Born in the USA (21 page)

Another sign that American obstetricians have turned birth into a surgical event is the simple fact that between 60 and 80 percent of American births involve actual medical procedures—whether it's drugs to start or
speed up labor, cutting the genitals to widen the vaginal opening, using metal forceps or a vacuum extractor to pull the baby out, or performing a cesarean section.
¹¹
There is a need for these procedures in no more than 20 percent of all births, and in births where the midwife is the primary assistant they occur no more than 20 percent of the time.
¹²
And, as discussed in previous chapters, since all medical procedures carry risks, the high rate of unnecessary medical procedures in physician-attended births means more dead and damaged babies and women.

Midwives have good hands, and they know how to sit on them. Midwives use fewer interventions because they tend to trust women's bodies, favor low-tech assistance (such as skilled use of their hands), and pursue normalcy, while obstetricians in general trust drugs and machines more than bodies, use high-tech assistance, and focus on abnormality. One simple example: midwifery considers breech birth (cases where the baby's head is not first coming out of the vagina) a variation of normal, whereas obstetricians consider it an abnormality.

In the past two decades we've seen a renaissance of midwifery in the United States. Each year, the number of births attended by midwives increases. According to the CDC, in 2004, 10 percent of all births in the United States had a midwife as primary birth attendant, and in New Mexico it was 30 percent of all births.
¹³
Several large HMOs are hiring more midwives and some now have more midwives than obstetricians on staff.

Another group that has been attacked by doctors and hospital administrators who have very little understanding of what they do is doulas. Doulas are woman who provide support to birthing women. They receive professional training for this (like midwives, they are trained by apprenticeship and must pass an examination) and have knowledge of common birth procedures, as well as of problems that can come up. But doulas do not pretend to be nurses or midwives or doctors. They do not serve as the primary attendant at a birth. Their role is to offer loving support and practical help. Doulas work primarily in hospitals, although some also provide postpartum home care. As we've seen in earlier chapters, many labor and delivery wards in the United States are not particularly supportive places for women. Overworked nurses cannot provide continuous support, and when the birth attendant is supposed to be an obstetrician (as is the case in about 90 percent of births), and there is likely to be no one around, a doula can be a godsend. In fact, research clearly shows that the presence of a doula at a birth shortens the length of labor and reduces the number of complications.
¹⁴

Nevertheless, by now I'm sure it will not surprise you to hear that many obstetricians don't like having doulas around. One of the things a doula does is to advocate for the laboring mother, who may be in pain and may not have the ability to ensure that her wishes are honored. For example, when a woman employs a doula, she will usually develop a written birth plan. The doula will be familiar with the plan, so when the obstetrician comes with scissors to do an episiotomy, it may be the doula who reminds the doctor that the birth plan specifies “no episiotomy.” Although doulas are not generally legally persecuted, they must have thick skins, as doctors have been known to throw them out of the delivery room. Sadly, some hospitals forbid doulas from entering the hospital at all or develop protocols that doulas must follow that severely limit their role. Doulas must walk a fine line between supporting and protecting a woman giving birth and offending the hospital staff. Good luck.

The more the practice of midwifery grows and succeeds, the more threatening midwives are to the obstetric monopoly, so, predictably, there has been an obstetric backlash. Now, a hundred years after Hanna Porn was persecuted, we have another American witch-hunt against midwives. In many states, doctors are reporting midwives to various authorities as dangerous. In 1995, I wrote an article about this published in a prestigious medical journal, titled “A Global Witch Hunt,” and the hunt is still on. No one knows how many midwives have actually been charged, but in 1995, I was aware of legal altercations involving more than 145 out-of-hospital midwives in thirty-six states.
¹⁵
In the past ten years, at least that many more midwives have been charged.
¹⁶

The challenge faced by nurse-midwives, most of whom work in obstetricians' offices or in hospitals, is somewhat different but also daunting. During the latter part of the twentieth century, nurse-midwives were the first midwives to be recognized and accepted in the United States. In the beginning, they were tolerated by obstetricians because they were providing care in areas where no obstetrician wanted to go, such as Appalachia. Later they were seen as handy helpers who would do an obstetrician's bidding. Historically, accommodating obstetricians has been a central strategy for nurse-midwives. They are trying to live in a doctor's world and survive. But as more nurse-midwives are hassled by obstetricians, obstetric residents, and so on, and often eventually fired, they are beginning to realize the need to assert their independence.

In the past five years, most of the nurse-midwives in Austin and San Antonio, Texas, and most of the nurse-midwives in Cleveland, Ohio, were
summarily fired—for no apparent reason other than that the hospitals where they worked said they needed to save money. This reason is hard to accept, given that midwives cost much less than obstetricians. One of the largest hospitals in New York City, Columbia Presbyterian, recently disallowed its midwives from attending births, and one of the largest hospitals in Washington, D.C., Georgetown University Hospital, recently fired all its nurse-midwives, again claiming it was for financial reasons. None of the nurse-midwives who were let go had been accused of malpractice or anything else. They were simply getting in the way of the obstetric monopoly.

Over time, the presence of nurse-midwives in hospitals has had both a positive and a negative influence on the midwifery profession. The good news is that they can provide midwifery care to women giving birth in hospitals, which is where most childbirth in America takes place. The bad news is that hospital-based nurse-midwives must struggle daily to practice real midwifery and to resist pressure from doctors to become “medwives” who accept the medical model of birth. Many nurse-midwives and labor and delivery nurses tell me that they prefer to work nights and weekends, because they feel they can give their patients better care when the doctors are not around.

Nurse-midwives are often victims of hospital politics, and those politics can become quite vicious. Here is a real-life illustration. A nurse-midwife was in independent practice in a large suburban private hospital in Washington State. A number of private practicing obstetricians worked in the same hospital. Many of these obstetricians had high intervention rates; several had 50 percent C-section rates, and one had a combined C-section plus forceps delivery plus vacuum extraction rate of 80 percent. By contrast, the nurse-midwife's practice was low-intervention, with less than 15 percent of births involving forceps, vacuum, or C-section. She had a good reputation in the community, and her practice was growing rapidly. The obstetricians in the hospital asked her to cut down on her practice, giving no reason although it was apparently out of fear of competition. She did not comply with their wishes.

Then a baby died under the nurse-midwife's care. In view of her large practice and the number of births she had attended—and in view of the usual perinatal mortality rate in that hospital and state—this was not unexpected. Ordinarily, a perinatal death in this hospital resulted in an internal review by a perinatal committee to determine if any serious mistakes had been made. But in this case, the nurse-midwife was immediately reported by the hospital to the state's Nursing Care Quality Assurance Commission.

There are three major issues with this referral to the state. First, the
referral was made before the hospital had conducted an investigation—the nurse-midwife was considered guilty until proven innocent. Second, there were several perinatal deaths attended by obstetricians in this hospital the same year, and the obstetricians were not reported to the state, so it appeared to be a case of doctors and hospital administrators using selective reporting to the state for professional and personal gain. Finally, in Washington State, nurse-midwifery practice is monitored by nurses, not by nurse-midwives or other midwives, and there were no midwives on the Nursing Commission.

After making its report to the state Nursing Commission, the hospital searched through the nurse-midwife's patient charts looking for something with which to accuse her. As someone who has practiced medicine for many years, I know that no doctor, midwife, or nurse can survive such a fishing expedition unscathed.

Then two events took place further indicating that the hospital's complaint to the Nursing Commission was motivated by doctors' fear of competition. Before the hospital's investigation was completed, the obstetricians who had been providing backup to the nurse-midwife announced that they were withdrawing their backup. (As I have pointed out elsewhere, withdrawing backup is one of the most common ways obstetricians successfully eliminate competition from midwives.)
¹⁷
Then a new hospital brochure for the public was published before any investigation of the midwife had been completed that listed the maternity services staff, and the nurse-midwife's name had mysteriously disappeared.

Although the hospital completed its investigation of the nurse-midwife and found no malpractice, the hospital report nevertheless demanded that she get psychotherapy and stipulated that the hospital must have the opportunity to tell the therapist what was wrong with her. Her problem, in their view, was her insistence that she be treated as an equal. The doctors felt that this revealed her “inability to be a team player,” a euphemism for not doing what she was told. (Many doctors love a team as long as they are the team leader.) Careful reading of the case makes it clear that there were two real problems: doctors who were afraid of the competition and a hospital staff that did not understand the role of nurse-midwives in maternity services. In the doctors' view, the nurse-midwife was not subservient and compliant enough, when in truth she correctly saw herself as a professional equal. She was practicing midwifery, which is not the practice of medicine.

In her practice, when nurses or doctors, misunderstanding what she was doing, had tried to prevent her from using her midwifery skills, she put the
needs of the woman first and occasionally asserted her authority as the principle caregiver in a case. Long before the death and the legal case, the nurse-midwife had repeatedly expressed concern that the staff was not familiar enough with midwifery practice and had suggested staff training on the appropriate roles of maternity care professionals to improve their understanding, but no action was taken. Instead, she was told she needed psychotherapy. Labeling someone emotionally unbalanced and using psychotherapy as a tool to force compliance was a method used in the former Soviet Union. Even after years of experience in medicine, I was startled to find such draconian tactics in an American hospital.

In one of my papers on the midwife witch-hunt, I pointed out that in the United States, hospital and state quality assurance systems are increasingly used to punish deviance from the style of practice preferred by those in authority.
¹⁸
I suggested that abuses of the system can be identified by asking two questions: Is the complaint evidence-based? (That is, is it about a practice that has been determined to be faulty by scientific studies?) And are there clear professional (or nonprofessional) gains to be had by those making the complaint? In this case, the complaint was in no way evidence-based. Furthermore, the obstetricians in the hospital clearly had something to gain by complaining—a chance to maintain their monopoly in maternity services and a chance to maintain their hierarchical system among hospital staff. And, in this case, the obstetricians succeeded: the nurse-midwife was driven out. The nurse-midwife resigned and opened a home birth practice in the community with an obstetrician who was not practicing at her former hospital providing backup.

The nurse-midwife's decision to leave the hospital was a predictable outcome. I know of quite a few nurse-midwives who have gotten tired of the prejudice they face in hospitals and have moved into out-of-hospital practices, either working in a free-standing birth center or attending home births. However, even moving out of the hospital does not always mean that a midwife can escape persecution. In New Jersey, an obstetrician filed a complaint with the state medical board against a nurse-midwife attending home births, a practice of which he did not approve.
¹⁹
The board searched through her home birth cases trying to find evidence of incompetence. The board pulled several cases and asked a nurse-midwife with no experience in home birth to review them. The reviewer, a “medwife” in her opinions, aggressively attacked some of the home birth practices. Fortunately, the nurse-midwife under investigation was able to get other midwives with considerable home birth experience to evaluate the same cases, and they
reported no evidence of incompetence. The board found no cause for alarm, but still asked that all of this nurse-midwife's home birth cases be reviewed by another nurse-midwife with home birth experience for one year. At the end of this year of observation, the nurse-midwife was again free to practice home birth, but this unjustified attack caused her much anxiety and emotional distress.

It is more difficult for obstetricians to control direct-entry midwives, as most have independent out-of-hospital practices in the community, either attending home births or serving in a birth center—which explains why doctors resort to witch-hunt tactics. One tactic is to pretend that they don't exist. As recently as 2006, ACOG issued a policy statement titled “Lay Midwifery,” stating: “While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the AMCB [American Midwifery Certification Board].” The AMCB certifies nurse-midwives and certified midwives (CMs), the latter trained under a program approved by nurse-midwives. So ACOG completely ignores the thousands of qualified direct-entry certified professional midwives with proven track records (see the Johnson and Daviss study discussed in
chapter 6
) and their highly developed training program, approved by the federal government, and characterizes them with the pejorative descriptor
lay
. Such a public statement makes ACOG look foolish: first it says that it supports women having a choice of providers of care and then it tries to eliminate certified professional midwives, a legitimate choice of provider.
²⁰