Joan with Javonn, one of the many babies she helped deliver
Joan Bryson became a midwife in 1991, and between her nursing experience and midwifery practice, she's assisted in more than 1,000 births.
At her private practice in Brooklyn, NY--Community Midwifery--she provides midwifery and health care for women in their teens to post menopausal years, including regular gyn exams, breast exams, primary care screening, preconception counseling, STD screening and prevention and family planning.
She is also an active member of New York City midwives. Here's Joan...
How did you get into midwifery?
In my mid-20s my brother and his wife were having a baby and were doing a home birth with a lay midwife. They were so in love with the pregnancy and having a home birth. It really called to my heart. I began reading voraciously about midwifery and birth. But I was intimidated about doing it. Later, several years, I decided to plunge forward. I went to nursing school. I did get sidetracked with life for a long time, but after the birth of my daughter, I got a new job and met my first practicing midwives. Two years later I went back to school, and the rest is history.
What is the role of a midwife for those who are not familiar with the practice?
Midwives care for healthy women, independently from physician care. Their 'role' or scope of practice depends on route of entry into the profession.
Midwives are healthcare professionals who are educated in a variety of ways. There are nurse-midwives (CNMs) and certified midwives (CMs) who are certified by the same certifying exam as nurse-midwives are even though they're referred to as CNMs and CMs they are essentially the same. The difference is CNMs enter through nursing and CMs enter through an equivalent science background. Their scope of practice includes gynecology, primary care, birth and early newborn care and usually have prescriptive privileges depending on their state laws.
There are also certified professional midwives (CPMs) who study midwifery in a variety of ways but take a different certifying exam than CNMs/CMs, it is rigorous. They are usually licensed by their state's department of education. Their scope of practice is limited to pregnancy and birth and to my knowledge none have prescriptive authority. CPMs are not recognized by all 50 states.
Midwives do not do surgery. Most CNM/sCMs work for hospitals, or in private practices and deliver their clients in hospital. A very small percentage, like myself, provide homebirth services. CPMs almost exclusively do homebirths, as their scope of practice prohibits hospital privileges. The philosophy of midwifery, regardless of route of entry into practice, is woman-centered, focusing on well being and holistic approaches to care.
Can you discuss a midwife-assisted birth, and how it differs from many of the births that take place in today's hospitals?
Midwives who provide homebirth services are committed to humanistic, individualized care that focuses on the needs of the woman. Because care during birth is in the home, authority shifts to a shared status. We believe in a woman's ability to birth normally without pharmaceutical pain relief. Women feel their most supported, private and empowered in their own homes, and this really affects the process of labor. Any person at the birth is totally there for that woman alone. There are no other distractions. There is usually deep trust. Women don't have to 'ask' permission to shower, be in the tub, go to the bathroom, walk around. She is her own boss. In hospitals, there is an inherent assumption that the hospital rules and physician orders are to be followed without question. The rules are made to keep the unit running smoothly and personnel utilized efficiently. Any attempt to bend them to an individual's needs is viewed as unfair and unsafe. In my 17 years of experience, I have never had a mother ask to do something unsafe.
What are the benefits of a midwife-assisted birth? What are the challenges?
Remember that midwifery care is complete maternity care as well as gyn care. In homebirth, the prenatal visit is scheduled to meet the client's needs outside of the routine blood pressure, weight, growth measurement and fetal heart. Time is spent getting to know this woman, her family, what her fears may be, preparation of the home, as well as time to discuss labor, birth and care of the baby afterwards. I spend a fair amount of time opening up discussion around what this is really preparation for: Parenthood! How does life change. How might they begin during the pregnancy to discuss those changes and how will they face those changes.
I think the challenges are mainly trying to practice humanistic care in a system that is mechanistic and often cruel. Midwifery care and homebirth with trained midwives have been shown to be safe, satisfying, cost effective, and have incredibly lower C-section rates and other interventions in numerous studies over decades of time. People were told midwives were uneducated and causing all of the infant mortality at the turn of the last century by a very effective PR campaign and it has stuck. The truth is that the safety in childbirth has largely come about because doctors finally started using aseptic technique (i.e. hand washing, etc., that midwives and nurses kept telling them to do!), antibiotics, improved nutrition and spacing of pregnancies. Not much has really changed since these 'discoveries,' especially in this country.
We rank highest of all industrialized nations in maternal and infant mortality and morbidity, in spite of the fact that we spend more money per capita than any other country on maternity care. And we use the least amount of midwives (11% vs. 71% in most European countries).
What is one of your favorite delivery stories?
I have so many favorite delivery stories. Women are so beautiful and strong in labor. They are so unconscious of how they look, and would probably say that they looked terrible. But they all must reach deep inside themselves and discover their true strength to deliver the baby. To me, this is profoundly beautiful.
What advice do you have for expectant mothers?
Research your options and exercise them. You are intelligent beings who know how to take care of yourselves. If something doesn't feel right, change providers. My opinion is that the first most important decision you make, is the provider you choose. If you feel free to be yourself, safe to discuss the most personal of issues with your provider, and that who you are and the things you find important for your birth are important to that provider, then where you have your baby will be secondary. Unfortunately, most providers, even midwives, often are unable to challenge the system they work in to do this. That is why homebirth is such an important option.
Is there anything you would like to add?
In New York state, CNMs and CMs are the only legal midwives. And our practice is severely hampered by a provision in our practice act requiring a 'signed' practice agreement with a physician or hospital. We are the only health care professional required to get 'permission' to practice by our financial competitors. Consequently, many of us are unable to practice outside an 'employment' setting because we are unable to satisfy that provision of the law. And the few physicians who will sign these agreements are told by their malpractice insurers that they can only work with one or two midwives or not at all. The signature increases their liability for clients they are not even caring for.
Can you imagine a family practice physician needing a signed agreement with a cardiologist in order to refer or consult a patient with a heart problem? And the cardiologist thinking it was too risky to take patients from another doctor? While we are not doctors, we are OB/GYN providers under the law and should be afforded the same rights to practice, consult and refer as any other provider. The safety of care primarily relies on smooth, seamless transfer to a higher level of care when indicated. The implication that midwives cannot be relied upon to do that without a signed agreement with a physician is insulting and ridiculous.
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If you choose to go to a midwife, be sure and get plenty of references and checks on them first. There are far fewer barriers to entry to midwifery as opposed to a real OB/GYN M.D., which means that there is a much greater danger that a given midwife is incompetent.
This does not mean that all or even most midwives are incompetent. But as just about anyone can get their midwife license, you have to be more careful.
We had a patient a couple months ago who had a history of placental abruption. She then went to a midwife who suggested that she deliver her next child vaginally because it would be more "natural" or some such rot. We couldn't believe it when we heard it. The woman's entire uterus ruptured open, she lost the baby, and the woman nearly died.
Thankfully, she got to an ER in time for an M.D. to save her life.
While midwifery is undoubtedly the more "feel-good" option next to traditional OB/GYNs, and while I'm sure Ms. Bryson herself is quite good at her job... please be careful on whom you select, and always go to an actual OB/GYN M.D. or D.O. if you have a high-risk pregnancy or history of previous complications such as abruption.
Great idea for feministing to bring this up, and thanks to Joan for your work.
I had my first child with a doctor and my second with a midwife while living in Norway. The experiences were night and day different from one another. I wish I'd known earlier because I would no doubt have chosen a midwife the first time around.
A midwife respects the female body's ability to handle the hard work of birth while most doctors poke, prod and force procedures into the process -- it often leads to all the complications that in fact scare women into using doctors in the first place.
Incidentally in Norway, you go through the entire birth process at the main county hospital without ever seeing a doctor; the midwives handle everything and it is the preferred/default method. And rightly so.
"If you choose to go to a midwife, be sure and get plenty of references and checks on them first. There are far fewer barriers to entry to midwifery as opposed to a real OB/GYN M.D., which means that there is a much greater danger that a given midwife is incompetent."
Good point, and I'd add that it's good advice for choosing MDs, NPs, dentists, etc. too. :)
"Incidentally in Norway, you go through the entire birth process at the main county hospital without ever seeing a doctor"
That sounds like the best of both worlds.
It also reminds me that having multiple options right there would add flexibility. Just curious, how often do women and girls giving birth change their minds in the process? If someone giving birth who wanted less tech at first wants more tech later or vice versa, can she speak up about that without losing face?
In the Netherlands, you usually have the baby at home. And they have some of the best birth statistics in the world.
ForbiddenComma, there are incompetent people in any profession. In Florida, a history of placental abruption would preclude you from being able to deliver with a midwife, and that is written in the health code. It is a regulated and licensed profession.
And, thanks for adding D.O. at the end. I will be a D.O OB/gyn when I am done with my extensive schooling...
The first response completely typifies the condescension that the medical industry shows towards women as consumers of medicine, especially surrounding pregnancy. "Be sure to get lots of references"?! Are you kidding me? I'm sure that someone who, by the above account, already had at least one pregnancy just stumbled in to a midwife's care without doing any due diligence. And yet strangely, on the other hand, women are supposed to blindly trust anyone in scrubs or a lab coat.
With treatment like that, it's no wonder that poor woman (and scores more like her), fled MD care.
Furthermore, I find it irksome that discussions of midwifery always turn to the worst-case scenario ("I had this case where everybody DIED and she had a MIDWIFE"), whereas maternal and infant deaths that happen in hospitals are seldom attributed to the doctor ("A woman and her baby died due to a hemorrhage during a caesarean section but, well, those are the risks"). Take the case as what it was - a woman with a history of placental abruption probably decided she was sick of being put on the butcher block by uncaring hands and decided to make her own decisions. There are risks involved with that, and let's give the woman the benefit of the doubt here that she was aware of the risks -- especially since she was most likely told many times over by doctors that she'd never deliver vaginally again, because they seem to love to tell people that. The midwife may have thought that a vaginal delivery would be more "natural" (it is, by the way), but the MOTHER made the call to deliver with a midwife, and the MOTHER made the call to deliver at home. Now, chances are the midwife made the call to transfer, which is why the woman is still alive today, but nobody thinks about that...
Such digressions into anecdata really don't advance anyone's argument.
The first response completely typifies the condescension that the medical industry shows towards women as consumers of medicine, especially surrounding pregnancy. "Be sure to get lots of references"?! Are you kidding me? I'm sure that someone who, by the above account, already had at least one pregnancy just stumbled in to a midwife's care without doing any due diligence. And yet strangely, on the other hand, women are supposed to blindly trust anyone in scrubs or a lab coat.
With treatment like that, it's no wonder that poor woman (and scores more like her), fled MD care.
Furthermore, I find it irksome that discussions of midwifery always turn to the worst-case scenario ("I had this case where everybody DIED and she had a MIDWIFE"), whereas maternal and infant deaths that happen in hospitals are seldom attributed to the doctor ("A woman and her baby died due to a hemorrhage during a caesarean section but, well, those are the risks"). Take the case as what it was - a woman with a history of placental abruption probably decided she was sick of being put on the butcher block by uncaring hands and decided to make her own decisions. There are risks involved with that, and let's give the woman the benefit of the doubt here that she was aware of the risks -- especially since she was most likely told many times over by doctors that she'd never deliver vaginally again, because they seem to love to tell people that. The midwife may have thought that a vaginal delivery would be more "natural" (it is, by the way), but the MOTHER made the call to deliver with a midwife, and the MOTHER made the call to deliver at home. Now, chances are the midwife made the call to transfer, which is why the woman is still alive today, but nobody thinks about that...
Such digressions into anecdata really don't advance anyone's argument.
It also reminds me that having multiple options right there would add flexibility. Just curious, how often do women and girls giving birth change their minds in the process? If someone giving birth who wanted less tech at first wants more tech later or vice versa, can she speak up about that without losing face?
Yes, women in Norway can opt for a doctor at any time without a problem, but I didn't find any of my peers doing so. I'm sure it happens, but I don't know any numbers. There is a doctor on-call at the hospital for any complications. They also had more high-tech neo-natal equipment than I've ever seen in a US hospital.
singoutsingout: I totally agree.
I've always had a fantasy of going into midwifery.
Maybe I'll do that if I burn on on social work.
Just curious, how often do women and girls giving birth change their minds in the process? If someone giving birth who wanted less tech at first wants more tech later or vice versa, can she speak up about that without losing face?
I've had two kids now, both with the same midwife. My daughter was going to be all-natural (although in hospital), but after 24 hours of labor I was extremely sick of contractions and got an epidural to finish it out. The midwife was pretty supportive of this. At no point did I want to switch to a different person (i.e. from midwife to doctor) managing the birth though, I just wanted to stop the pain :) She was also supportive when I said I didn't feel like I'd done a good job sticking with it the first time and I wanted to do it medication-free the second time (which I managed to).
I think that the whole birth process is something that it is extremely hard to describe to a first-time mother. Contractions are a NASTY surprise. The pain and stress affect your thoughts, and there's fear, and what you thought was a great plan a few months ago suddenly sounds a whole lot less great. Having somebody who's watching over that process and calmly giving you options and advice is invaluable.
The only thing I would complain about is that my midwife told me (when I complained about the contractions) that it would "be easier" when it came time to push. I took that to mean it would be less painful, while she meant it was more "satisfying" or "productive" (and "over soon"). When pushing started (quite a lot more painful!!!) I was furious :) But hey, I got over it.
I speak only from personal experience, of course -- there are as many birth stories in the world as there are children! Well, maybe fewer, since some involve twins ;)
"Take the case as what it was - a woman with a history of placental abruption probably decided she was sick of being put on the butcher block by uncaring hands and decided to make her own decisions. There are risks involved with that, and let's give the woman the benefit of the doubt here that she was aware of the risks -- especially since she was most likely told many times over by doctors that she'd never deliver vaginally again, because they seem to love to tell people that. The midwife may have thought that a vaginal delivery would be more "natural" (it is, by the way), but the MOTHER made the call to deliver with a midwife, and the MOTHER made the call to deliver at home. Now, chances are the midwife made the call to transfer, which is why the woman is still alive today, but nobody thinks about that..."
Another thing left out of the anecdote post is: how did she order her priorities? We can't automatically assume that ending up with a live newborn was tops on the list...
I'm so glad to see homebirth and midwifery addressed (again!) on Feministing. Any "pro-choice" discussion should include the choice of where, when and with whom a woman births.
As to the first post, I chuckled when I got to "We had a patient..." Having a doctor or medical professional tell us what's wrong with homebirth is about as instructive as having public school teachers tell me what's wrong with homeschooling my children. These people represent an INDUSTRY against which the alternative competes. Of course they think homebirth is bad for you, just as PS teachers think homeschool is bad for you and Olive Garden thinks McDonald's is bad for you. So what?
If you want to know the truth about homebirth, ask people who have experienced it! I'm one. I've had 2 hospital births and 3 homebirths. The homebirths were happier, safer, healthier (no exposure to other people's germs!), less physicall traumatic (didn't tear, no stitches), and more affordable.
Homebirth is empowering. Homebirth puts the woman back in charge, which is where a birthing woman should be. "My body, my choice."
It's safer for babies, too.
And what do you do if something goes wrong? Well, duh, if you need emergency medical care, you go to the hospital. Even the "worst case scenario" in the first post ends with a healthy woman who did not, in fact, bleed to death. Many more women die in hospitals than at home -- whether you're looking at numbers or percentages.
Homebirth is also safer for babies. Babies born naturally are more likely to breathe on their own, are not on drugs at birth, are not exposed to hospital germs, don't die in incubator fires, aren't accidentally given carbon dioxide instead of oxygen, etc.
Sorry for the repitition. I'm sleepy......
I'm really glad to see some information on this here at Feministing.
Reproductive choice and justice has to do not just with contraception and abortion, but with the birthing process as well. And women get just as screwed over in this area too. Good on Joan for her work!
And singoutsingout, I agree with you also.
Thank you so much for this, feministing and Joan!
Many years ago, when I was considering becoming a midwife (I didn't because I realized that I don't have the kind of personality that can be on call), I volunteered for a year at the now-defunct Elizabeth Seton Childbearing Center in NYC and trained as a doula. I learned so much about pregnancy and birth, and also about how seriously midwives take their commitment to health, respect, and support.
just about anyone can get their midwife license,
That's just...not true. To become a licensed midwife, you have to attend postgraduate study as a Nurse-Midwife. This is like saying that "anyone" can practice as a doctor. Sure, if by "anyone" you mean "anyone who completes the required course of study, passes his/her exams, and trains appropriately."
My fully-licensed OB started cutting on me while I could still feel...and almost didn't stop when I screamed for him to do so. He also left tissue inside which caused me to hemorrhage 10 days later. Since I didn't keep the tissue but passed it, I had no evidence with which to charge him, and so he suffered no repercussions for his mistake.
So yeah. Get references. But an MD =! safe care. Birth, like all of life, has risks; lots of beeping machines and people with med school degrees is not a magic ticket. The irony is that had I homebirthed, I would not have been forced to use Pitocin to speed up my "slow" labor, causing my son's head to move down too fast and get stuck, and might not have needed a c/sec at all.
Sorry, I know it's anecdote....:)
Can I also just say, that newborn is supercute and I am jealous of Joan for getting to hold it?
And on the unreliable OB/GYN tip, my mother's OB/GYN gave her such a vicious episiotomy that she couldn't set up for six weeks. Midwives are trained to gently and slowly stretch the perineum, thus obviating the need for an episeotomy.
Also, a CNM will be fully trained in all emergency life-saving procedures and have the equipment to do them--if you have an emergency while giving birth at a birthing center or at home with a CNM, your midwife will perform exactly the same emergency procedures a doctor would to stabilize you before getting you to a hospital--and these days, many hospitals have birthing centers either attached or within a block. When I volunteered at ESCbC, the vast majority of transfers to the affiliated hospital involved the laboring mother just getting up and walking the two blocks to the hospital, where she continued to be treated by the midwife; those transfers only happened because NY has/had some regulation about the maximum number of hours a woman is allowed to labor in a birthing center after her waters break.
"Having a doctor or medical professional tell us what's wrong with homebirth is about as instructive as having public school teachers tell me what's wrong with homeschooling my children."
Is it also about as instructive as having homebirthers and homeschoolers tell my mom what was wrong with having me at a hospital and sending me to school would have been?
"These people represent an INDUSTRY against which the alternative competes."
Now *this* bit reminds me of when Planned Parenthood gets criticized for being industrial.
"and these days, many hospitals have birthing centers either attached or within a block."
Whichever hospital admins approved that followed smart advice.
"Also, a CNM will be fully trained in all emergency life-saving procedures and have the equipment to do them"
Yeah, having one sounds way better than just following patriarchial advice (whether that advice is "shut up and get cut, your husband wants you sewn up tight again" or "shut up and stay home alone, your husband doesn't want to spend money on a midwife").
I'm pleased to see the subject of midwifery addressed here. As a 50-ish woman who had two of her three children at home with a midwife, I get very depressed (as do my friends) reading about the state of childbirth today -- Caesareans are once again on the rise, breastfeeding is on the decrease, and the growing trend seems to be for people to "schedule" their births so that they aren't inconvenienced by allowing birth to occur naturally. We've become so distanced from the real world (and so over "medicalized") that we forget (or seem to want to deny)that women's bodies are designed to give birth.
There is a lot of mis-information spread regarding midwifery (as per the first poster) -- it is extremely important to be an informed consumer, and to take responsibility for your own health throughout pregnancy. I've found that physicians typically spend very little time talking about nutrition and fitness during pregnancy (mainly, I think, because they don't know very much about it). Many are unaware of how to facilitate a natural delivery (perhaps because they may have never SEEN a natural delivery).
In any case, I don't think that you can talk about feminism without including the issue of childbirth. It is the ultimate feminist issue.
Many are unaware of how to facilitate a natural delivery (perhaps because they may have never SEEN a natural delivery).
This is a real problem; doctors (as far as I know from my volunteer work) are no longer trained in how to deliver a breach baby vaginally, which means that there are definitely a number of unnecessary and unwanted c-sections out there. Midwives learn not only how to turn a baby, but how to deliver a breach baby that refuses to turn. And it is very possible--my father was breach and was delivered vaginally with no complications for him or my grandmother.
I rolled my eyes at the demeaning attitude displayed by the first commenter, but I'm most intrigued by this assertion;
There are far fewer barriers to entry to midwifery as opposed to a real OB/GYN M.D., which means that there is a much greater danger that a given midwife is incompetent.
It seems to suggest that ForbiddenComma - probably many other OB/GYNs too - has fundamentally misunderstood what midwifery is about - a 'real' OB/GYN M.D.? As if midwives are wannabes, less highly developed specimens of the same career? Midwives aren't, and have never been 'OB/GYN Lite'. They are (generally) trained in a fundamentally different approach to birth as both a physiological process and an emotional one.
It's also interesting to see a doctor refer to midwives as "feel-good" by comparison to a "traditional" doctor. Obstetrics as a medical field only came into existence in the seventeenth century, and is possibly the least scientific medical field there is; the early OBs invented equipment to distinguish themselves from non-interventionist midwives - their inventions were about commercial gain, and had very little to do with increased positive outcomes for women or babies. The obstetrics field has, from its very formation, had a tendency to revere new equipment and intervention, whether or not it has a proven record of positive outcomes (the history of electronic foetal heartbeat monitoring is an excellent example).
Any history of birth and birth technology is fascinating to read from a feminist perspective, and the OBs who parrot falacies like ForbiddenComma are simply repeating the same weak arguments as 300 years of OBs before them.
"and the growing trend seems to be for people to 'schedule' their births so that they aren't inconvenienced by allowing birth to occur naturally."
...and *this* comment reminds me of how abortion gets condemned with the "so they aren't inconvenienced by pregnancy" argument.
How much of wanting to schedule a birth comes from anti-natural-birth propaganda, and how much from pressures on the rest of her schedule?
For example, I've heard of temps getting fired for taking a sick day. Is it merely inconvenience if someone risks losing her job (and her ability to nurture her upcoming baby with a roof over their head) if she leaves in the middle of a work shift (escpecially if she's recently divorced instead of following the tradition of living on her husband's income even after he hits her)...?
My mom had such horrible experiences giving birth in a hospital that it made me never want to have kids when I was younger. Her labor with me was particularly difficult and took a long time, and at one point one of the nurses snarled at her, "It's not coming out as easy as it went in, is it?" (I was her first child, she'd been married to my dad for seven years and was 24 when she had me -- I don't even want to imagine how this woman would have treated a young, unmarried mother.)
When she gave birth to my brother, the goddamn doctors and nurses left most of the placenta inside of her, and as one can imagine, she was going through boxes and boxes of maxi pads. Every time she would try to call her doctor and told them how many pads she was going through per day, the nurse would say, "Oh, you can't be going through that many!" It took my dad getting really sick of buying pads (and yelling at somebody at the hospital, I presume, because he likes to yell) before they would schedule her for an appointment. So, yeah. Most people in my family have learned the hard way that doctors don't really give a shit about women -- the last time I went to a regular doctor, I was having really, really bad nausea and the only thing this dumbass doctor could come up with was that I must be pregnant, despite the fact that I hadn't been sexually active for like eight months. She just kept repeating it, even when I said that it wasn't possible, clearly implying that I was lying. I swear to Isis that the next time I have to see a doctor I'm going to dress up as a man and get a fake ID so I stand a chance of getting some decent care. (But if they don't fall for it they'll think I'm trans, and then I will REALLY learn the meaning of shit outta luck.)
"How much of wanting to schedule a birth comes from anti-natural-birth propaganda, and how much from pressures on the rest of her schedule?"
BTW, I just remembered that this sort of thing can apply to the other end of a lifespan as well:
How many dead people who had wanted burial instead of cremation or whatever get embalmed because (a) not all of their friends and family can afford to drop everyhing and attend the funeral before decomposition sets in and (b) whoever's running the funeral still wants them to attend?
"Most people in my family have learned the hard way that doctors don't really give a shit about women"
Damn, that sucks. :(
I'm fortunate that the doctors I see do give a shit about women. At the same time, trying to find a good one (by making an appointment with a doc, talking to her to see if we can get along, choosing her or starting over, etc.) if the recommendation from my previous doctor (who I can't see anymore because I graduated and her practice is limited to my school's clinic) hadn't worked out would take more time than I can afford to take off work. That would also be even worse if I didn't live near several hospitals. So I think I understand how difficult it would be for you to go find a doctor who does care.
Yes, women's bodies are designed to give birth. That didn't stop millions of women dying in childbirth since the dawn of time. I'm pregnant, and I do have a high-risk pregnancy for a bunch of reasons, but even if I didn't, I'd be having my baby in a hospital. Because if something does go wrong, I don't want the tiniest bit of chance that things can't be dealt with immediately. I say that as the daughter of a mother who nearly died in childbirth of placenta previa. If she hadn't been young, with naturally low blood pressure, she would have died. My baby brother did die. My boss also nearly died in childbirth, from hemorrhage of a different type. Something no one could have known, and she did have the best of modern care.
Maybe I'm nervous, maybe I'm a pessimist. But it's my baby's life, and my life, we're talking about here. No amount of "empowerment" can overshadow that. I want my baby to be delivered in the safest, most pain-free way possible for both of us. For all of you who want to use midwives, great. More power to you. But don't denigrate me as part of the patriarchal system because I don't want a midwife. It doesn't have to be one or the other.
Forbidden Comma I find the tone of your comment very insulting to midwifes out there. Midwives are trained medical professionals and I doubt their training is easy, not only that but they have plenty of personal experience. I have no doubt a midwife could handle saving a patients life in an emergency situation, just like a MD (which how often these day is the only person in a emergency room a physician's assistant who has as much education as a midwife anyways)but midwives have relationships with hospitals, not because MDs have better training, but hospitals are better prepared to deal with emergency situations. Not just anyone can become a midwife. It's a hard job both emotionally, it can also be physically demanding and demanding on a person's time. Unlike a doctor a midwife can't just sign their patient off to the attending physician during delivery or count on a team of nurses. The midwife is the doctor, the nurse, the doula, the birth coach, the lactation consultant and the pediatrician. Women are not choosing midwives because they are the "feel-good" option but because they can for many women provide one on one care that women are looking for during their pregnancies.
Sansa - certainly, nobody is saying that you are "part of the patriarchal system" for wanting an MD. All of us thank our lucky stars that birth technology and surgical practitioners exist. But they are not what stopped millions of women from dying in childbirth since the dawn of time. Simpler things like understanding how the body works and antiseptic technology did. What IS part of the "patriarchal system" is extrapolating from the bad outcomes of relatively few women that women's bodies are faulty vessels from which babies need to be removed - lest the woman mess things up, I suppose...
I am terribly sorry to hear about your mother and brother, and your mother certainly probably would have died if she delivered at home. That said, the reality of the matter is that a good midwife would know far in advance if a woman has placenta previa, and would transfer her to MD care. According to Joan herself, what makes a good homebirth practitioner is knowing when home birth is appropriate and when it is not. You say you have a high risk pregnancy, I can nearly guarantee that you won't find a midwife willing to deliver you at home. And I say that speaking as someone who has had a caesarean delivery - I'll probably never find anyone willing to deliver my so-called high-risk pregnancy at home.
Seriously, though, I think that scare quotes around empowerment is unnecessary disrespect toward a philosophy of birth that is really in everyone's best interest. The point is not "natural home crystal hippie water birth for everyone," it's "CHOICE in childbirth for everyone," even if that choice is an epidural as soon as you hit 6 cm. There's no reason to be condescending toward the people standing up for your rights.
"Yes, women's bodies are designed to give birth. That didn't stop millions of women dying in childbirth since the dawn of time."
For that matter, we're "designed" to get pregnant. That doesn't stop women from getting pregnant while being raped...
"The point is not 'natural home crystal hippie water birth for everyone,' it's 'CHOICE in childbirth for everyone,' even if that choice is an epidural as soon as you hit 6 cm."
I got the impression that there are at least two different pro-homebirth points since *not all of the people promoting it agree with each other.* There's the pro-choice point ("even if that choice is an epidural") and the anti-technology point ("but [insert name of painful physical symptom] is natural").
Seriously, though, I think that scare quotes around empowerment is unnecessary disrespect toward a philosophy of birth that is really in everyone's best interest
I don't have to respect it. I think it's stupid. The amazing thing is that a woman has created this baby over nine (or ten) months, out of nothing but a couple of cells. How she squeezes the baby out of her body--or doesn't--is in my opinion, immaterial, other than it should be as safe and painless as possible for both mother and baby.
I'm very much a feminist, and I think women should be able to make whatever choices they want as to how they give birth. But it's impossible to ignore the attitude of natural birth advocates that their way is better. Including in the post above. Of course you're going to deny it, but it's there. I find it very tiresome.
It is less that the birth is "natural," in my opinion, and more that the woman has more control over her situation. If she doesn't want an episiotomy, a doctor doesn't just decide to cut her open against her wishes and without telling her what he is doing. (happened to my friend in labor) If she wants to do a VBAC (which is actually pretty safe, the main problem with VBAC is that docs were using pitocin on women who had had cesereans, and that's why they were more likely to rupture their uterus), she doesn't have a doctor telling her she is crazy and stupid. I think it would be beneficial for a woman to have an advocate at her birth, even in a hospital surrounded by doctors and nurses. Someone who could make sure that her choices were respected. I think that is the main problem. Women's choices aren't necessarly respected by doctors in hospitals, but they are respected by midwives/doulas. If you can find a doctor who respects your choices and won't force procedures on you you don't want (or force you to go through labor when you want a procedure), then that's great, and that's what I want for all women. It just happens to be easier to find midwives who will respect your decision than it is to find doctors.
"It is less that the birth is 'natural,' in my opinion, and more that the woman has more control over her situation."
Right on!
Now I'm also reminded of another case I read about a few years ago in which the OB/GYN did ask the woman in labor whether she wanted pain meds...but asked through an interpreter, since the two didn't have a language in common. Instead of having a neutral interpreter, the hospital figured relying on her husband was good enough and he was saying "she's fine, she doesn't want pain meds" when she did want them. Unfortunately, I don't have the bookmark file with it anymore. Does anyone else remember reading this?
FemiDancer, I agree completely.
I think that midwives or doulas who make women feel bad for wanting pain relief are just as much at fault. The thing is, they are much more rare than, say, doctors who will sweep membranes without even telling women what they are doing, or slip pitocin into an IV like it was no big deal.
I think the reason that midwives that disrespect a woman's bodily integrity like that are more rare is that midwifery is more client-centered; the expert/client power differential is diminished by the personalized relationship between midwife and client.
"Homebirth is empowering"
Oh God, you just played the e-word didn't you. Shouldn't there be some sort of Godwin rule for using the word "empower" in a feminist forum? i.e. using such a tired cliche means you automatically lose the argument, same as if you bring up Hitler?
Homebirth is a wonderful option if you have an uncomplicated pregnancy, yes. Then, a midwife is perfect. Hell, I could train a high school student how to catch a baby if everything goes perfectly.
But what if everything does not go perfectly?
It's like with nurse practitioners... they're all you need if you have the sniffles, and maybe they can help you feel "empowered" (ha, still trying to figure out what that term exactly means), but if you have a more serious situation like leukemia, you might want to find an actual physician.
I don't want to come off as seeming too harsh on nurse practitioners or midwives. They do have a role, and unfortunately it is a valid complaint that many physicians have a problem with personal skills/customer relations.
But be that as it may, please be careful with whom you choose, and please go to someone with the maximum training, qualifications and equipment available (i.e. a physician in a hospital) if you have a high-risk pregnancy.
(I may be a member of the Evil Patriarchal Physician Establishment, but I am not an OB/GYN...)
"It's like with nurse practitioners... they're all you need if you have the sniffles"
Or if you need prescription painkillers for migraines (yeah, I've had Rxs written by NPs before).
"and maybe they can help you feel 'empowered' (ha, still trying to figure out what that term exactly means), but if you have a more serious situation like leukemia, you might want to find an actual physician."
If you have a more serious condition like leukemia, you might want to find an actual oncologist.
"If you have a more serious condition like leukemia, you might want to find an actual oncologist."
er yeah... and oncologists are, uh, physicians.
But still unanswered is my greater question....
What the heck does "empowering" even mean??? THE WORD MAKES MY HEAD EXPLODE AHHHHH!!! I CAN'T TAKE IT ANYMORE!!!
Of course natural birth advocates think their way is better, that's why they're natural birth advocates. :P
But even they almost always recognize that natural births aren't possible for everyone.
That doesn't make the philosophy "stupid." NBA's pushing their agenda are the reason we have such a thing as a birthing center in a hospital, among other things. So even those of you who want to have your child in a hospital owe some of your comfort to them.
Right, FC. I can't imagine how any of us wouldn't think that you are doing your best to be respectful of nurse-midwives when you compare trained medical professionals to high school students.
You do know, right, that nurse-midwives don't just hang around "catching" babies when everything goes well? That they actually handle problems that come up?
You write as though birth is either a matter of squatting down and popping out a kid no problem or a life-threatening hazard. You do realize that there's a whole lot of middle ground there, right? And you realize that almost all midwives will refuse to take on a high-risk pregnancy that requires a doctor?
I'm sorry you've encountered a horrible, incompetent midwife. I've encountered horrible, incompetent physicians. That doesn't mean that the profession of physicians is incompetent and worthless. It means that you get idiots sometimes wherever you go.
And...you do know, right, that nobody goes to a nurse-practitioner for sniffles? One stays home and drinks orange juice for sniffles. I've gone to a nurse-practioner for things like, oh, recurrent yeast infections that wouldn't go away, recurrent bacterial infections, pap smears, unexplained weight loss. She treated what she was qualified to treat in the best way I have ever experienced treatment, and referred me on for what she couldn't.
And you know...look it up. This isn't a dictionary.
Lets get real here people. Home births by midwives are ABSOLUTELY APPROPRIATE for about 90% of all births.
I think all women should seriously consider it. For those with normal pregnancies, a home birth with midwife is the best way to go.
That being said, I absolutely believe that midwives should be required by law to have OB/GYN physician backup in case complications arise that require a c-section or other surgical repair. Its not responsible for midwives to take on the responsibility of delivering a baby without having adequate backup JUST IN CASE something goes wrong.
The legal climate regarding deliveries is insane and that explains why 95% of midwives dont do homebirths but instead work out of hospitals or birthing centers. The laws state that a midwife or ob/gyn who delivers a baby is legally responsible all the way up until 21 years of age. That means you could have a totally normal birth, and then at age 16 the child is diagnosed with some kind of learning disability and they can sue the midwife or ob/gyn for a difficult delivery. Its absolutely outrageous.
If midwives really want to increase the number of homebirths and make this option available to more women, they need to speak out on the outrageous legal system that forces women to have far more births than necessary at hospitals or birthing centers which greatly drives up costs.
MedicalStudent29, it's not the midwives' fault that they don't have backup; it's a system set up to put midwives and OBs in conflict, a system in which OBs see midwives as a threat, and when they will withold official backup and hospital privileges for financial reasons, not for good practice reasons. Almost no OBs will backup homebirth; this is their decision, not a lack of effort on the midwives' part. Which is why it's mostly CPMs, who do not have to have this sort of official backup, who do homebirths. Many of them instead have to cultivate personal relationships with local docs so that if they transfer, their patients will get decent treatment. And they are very selective about who they take, can deal with postpartum hemorrhage long enough to get to an ER, and know the trouble signs that signal things like placenta previa and pre-eclampsia.
And we ARE fighting the system...if you do any googling whatsoever on rights of pregnant women, midwife associations, etc. etc., then you will run across dozens of organizations. But the system as-is is entrenched and full of people who think certified midwives=high school students, medically speaking.
You want to know what I mean by "Homebirth is empowering," fine. I will be very explicit. The root word of "empowering" is "power." In this case a synonym is "control."
When I give birth at a hospital, the hospital is in control. I have to sign papers to that effect. And when it's all said and done, maybe they will "release" my own baby to me. That's not being in control.
At home, I'm the boss. I'm in control (power) of my own destiny. Thus I can birth how I want to without getting permission to peepee or squat or take off all my clothes or shower or get in the tub.
This matters, even at home. At one of my births, the midwife just couldn't leave the cord alone. (I wanted to keep it intact till the placenta delivered, because of my history with retained placenta.) So you know what I did? I told her to leave the room for a while. She did, because it was clearly understood that I was the boss. After she left, I delivered the placenta and then invited her back in to cut the cord. I love my midwife, who is excellent and very skilled, and I'm thankful that she and I both realized who was calling the shots.
forbiddencomma's bit about "even a highschooler" is disrespectful and erroneous. I bet my midwife has caught as many babies as a lot of OBGYNs. Or maybe not, since she actually spends hours and hours with the laboring woman rather than just stepping into the room to wield a scalpel at the last second!
My midwife is extremely skilled. I birth large babies (11 lb, 14 oz was the largest) and I felt very confident placing my life in her hands. Twice we experienced shoulder dystocia (shoulders stuck in pelvic girdle.) This is a dangerous condition, and it cannot be resolved with a scalpel since it is the bones, not flesh, holding the baby back. It cannot be resolved with c-section, since the head is out when it occurs. But traditional midwives are trained in resolving such problems through repositioning.
My midwife (and every other midwife I know) also carries oxygen and such. Midwives recognize that babies are birthed by pregnant women, not "delivered" by professionals. But they are extremely well-versed in problems, preventions and comfort measures. I am finished having babies but still call on my midwife with many questions regarding feminine health, children's health, etc.
A visit to the OBGYN means an hour in the waiting room followed by 5 minutes with the doctor. A visit to the midwife means 5 minutes in the waiting room (if there even is one) followed by an hour with the midwife. Both have their place.
Midwives have been helping and healing women for thousands of years. They should be honored, not targeted by ACOG witch hunts.
"When I give birth at a hospital, the hospital is in control. I have to sign papers to that effect. And when it's all said and done, maybe they will 'release' my own baby to me. That's not being in control.
"At home, I'm the boss. I'm in control (power) of my own destiny. Thus I can birth how I want to without getting permission to peepee or squat or take off all my clothes or shower or get in the tub."
That's assuming the woman or girl giving birth has control over the rest of her life. Sadly, that's not always the case. sometimes her husband/parents/in-laws run the show instead of her and they can override her preferences whether at home (like deciding which midwife to let in their house if she doesn't have her own home) or at hospital (like deciding which hospital to take her to if she's too young for her own driver's license).
I'm not in ob/gyn, and I think they are too aggressive about c-sections, but I have to call out some of the nonsense here.
The ob/gyn is much more "factory line" and more impersonal than midwife care, to be sure.
But in terms of labor experience, ob/gyns are JUST AS MUCH QUALIFIED as midwives are for manual labor maneuvers. They are just as good (if not better) at resolving issue like shoulder dystocia by different manual techniques.
Its true that ob/gyns are more aggressive about c-sections, but lets not pretend they send every single "difficult" delivery to surgery, because thats not even remotely accurate.
Like I said, midwife care is absolutely appropriate for at least 90% of patients. From a technical standpoint, an ob/gyn is just as good at manual deliveries as a midwife (if not better), although they are clearly not as "personal" or "involved" as the midwife is generally.
I think we can all be reasonable here and recognize that midwives and ob/gyns both have their own set of strengths and weaknesses. Neither one is "better" than the other.
I had a hospital birth with my first son, HORRIBLE! I had no control whatsoever over what happened with my body. There was a nurse rubbing my stomach in between contractions, it hurt! I yelled at her to stop and she told me that it would help get the baby out. I said, "Well, then I will just lie here and let you rub the baby out!"
My second son was born at home with an extremely competent midwife and her two apprentices. She did more than just "catch the baby". My son was ten pounds and a compound presentation, he had his arm up over his head, ouch! No only did she help me through my very painful contractions, but she knew enough to reach on in there and move his arm so that it wouldn't break. A doctor would have given me a c section, which was the last thing I wanted. Both of us were fine and still are, I only needed two stitches, I didn't tear much or need an episiotomy because my midwife and her apprentices made sure to massage my perineum with warm oil so that it would stretch instead of tear. They had oxygen, which they gave to me when my son was having trouble getting out, just in case.
They came back the next day and to check on both of us and took some blood for disease screening.
They did so much more than what your typical high schooler could do.
To be fair to OB's they are TRAINED to be good with their scalpels. And I'm sure they are very comfortable with them, which is great. But I do think that makes it so they are also in many cases rather quick with that scalpel. It's nothing BAD about them, but were I to have children I would prefer to go to someone whose training predisposes them to finding non-cutting solutions, and whose training is more in line with my own holistic health worldview than the triage-disease-treatment training of western doctors in general.
Neither type is better or worse overall I think, but they definitely have their strengths and weaknesses.
Yes, women's bodies are designed to give birth. That didn't stop millions of women dying in childbirth since the dawn of time. I'm pregnant, and I do have a high-risk pregnancy for a bunch of reasons, but even if I didn't, I'd be having my baby in a hospital. Because if something does go wrong, I don't want the tiniest bit of chance that things can't be dealt with immediately.
Sansa, just to clear up a misconception that also seems to be going on with a lot of commenters here, midwives also deliver babies in hospitals and well-equipt birth centers. I never considered home birth mainly because I knew I'd be too tired to clean up all the mess!
I don't understand why the discussion of midwives seems to turn into an attack on giving birth within a hospitals.
I am all for women making the informed choices that they feel are best for themselves and their newborn but why do we have to marginalize the women who feel more confident/comfortable with medical professionals helping them with their childbirth.
I'm pro-choice, and I think that women should have all the options available to them that they can regarding childbirth. Can we please discuss these options without attacking more conventional options at the same time?
"To be fair to OB's they are TRAINED to be good with their scalpels."
When it comes to episiotomy, it can cause more harm then good, particularly when the incision *continues* to tear, in some cases into the anus or causing an actual rectovaginal fistula. My nursing instructors were against episiotomy.
Medical illustrations, not for the squeamish:
http://catalog.nucleusinc.com/chooseexhibit.php?A=2&I=2&TL=1793&ExhibitKeywords=+episiotomy+tear&Action=Search
But as just about anyone can get their midwife license, you have to be more careful.
I'm guessing this commenter is a practicing M.D. who may be feeling a bit threatened by the competition?
Certified-Nurse Midwives are Master's educated nurses who completed a four year Bachelor's degree in addition to 2 to 4 years of advanced coursework in nursing and midwifery. That's hardly "just about anyone" who feels like delivering babies.
In fact, research has shown that CNM's actually have better birth outcomes than physicians, controlling for a variety of social and medical risk factors.
Of course, it is a woman's decision how, where, and with whom she would like to give birth, but midwifery-assisted birth should be an option for everyone and no one should be frightened away from it based on dubious claims and scare tactics.
"In fact, research has shown that CNM's actually have better birth outcomes than physicians, controlling for a variety of social and medical risk factors."
Of course they have better birth outcomes, but that has NOTHING to do with them being better PROVIDERS. High risk pregnancies get funneled towards OB/GYN doctors and away from midwives.
If you read this study, you'll find that it shows that the OB/GYN group had higher rates of placental abruption and other complications, which explains the rise in mortality.
Ob/gyns are much more likely to deliver eclamptics, abruptions, malpresentations, etc whereas midwives are much more likely to deliver non high-risk pregnancies.
Its the same thing as saying that endocrinologists have worse diabetic outcomes than family practice doctors. Its not because FPs are better at treating diabetes, its because FPs take the simple cases while all the refractory, hard to control diabetics get referred to endocrinologists.
Medical Student29,
I would suggest that you take a look at the work of Marsden Wagner on the subject of ob/gyn and midwifery care in the United States. He is a physician and scientist, and a former Director of Women's and Children's Health at the World Health Organization and has a recent book out on this subject (as well as numerous scholarly articles). The book is called Born in the USA. He is not against ob/gyn care, but argues persuasively that in the United States it is grossly mis-applied, over-medicalizing childbirth in a way that is detrimental to both women and infants.
Currently, the majority of women with low-risk pregnancies in the U.S. do NOT get their prenatal and birthing care from midwives, but from ob/gyns. And data as well as anecdotal evidence are showing that many American women are suffering the consequences of this mis-application of care in the form of unnecessary and often harmful medical intervention. This is NOT the case of high-risk cases skewing the outcomes. This is the result of uncomplicated cases being turned problematic by procedures that do more harm than good.
"I never considered home birth mainly because I knew I'd be too tired to clean up all the mess!"
Oh, my midwife and her apprentices not only cleaned up the "birth mess", they also did a load of laundry, swept up the living room, did the dishes, made me something to eat, made me some iced tea (it was August), packed up my placenta in the freezer and they got me all tucked in and ready to sleep!
The mess isn't bad. They gave me a list of supplies to buy before the birth, which includes a plastic shower curtain liner, sheets and LOTS of towels. We bought some extra sheets and towels at a yard sale so that they could just ball it all up and throw it in the garbage.
A male, my point was more that let's not fault people for following their training. Let's just understand the training and decide what we want more from there.
Medical Student29,
You are mistaken about the funneling in this study, and it is right in the abstract:
"After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower."
The first part of that sentence again, because it is very important, "After controlling for social and medical risk factors,".
This means that the risk factors (i.e. high-risk v. low-risk pregnancies) were approximately equivalent between the two study groups (physician or midwife attended), therefore the differences found in this study could not be attributable to higher-risk pregnancies being funneled towards physicians (which they certainly are).
Like others have said, each option (midwife v. physician) has it's place but, unfortunately, it is up to us women to research our options because the medical industry does not fully disclose this information to patients who are delivering. The maternal and fetal effects of pitocin, epidural, EFM, episiotomy and C-section are generally poorly explained to patients (for instance, EFM has shown no effect in outcome for the fetus, and in approximately 33% of C-sections the baby is cut so badly it needs stitches).
I don't understand why the discussion of midwives seems to turn into an attack on giving birth within a hospitals.
Me neither. My CNM only delivered in hospital. Midwife doesn't mean home birth.
"Certified-Nurse Midwives are Master's educated nurses who completed a four year Bachelor's degree in addition to 2 to 4 years of advanced coursework in nursing and midwifery."
Yeah, I got the impression that CNMs get criticized both for "being unprofessional" because they're professional nurses instead of MDs and for "selling out to the system" because they earned graduate degrees. o_O
Leah, you didnt read the study. The OB/GYN group had higher rates of placental abruptions, fetal distress, and other complications.
Its in the first and second tables in the article. The odds ratios they calculated in the last table also showed that OB/GYNS were more likely to get these patients and that those factors by themselves were independent risk factors for low birth weight and neonatal mortality.
Like I said before, midwives are perfectly fine for 90% of births and I think more women should use them. But its wrong for people on this board to imply that ob/gyns dont know how to deliver babies as well as midwives and they only thing they can do is c-sections, because thats clearly a load of crap.
Midwives are better at establishing a more "patient friendly" environment, but they are no better (or worse) at vaginal deliveries than ob/gyns are from a technical/procedural standpoint.
I have to say, this is the first weekly-interview post here at Feministing for a long time that has generated an actual debate. :) A lot of good opinions here on both sides.
Certified-Nurse Midwives are Master's educated nurses who completed a four year Bachelor's degree in addition to 2 to 4 years of advanced coursework in nursing and midwifery. That's hardly "just about anyone" who feels like delivering babies.
Yes, advanced-practice nurses including nurse midwives require a BSN plus a master's. That's usually 4+2=6 years or so if they go to school fulltime. Lay midwives require considerably less coursework or qualifications.
An OB/GYN M.D./D.O. needs a bachelor's, a 4-year medical degree, and must complete a 4 year residency. That's 4+4+4=12, or twice the amount of years as the highest level of midwifery.
Also, and I really don't want to be demeaning NPs or their various iterations such as nurse midwives at all but... NP school is a bit easier to get into than med school.
Finally, the coursework of med school and residency is strictly regulated by a number of entities, including the federal government via Medicare, and tough universal board exams that every OB practicing in the U.S. must take. There is no such level of standards for advanced nursing schools, let alone lay midwives.
Sure, they may be superstars like Ms. Bryson, no question; there are certainly physician quacks; and I have met more than one NP who could put most MDs to shame... but there are a lot fewer barriers to prevent a complete moron from entering NP/nuse midwife practice compared to actual OB/GYN physicians.
Which means to need to be even more careful selecting a midwife than an OB/GYN.
That's really all I'm saying. They can provide a wonderful service to any woman with a low-risk pregancy... and enough money not to be on Medicaid. (but that's a subject for another post.)
"Sure, they may be superstars like Ms. Bryson, no question; there are certainly physician quacks; and I have met more than one NP who could put most MDs to shame... but there are a lot fewer barriers to prevent a complete moron from entering NP/nuse midwife practice compared to actual OB/GYN physicians."
Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a "complete moron" to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards. Threads about childbirth or visits to the OB/GYN may not be friendly to people in the health care profession, physicians or nurses like myself, but geez. Are you this friendly to the hospital nurses you work with?
Medical Student29,
You have made two erroneous assumptions:
1. That I have not read the paper cited. Perhaps you assumed I do not work for and am a student at a world-famous medical institution in southern Minnesota (of which I cannot legally say the name) and am not part of the medical field and therefore do not have a subscription to this journal?
2. That just because, in this study, the physicians experienced more medical complications, that this means the two study groups differed significantly in risk factors from the onset. Please read the materials and methods section, and if you don't understand it please get one of your MD-PhD classmates or profs to explain it to you. This was a prospective study with two groups that DID NOT differ in medical or socioeconomic risk factors, only in the choice to receive pre-natal and labor care. Those individuals that switched from midwife-attended to physician-attended births due to complications WERE NOT INCLUDED in this study, meaning that the "funneling effect" meme that so many doctors love to espouse and indoctrinate their students with did not occur in the patients included in this study (in fact so many studies where these pregnancies and labors are not included has pretty much disproven the funneling effect. It was a problem with studies done in the early-mid 80's but since then no study will be published that fails to control these factors). That the physician-attended births experienced more complications does not mean the two groups differed significantly from the study onset. Granted it can explain some of the results, however it does not mean that the study design did not have the proper controls. What the authors did not address is *why*, when the two groups were medically and socioeconomically equitable to begin with, the physician-attended births experienced more complications. Sampling error? Use of interventions that can lead to complications (pitocin use has been shown to increase fetal distress, membrane rupture and pitocin use have also been shown to increase incidence of membrane rupture)? Dunno. There are many possibilities.
Oops it's too early. I meant "membrane rupture and pitocin use have also been shown to increase incidence of placental abruption".
Leah, drop the patronizing attitude. I dont care who you are or what you do, and its irrelevant to the debate.
The bottom line is that the physician group had higher complication rates that GREATLY affect infant mortality and this paper was not designed to determine whether this was a selection bias artifact or a real difference in quality of care between ob/gyns and midwives. It did NOT control for all medical confounders (gestational DM, pre-eclampsia, and gestational HTN come to mind immediately) so its not true that "everything" was controlled for.
As for the "funneling" argument, what you fail to understand is that mid-pregnancy shifting to ob/gyn care is only ONE FORM of funneling, and the only one that hte paper controlled for. Other types of funneling happen at the very beginning of pregnancy when a woman chooses her provider from the outset, or when a primary care doctor shifts her to either midwife or ob/gyn care based on things like previous high risk pregnancies which this paper did not account for.
Also, this paper failed to properly split the two provider groups. It notes that a "sizable minority" of midwives co-practice with ob/gyns and they failed to account for this kind of split practice.
This paper showed us two things that we already knew (increased infant mortality and complications) and certainly doesnt prove what the other poster said it does (that practice patterns account for increased infant mortality and complications in ob/gyns).
This retrospective study has too many confounders that were not accounted for, and thus the mortality statistics they cite are meaningless.
Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a "complete moron" to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards.
This is precisely what I am implying. There are few standards to block a complete moron from practicing as an advanced nurse (NP, midwife, or othersise), compared to the barriers that exist to keep morons from being phyisicians.
You forget that the hardcore standards that real medical professionals are subject to, exist in order to protect patients from incompetent providers. The public deserves to count on some minimum standard of skills from their doctors, no matter who that doctor is.
If you are in an emergency situation, after all, you won't have a whole lot of time to run background checks, right?
Advanced practice nursing decided to do away with such standards because they felt that the standards might hurt the feelings of incompetent people who would otherwise be unable to practice medicine.
And you know what? Such people really should not be able to practice independently. I'm sorry that such tough rules hurt the feelings of Jane Doe, ARNP, but the patient is more important. At least in my humble opinion.
Same thing with midwives. Many if not most midwife practices exist less to benefit the patient, and more to assuage the ego of some person who was not able to cut it in actual med school.
This is not to say that (competent) midwives don't have any advantages.
Midwives have more time to spend with each individual patient, compared to M.D.s and D.O.s., since they only cater to well-heeled patients with cash to spend and who do not have to worry about Medicaid. No question. (Yep... Ms. Bryson doesn't have too many low-income patients. How else do you think she has so much time to spend with each individual? I guess there aren't too many poor people in your women's studies course at college so that doesn't matter eh?)
And I do not deny that it is a huge flaw of the U.S. medical system that real phyisican OB/GYNs have such little time to spare per patient due to the realities of the current system.
But that does not change the fact that midwives have a vastly inferior skill set compared to an actual physician OB/GYN.
But please, pretty please, don't believe that your midwife's lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience.
Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a "complete moron" to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards.
This is precisely what I am implying. There are few standards to block a complete moron from practicing as an advanced nurse (NP, midwife, or othersise), compared to the barriers that exist to keep morons from being phyisicians.
You forget that the hardcore standards that real medical professionals are subject to, exist in order to protect patients from incompetent providers. The public deserves to count on some minimum standard of skills from their doctors, no matter who that doctor is.
If you are in an emergency situation, after all, you won't have a whole lot of time to run background checks, right?
Advanced practice nursing decided to do away with such standards because they felt that the standards might hurt the feelings of incompetent people who would otherwise be unable to practice medicine.
And you know what? Such people really should not be able to practice independently. I'm sorry that such tough rules hurt the feelings of Jane Doe, ARNP, but the patient is more important. At least in my humble opinion.
Same thing with midwives. Many if not most midwife practices exist less to benefit the patient, and more to assuage the ego of some person who was not able to cut it in actual med school.
This is not to say that (competent) midwives don't have any advantages.
Midwives have more time to spend with each individual patient, compared to M.D.s and D.O.s., since they only cater to well-heeled patients with cash to spend and who do not have to worry about Medicaid. No question. (Yep... Ms. Bryson doesn't have too many low-income patients. How else do you think she has so much time to spend with each individual? I guess there aren't too many poor people in your women's studies course at college so that doesn't matter eh?)
And I do not deny that it is a huge flaw of the U.S. medical system that real phyisican OB/GYNs have such little time to spare per patient due to the realities of the current system.
But that does not change the fact that midwives have a vastly inferior skill set compared to an actual physician OB/GYN.
But please, pretty please, don't believe that your midwife's lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience.
"But please, pretty please, don't believe that your midwife's lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience."
Holy shit. I guess you are one of those asshole doctors nurses talk about who think they are God's gift to patients.
And by the way, doctor - it seems your superior IQ has not figured it out for you: people don't become nurses, APRNs or midwives "because" they can't cut it as doctors. Even if I were cut out to be a doctor, I wouldn't want to be one. I prefer spending my time with patients, not acting like an asshole.
Something tells me that the sort of doctor who goes on about IQ scores could never cut it in nursing school.
Forbidden Comma, you are the reason many of us loathe OB/GYNs. Feel proud of your IQ now?
"Something tells me that the sort of doctor who goes on about IQ scores could never cut it in nursing school."
I will allow that I am also amazed and sometimes appalled that nursing students in my program are allowed to begin practicing on real human beings after just eight weeks of lecture and textbook study, or allowed to give injections, start IVs, etc., after a few hours of practice and an adequate demonstration for an instructor. This just further demonstrates that there is much more to nursing than what can be learned out of books, i.e., the ability to work with their colleagues to get the job done as well as gain knowledge and skills to become effective nurses themselves (over the course of 2-5 years on the job), and an ability to empathize and bond with patients. Because patients in recovery wards and long term care spend considerably more time with nurses than doctors (in local long term care, doctors are required to show up for exams only once a year; in my school's wellness center/women's health clinic, there is no doctor at all), it is more important for nurses to have good "bedside" manner, as the "face" of the facility. I am always disappointed to hear of how some nurses in OB/GYN or L+D have contributed to the trauma of many posters. Nurses are supposed to be patient advocates, well versed in the rights of patients particularly when it comes to choice, dignity and privacy; and sensitive to the needs of women in particular, as women's health is such an important issue, and 95% of nurses being women (and likely mothers, at an average RN age of 46.8) themselves.
So what does a pregnant woman who is also a pain-o-phobe do?