor will pop in only from time to time—usually once every few hours. Between doctor visits, she'll have brief visits from one or more labor and delivery nurses (whom she probably has never met before), but again only from time to time.

Generally speaking, midwives are direct, open, and honest in their dealings with clients and take an egalitarian, intimate, woman-to-woman approach. Midwives do not guarantee a good outcome, and their honesty about their role and its limitations contributes to the level of satisfaction women feel with their services. On the other hand, in a doctor-patient relationship, there is no egalitarian tradition. Rather the doctor's superior knowledge and status are for the most part unquestioned and there is a belief (or hope) that the doctor can perform miracles.

After experiencing both the obstetric and the midwifery worlds for some years, I see a sharp contrast. Go to an obstetric meeting and you'll see serious faces, hierarchical maneuvering, obsequious behavior by lower-ranking medical students, interns, and obstetric residents, and condescension and occasional strutting by doctors in the higher ranks. It is not an exaggeration to describe most obstetric meetings as a celebration of self-importance and success. Casual talk runs to cars, boats, private planes, the evils of interference from managed-care organizations or government agencies, greedy lawyers, and how to make more money to pay for high malpractice premiums. Words that come to mind in such a setting are
hard, competitive, elitist, aggressive
, and
a man's world
. It's amazing to me that there are doctors who survive in this world and remain open and caring.

Go to a midwifery meeting, and you'll see women breast-feeding babies, kids running around, lots of laughter and warmth—a celebration of life, family, and birth. Casual talk runs to child rearing, long-suffering husbands, tricks of the trade, how obstetricians interfere with midwifery, and how to make enough money to pay the mortgage. Words that come to mind in that setting are
humble, warm, cooperative, we're all in the same leaky boat together
, and
a woman's world
.

Midwives, like doctors, are human. They have bad days and they make mistakes. Science now tells us, however, that overall midwives are safer than
doctors for low-risk births. Of course, American obstetricians have worked hard to convince the public that they are the “safest” kind of professional to assist at
all
births, but the evidence simply does not support their position. A large study, published in 1998, looked at all births in the United States in one year—more than four million births. Because doctors really do need to manage the few births that develop serious complications (around 10 percent), the study eliminated these high-risk births, and looked only at low-risk births. Compared with physician-attended low-risk births, midwife-attended low-risk births have 33 percent fewer newborn infant deaths. Furthermore, midwife-attended low-risk births have 31 percent fewer babies born too small, which means fewer brain-damaged infants.
⁸
So if a woman is among the 80 to 90 percent of all women who have normal pregnancies, the safest attendant for her hospital birth is not a doctor but a midwife. In
chapter 6
, we will look closely at the scientific evidence on planned out-of-hospital births attended by midwives.

One of the primary reasons midwives are safer than doctors is that they use far fewer unnecessary interventions.
⁹
Obstetricians are surgeons, and their training leads them to turn birth into a surgical procedure. In earlier chapters I discussed some of the problems with the practice of putting a birthing woman on her back in a bed. High-tech birthing beds are really nothing more than modified surgical tables, where the surgical patient (a woman in labor) has her legs up in surgical stirrups. In this position, the baby's head compresses the woman's main blood vessel (aorta), reducing the blood and oxygen going to the womb and to the baby. When a woman is in a vertical position (sitting, squatting, or standing), more blood and oxygen gets to the baby, the woman's pelvis is more open to let the baby out, and the woman is giving birth downhill instead of uphill against gravity.
¹⁰
We've known for more than twenty-five years that a horizontal position is the worst possible position for a woman giving birth, but with obstetricians controlling maternity care, the practice continues. I've been telling women for years that an easy way to tell whether a hospital is practicing modern, evidence-based maternity care is simply to find out what position women are put in to give birth. If the hospital is still putting women on their backs (and elevating the head and shoulders does not make a difference), they are ignoring the scientific data, and it is a sign that the hospital is pretending that birth is a surgical procedure.