Faith Gibson, LM, CPM
3889 Middlefield Road
Palo Alto, Ca 94303

650 / 328-8491

J---- K---------, Attorney-at-law
915 -- Street, Suite 1000
Sacramento, Ca 

December 17th,  2001
Dear John, 

I wanted to thank you for your work and interest in arranging the meeting Tuesday and help in teasing the litigious possibilities of the situation out a bit further. Tuesday was a difficult day for me, what with the extremely disturbing news that the MBC is publicly entrenched in “protecting babies” from licensed midwives, irrespective of the impossibility of finding physician supervisors and the absurdity of the claim that non-interventive midwives (in contrast to obstetrical interventionists) are harming babies. If they want to be in the ‘baby protection business’, they should get to know a bit about obstetrical practices.  They would never run out of things to do.  

However, this legal threat is very personal to me (as well as political) as it means that I am again vulnerable to being irrationally prosecuted. I and many other midwives have been living with medical board terrorism for a long time. The extraordinary events of 9-11 only compounds our feeling of being terrorized all the time and everywhere. The original arrest and 21-month prosecution process (legal expenses of $30K, loss of income, public humiliation, family stress, etc) were deeply traumatizing to me and the mere thought of going through a similar ordeal is overwhelming. My post-traumatic stress symptoms are in full bloom again. I can’t wait to have a “real” life when this is all over.

I was so upset Tuesday that I did not make a very cogent presentation of the facts and ideas necessary to develop a successful lawsuit. I also forgot to leave you with the other information binders I put together for the anti-trust lawyers. One of the binders contains essays written by me on the politics of the situation. The other is extensive documentation of organized medicine’s campaign to deconstruct midwifery by forcing unworkable laws on licensed midwives. I have highlighted the pertinent phases and paragraphs in these documents in day-glow yellow so as to permit “white-water rafting” through the material. I am mailing them to you via the US post office. I certify them to be bio-terrorism free, although the thought sometimes crosses my mind that mailing a letter containing athlete’s foot fungus (hoof-in-mouth disease?) to the medical board’s DAG would be particularly satisfying!

My comments here will be brief, as many pages of background and theory are elsewhere in the enclosed information packets. However I have filled in the information sufficiently that it may be forwarded to the anti-trust lawyers if helpful.  I will call you in a couple of weeks.
Happy Holy Days to you and your family……Warm regards, faith ^O^ 

Achieving the Goals of Litigation without having to go to Court --

Overview: I believe that ACOG is uniquely vulnerable to the threat of exposing the facts laid out in this paper to the court of public opinion. The most efficient access to the court of public opinion is the publicity normally associated with filing and pursuing litigation. I am convinced that ACOG would agree to support legislation authorizing the independent practice of LMs (“distinct calling” status) in return for avoiding this type of unflattering publicity and the malpractice nightmare it would generate. In return, we would need to collect a significant monetary settlement to pay the lawyers and have enough left over to help establish a California midwifery training program and to self-insure.

Methodology:  I have access to an extensive library of historical records and other documentation establishing the validity of the claims made in this paper, both historical and relative to contemporary medical practice. A more extensive list of these personal resources is included on the last page of this paper.  

Multi-media video editing equipment and software ~ I also have a sizable collection of 35 mm slides and video tapes of both medical and midwifery-based birth care and commercially-produced sources (Maternity Ward, Baby Story, “Born in the USA”, “All My Babies”). I am able to splice together from these disparate sources to produce videos and CD-ROMs that teach the theory and principles of physiological management, provide real time examples that demonstrate these principles being put in practice by midwives and midwifery friendly doctors and include compelling examples of the failure to use these principles and its deleterious consequences -- forceps, CS, hemorrhage, babies needing resuscitation. In the near future I will be able to copy these teaching productions to Digital Video Disks, which will permit the use of a menu so the viewer can pick the topics and the order of viewing. DVDs are very high quality video images and can easily be sent through the mail to members of the legislature, the media, other lawyers, potential expert witnesses, and fund-raising opportunities, etc.

Celebrity Circle: A significant number of film and television personalities have had babies at home with midwives. Some would be willing to speak publicly in support of midwifery if the circumstances were compelling. For instance, we could arrange a media event (“National Arrest Your Midwife Day”!) as a forum for this type of publicity.  A partial list: Demi Moore & Bruce Willis, Pamela Anderson & Tommy Lee, Cindy Crawford (two home births, most recent one Sept. 2001) Carole King, Meryl Streep, Tyne Daley's daughter, Richard Thomas, Mel Gibson, Kenny Rogers, David Soul, Michael Landon, John Schnieders and Gil Bellow’s wives all had home births, Val Kilmer's wife Joanne Whaley, Woody Harrelson’s girlfriend had a home waterbirth, Rob Reiner & Penny Marshall's daughter - Tracy Reiner, Mare Winningham, Lisa Bonet & Lenny Kravitz,  Liberty Phoenix and Sherilyn Finn. I delivered Bobby & Debbie McFerrin’s third child, Mattie Grace. I also provided home birth care (twice) to the daughter of the founder of the law firm ‘Fenwick and West’.

Docu-drama as Strategy: It would be possible to fund the production of a docu-drama for $50,000 to $100,000. This would permit us to teach the basic theory of normal birth, reveal the history of midwifery and its political relationship with obstetrics and permit us to construct a positive outcome to the “doctor vs. midwife” problem. In particular, as a docu-drama we could script a class action suit as part of the story. By writing the legal theory and dialogue for a trial we control the course of events and would be certain to win the case (after all it is our film!). Obviously the best way to get the judge to be cooperative is to write his/her lines (use Judge Roman’s transcript!). The most economical way to litigate is on film and it would also prepare the public consciousness for a real-time class action suit if necessary. 

Synopsis & Background Theory: I question the fundamental premise that American College of Obstetricians & Gynecologists’ objects to midwifery based on a fear of economic competition -- that is, the notion that mothers would abandon obstetricians, hospitals and epidural anesthesia in droves and rush home to have spontaneous unmedicated births with midwives if ACOG were to “permit” midwives to enjoy a normal professional relationship (i.e., a distinct calling). There is some legitimate concern by individual doctors and organized medicine about loss of business relative to increased number of midwife-attended births but this number is too tiny to count when it comes to “market share” concerns. The number of women choosing out-of-hospital birth has held steady at 1% for the last 30 years. In spite of the passage of nurse midwifery laws in 1974 and licensed midwifery in 1993, this number hasn’t budge up or down. Nurse-midwives deliver about ˝ % of babies in freestanding birth centers. LMs deliver less than ˝ % of all babies born in California – that is only one out of 200.

As a serious student of the topic, it is clear that the hidden agenda of the Hundred Years War and the real reason for deconstructing independent midwifery was not and is not primarily matter of economic jealousy. Historically the goal was to elevate the status of obstetricians by divorcing childbirth services from its association with women’s work and women caregivers. In contemporary times, the social status of obstetrics is still an important focus. But the real motivation is to avoid acknowledging the failure of the obstetrical model to learn, teach and utilize physiological (i.e. non-interventive) management for healthy women. The expensive and interventive “obstetrical model” that has dominated maternity care since 1910 depends on an uncritical acceptance by the public of an unscientific, unnatural and in comparison with midwifery, a statistically-unsuccessful method. ACOG works furiously to keep midwifery management out of the mind of the public, to hide the evidence that physiological management is the better, more cost effective method to provide normal maternity care.

If physiological management were to be acknowledged as scientifically valid for healthy women with normal pregnancies and that failure to use it increases intervention and complications, obstetricians would need to employ its principles and techniques under those circumstance. To avoid this upsetting possibility, organized medicine is devoted to keeping midwifery invisible and on the defensive, while endlessly devising additional ways to further deconstruct its professional practice (for example, mandatory physician supervision).

Imagine the litigious repercussions if the public were to identify obstetricians as having a primary duty to use physiological management techniques for healthy women. This requires a genuine respect for the spontaneous biology of childbirth and a deep commitment not to disturb the normal process. Its methods consist of continuity of care from a familiar caregiver, non-intervention, emotional support, non-scripted time lines, oral fluids, maternal mobility, psychological privacy, non-pharmaceutical pain management (i.e. continuous one-on-one labor support, touch relaxation, massage, showers, deep water, etc) and right use of gravity, pushing in upright postures, squatting in 2nd stage labor. Only if physiologically-sound, mother-centered care proves inadequate to the task would narcotic drugs for pain, Pitocin to stimulate labor, instruments to facilitate delivery or performing a CS for “failure to progress” be indicated. This is not to deny women the right to choose medical interventions and physician-only care but rather to say that women should be fully informed of the facts and risks relative to both methods. Only then are they able to make informed choices based on their personal preferences. At present, women really don’t have a choice and as a result, frequently become a “statistic” of obstetrical interventions runs amok.   

If you were the initially healthy but unlucky mother who was induced, drugged, kept in bed on your back through out your labor and then had an unexpected CS for fetal distress or failure to progress and suffered massive hemorrhage from a nicked uterine artery, which resulted in the need for an emergency hysterectomy and you got hepatitis from the blood transfusion -- you might begin to ask embarrassing questions and become convinced that you were a victim of malpractice.  Obviously, doctors don’t want people thinking like that.

Good News

People are really tired of being bombarded by the “crisis” of the month (especially after 9/11) in which some special interest group is exploiting hysteria over toxic dumps, bad schools, corporate welfare, defective tires, etc. The list is just endless. The public doesn’t want to hear that there is yet another reason to worry about something that no one knows what to do about. Or worse yet, is proposing the expenditure of huge sums of money researching a solution that will, no doubt, take decades to find and include some painful, expensive or far-fetched remedy.

Unlike global warming and bio-terrorism, we know what to do about the “problem” generated by the obstetrical profession’s ignorance (and rejection) of physiological management. There are lots of resources – sound scientific evidence, textbooks and knowledgeable, experienced people (midwives and midwifery-friendly doctors) who can teach the principles and demonstrate skills of physiological management. This will reduce our Cesarean rate by 50% while making for happier mothers and healthier babies and freeing up an additional 10% of the health care budget to spend on people who are genuinely ill or injured. In the long run it is a win-win solution, as obstetricians will get to do what they are trained for -- focus care on those suffering from the diseases and dysfunctions of fertility and childbearing. And should a terrorism event (biological or otherwise) occur and hospitals become overwhelmed with the injured or ill (perhaps with contagious diseases), we will have midwives available to provide safe, community-based maternity care without having to waste the precious medical resources of doctors and hospital beds for the care of healthy mothers and babies.  

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The Historical Doctor Problem ~ Can’t get no respect!

The vitriolic propaganda campaign and pernicious legal strategies to eliminate independent midwifery and erase the public memory of midwives was fueled by concern over the social status of obstetricians. If midwives (i.e. mere women) delivered babies, then how could obstetricians be properly respected by their physician colleagues (note TAASPIM comment by Dr Williams’ on the denigrating remarks of other doctors who likened the work of an obstetrician to “a terrier dog sitting in front of rat hole and waiting for the rat to escape”). In 1915 one of the most famous obstetricians of the day, Dr. Joseph DeLee, bitterly complained that: "Obstetrics is held in disdain by the {medical} profession and the public. The public reasons correctly. If an uneducated woman of the lowest class may practice obstetrics, is instructed by doctors and licensed by the State, then {attending births} certainly must require very little knowledge and skill ---surely it cannot belong the science and art of medicine."

The second ‘doctor problem’ was how aspiring obstetricians could expect to receive handsome professional fees for doing the same work as women/midwives, who received little compensation ($5) or even exchanged care for fresh-baked bread and a dozen eggs?  It would not do for a college-educated “medical man” (as doctors preferred to be called), to be forced to barter his services like a washer woman! 

The Midwife Problem ~ 1910

The “midwife problem” was an invention of organized medicine and refers to the problem doctors encountered as they tried to take the profession of midwifery away from its natural practitioners -- the midwives. The straightforward purpose was to commandeer normal ‘midwife’ births into “clinical material” (teaching cases) for medical students to rectify the glaring deficiencies in medical education as identified by the Flexner Report, circa 1910. The hidden agenda was to ultimately elevate status of obstetrics and the income of physicians by divorcing childbirth services from the care of women midwives. The untested hypothesis was that if female practitioners could do a decent job of delivering babies then “medical men” would be able to do a vastly superior job if provided with an improved medical education and a steady supply of teaching cases upon which to hone their clinical skills and “practice” operative procedures.

A crucial aspect of the plan to deconstruct midwifery was to divvy up the work of midwifery between doctors, nurses and other non-physician helpers, much like a piece of whole cloth taken from midwives and torn into two unequal pieces. The big piece went to doctors (high-pay, short time commitment) and the smaller, subservient portion (long hours, low pay) went to nurses and nursing assistants. An obstetrician of that era described the plan this way:  "Of the 3 professions---namely, the physician, the trained nurse and the midwife, there should be no attempt to perpetuate the last named (midwife), as a separate profession. The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse .. " [1915-A; Edgar MD, p. 104] 

Dividing childbearing services up between doctors and nurses not only left midwives out of the equation but also separated “birth” from “labor” and ultimately left the mother out of the picture as well. In the holistic midwifery model, childbearing is seen as a process (rather than a product), in which mother and midwife collaborate to bring about the birth of the baby. The moment of birth is merely one of many important events on the seamless continuum of labor, all equally under the care-giving ministration of the midwife. The word “birth” is an artifact of modern vocabulary that describes what an observer sees when the last labor contraction propels the baby across the mother’s perineum and into the world. Technically speaking, the baby is born during the second stage of labor. During the third stage of labor the placenta is spontaneously expelled.

Until 1910 it was the role of the midwife to assist women during all three stages of labor but it was clearly the mother who gave birth. However, early obstetricians divided and repackaged this holistic process into “the labor” (nurse) and “the delivery” (doctor) and turned the baby into the “product” produced by the doctor. In a doctor/nurse dyad the mother does not have an active role. The doctor, instead of the mother, was identified, as the “expert” in childbirth and it was his job to pull the baby from the inert body of its mother. In contrasted to the mother being assisted to give birth, the doctor “delivered” the baby. This was now viewed as a ‘surgical procedure’. Nurses and other non-physician assistants had to focus their helping capacities on assisting the doctor rather than the mother. She was merely expected to be a good “patient”, follow instructions, be grateful and cheerfully pay a professional fee several times higher for having her baby “delivered” by a doctor (rather than giving birth herself, with the of help of a midwife).

An obstetrician continues the doctor/nurse story, circa 1910:

"The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions; he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee. This means .. the doctors must be relieved of all work that can be done by others -- nurses, social workers, and midwives." 

 

"The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants when things go wrong; and the midwives should be trained to do the work of the so called "practical nurses," acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant-attendants upon women in labor---conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery." 

 "In this plan the work of the doctors would be limited to the delivery of patients, to consulting with the nurses, and to the making of complete physical and obstetrical examinations ... Under this arrangement the doctors would have to work together in a cooperative association with an equitable distribution of the work and earnings." [Ziegler MD, p. 412 to 413, 1922-A;]

The campaign against midwives also promoted the idea that chloroform and the routine use of forceps were such an important "improvement" in maternity care that it was unethical to deny such "advantages" to the clients of midwives [Dr. DeLee, TAASPIM, 1915]. The combination of all these inviting ideas soon convinced doctors that it was nothing less than their civic duty to take the practice of midwifery (normal maternity care) out of the hands of midwives. In their minds this justified putting midwives out of business, “en masse” and as quickly as possible.

This wasn’t all that hard to do. Doctors were male, Caucasian, of European ancestry, university-educated, white-coated and cosmopolitan. They provided care in hospitals with lots of gleaming stainless steel, floodlights, gauze bandages, hypodermic needles, antiseptics and the smell of ether. They were assisted by nurses in sparklingly white uniforms, who able and eager to handle every little detail. Medical care was a systemized corporate undertaking, larger than life with a mystique of god-like proportions. In contrast, the midwife was merely an individual (often on immigrant) providing care in the homes of the poorest of the poor, diminished by her intimate association with poverty, bodily functions and bodily fluids (in hospitals the nurses did “those” things).

The midwife was constantly portrayed by obstetricians as woefully inadequate for the job -- ignorant, unschooled, gin on her breath, dirt under her fingernails, a bone in her nose (an insult aimed at black midwives in the South), no common sense, only anxious for her fee which was thought of by organized medicine as money stolen out of the pockets of doctors and nurses who would have, could have, should have done the job right. (See TAASPIM)  To quote an obstetrician of the period: “We believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth. The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public."

The Peoples’ Problem

For women the ‘midwife problem’ was not that doctors instead of midwives were being employed to ‘deliver’ babies, as if the same basic safe services were simply being provided by another equally trained, skilled and adept category of provider. Nor was it just an employment problem for midwives. Were obstetricians in 1920 to have been providing a service superior to that of the midwives of the era we would have no complaint but that was decidedly not the case. The real “midwife problem”, from the perspective of history, was that in order to make midwives wrong, medical politicians also had to make the discipline of midwifery itself wrong by deconstructing the very foundation of “normal birth” – the philosophy and principles of physiological management.

Whatever midwives did, doctors had to do the opposite. If the discipline of midwifery related to childbirth in healthy women as a normal biological function, then obstetrics must relate to childbirth as abnormal and speak of childbirth always as the “danger of childbirth”. Instead of treating childbirth as a normal body process, physicians related to the care of healthy childbearing women as an opportunity to develop their skills in interventive obstetrics by routinely using chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. It is no wonder that anesthetic deaths, hemorrhage, infection, neurological injury to newborns and long-term gynecology complications for mothers followed in the wake of these ill-conceived ideas.

In order to take over the clientele of midwives and make them in the “clinical material” of doctors, medical politicians of the era publicly promoted the idea that obstetrician care was extraordinarily superior to that of ‘mere’ midwives, claiming that the lives of mother and baby were vastly safer in their hands. The words “dangers of” preceded the word ‘childbirth’ in virtually every public and professional discourse. As an added inducement to the public to “trade up” to doctor care, doctors could promise that the mother would be knocked out during birth and not remember anything – the original version of “painless childbirth”. What started as a “midwife problem” quickly became a life-threatening health problem for childbearing women and babies. When mothers or babies died or were permanently damaged, the “midwife problem” became a problem for the rest of society.

In 1932 a physician-statistician for the Metropolitan Life Insurance Company studied the care and the outcome statistics for births attended in the Appalachian Mountains by midwives from the Kentucky Frontier Nursing Service. In a public address he stated that lack of access to professional quality midwifery care as provided by trained midwives resulted in an estimated 70,000 preventable maternal-infant deaths per years in the US for decades in a row. At that time, the small nurse midwifery program (12 students per year) was the only professional midwifery training school left in the US. Organized medicine put all the other midwifery schools and 80% of the practicing midwives out of business between 1910 and 1925.

No Witnesses, No Complaints, No Problem!

When normal birth was taken over by physicians one of the first big changes was the routine use of chloroform  – thereby leaving no “witness” to the quality of the physician’s care and iatragenic complications it caused. What better cover up than to knock the mother out with general anesthesia while not permitting the father or other family members to be in the labor or delivery room to see the effects of hallucinogenic amnesic drugs combined with narcotics (“twilight sleep”), big episiotomies, forceps, manual removal of the placenta, postpartum hemorrhage and resuscitation of the narcotized infant. When new mothers got very sick from infection or hemorrhage the doctor told the family how the mother had almost died but luckily for them, his medical skills had saved her life. The choice between doctor and midwife was promoted by organized medicine as a “no brainer” ~ the obvious superiority of obstetrical care accepted as a “fact of life”, embraced by everyone except southern blacks for whom a policy of racial segregation prohibited the choice of hospital and doctor care.

However, the price for unconscious childbirth under medical (interventionist) instead of midwifery (physiological) management was staggering – an increase in maternal mortality (15% per year, usually from sepsis or hemorrhage) and increase in birth injuries by 44% in the first decade (1910 –1920). In addition to maternal death and infant brain damage, women also suffered from pelvic floor damage such as fistulas and incontinence subsequent to the damage from episiotomy and forceps, which were routinely used on every mother who did not deliver precipitously before the doctor arrived.

Ever clever, organized medicine use these horrific statistics to their advantage, promoting the idea that a high maternal and infant mortality rates and complications such as infection and fistulas merely confirmed the obstetrical hypothesis that birth was intrinsically pathological and needed to be managed by an obstetrically-trained surgeon in an operative theater. My goodness, if mothers died in the hospital under the care of obstetricians, surrounded by all that stainless steel and swabbed with antiseptics, then the care of a midwife was clearly unthinkable. It would be like driving while drunk – nothing less than a criminal act to permit a ‘not-doctor’ to take on the dangerous responsibility of not one but two lives. 

At the end of the Great Depression improved economic conditions in the US brought about improvements in education, housing, food, hygiene and sanitation. Luckily the general reduction in the effects of poverty (poor maternal health, lack of access to medical care) combined with medical developments during WWII - antibiotics and safe blood transfusions – reduced the scandalously high rate of maternal and infant deaths (recorded in the TAASPIM as “appallingly high”, “highest of any developed country”) to the near vicinity other industrialized nations. The reduction in maternal deaths was, in part, because the discovery of antibiotics and blood typing permitted the most frequent iatragenic complications of obstetrical intervention – hemorrhage and infection - to be successfully treated.

In the long run, these broad-based improvements also permitted parents the luxury of focusing on the health status of their baby instead of merely being happy that nobody died. Obstetrical medicine, as usual, took full credit for social improvements that they had no part in as well as the scientific improvements in life expectancy. As with the high mortality rate of the earlier era, organized medicine now used the decline in that mortality as just another opportunity to be sure that obstetrics stayed in the middle of the picture. In their minds, obstetrical medicine had absolutely “proven” itself to be life/death essential to healthy women and normal birth. Now they could go on to even greater heights – guaranteeing parents a perfectly healthy baby every time. This audacious claims would come back to haunt them and is at the core of the obstetrical malpractice crisis today.

Contemporary Times, Contemporary Controversy

The last three decades of obstetrical practice has been dominated by two remarkable circumstances. The first is the development of high tech maternal-fetal surveillance – ultrasound imaging, amniocentesis, various types of genetic testing and electronic fetal monitoring. The second is the US Supreme Court “Roe v. Wade” decision providing easy and socially approved access to abortion services. This results in an entirely new social “contract” between the childbearing family and obstetrical medicine. This changes the doctor’s primary focus from the end of the nine months during the limited period of the mother’s labor (mainly offering “painless childbirth”) to a vastly expanded focus on the unborn baby during the entire nine months of its intrauterine life. In 1976 the Williams OB textbook excitedly declared that for the first time, “the fetus is our primary patient”, a welcomed change made possible by ultrasound technology. This new contract between mother and obstetrician consists of independently saving either the mother or the baby from the other through the use of abortion (early pregnancy) or cesarean delivery (late pregnancy). This gives rise to a mother-versus-baby tension, in which it seems that the interest of each are in conflict with the other. Many in obstetrics see themselves as court-appointed guardians for the fetus, often prompting doctors to speak of protecting the baby from the choices of its mother by coercing her into unwanted interventions. Clearly the mother is no longer the primary focus of technologically-intensive obstetrical services.

During the first trimester of pregnancy the tacit contract of our day is to save the mother/family from a defective baby thru genetic and prenatal testing. This permits doctors to terminate a pregnancy when the baby is discovered to be physically deformed or mentally defective. It is appropriate for a woman to decide whether or not she is able or willing to raise a handicapped child. But it should be noted how far the practices of obstetrical medicine is from midwifery in regard to this issue. Midwives don’t practice medicine or perform surgical procedures – either abortions or cesarean deliveries. We provide care to women who have already considered and declined routine medical surveillance and surgical interventions. They don’t need or want to be “rescued” from their healthy pregnancies and are asking their midwife to assist them in staying healthy, with obstetrical care being reserved for complications.

In the middle months of the pregnancy healthy women enjoy a period of obstetrical quiescence and respite from these hard choices. The big decisions are already made and except for gestational diabetes testing, there is not much to do for either mother or baby. Then in the 3rd trimester the sleeping giant is awakened again as the obstetrical contract revs up to save the unborn baby from a possibly defective “maternal unit”. Increasingly frequent prenatal appointments are devoted to maternal-fetal surveillance to determine whether or not the obstetrician can “let” the mother continue to be pregnant for another week or she must be sent to the hospital to be medicated, have labor induced or be scheduled for a CS to save her baby from a “hostile uterine environment”.

This is predicated on the obstetrical concept that after the period of viability has been achieved there is no good reason to prolong the pregnancy in the presence of any possible complication, no matter how remote. The obstetrical axiom is “when in doubt, cut it out”, referring of course to Cesarean section. Pitocin induction, epidural anesthesia, antibiotics, operative or surgical delivery (in combination with neonatal intensive care) is the answer for all reasons. Obstetricians are the active agents, employed to rescue women from the many unpredictable deficiencies of the childbearing woman’s normally abnormal biology, an expanded version of  “the dangers of childbirth”. Of course, women make the false assumption that they are biologically defective and that it is their doctors (but not themselves) that are the truly essential person at their birth because organized medicine has programmed this marketing strategy into the public consciousness for nearly 100 years. The ‘big lie’ is all the more intractable for its audacity and longevity. How could all those millions of people be wrong for all those years? 

Unfulfilled Promises, Unmet Expectations

Unfortunately the “perfect baby every time” is another promise that actually has not, cannot be kept by obstetricians. One firth of all pregnancies miscarry in the first 12 weeks (an additional 20% are electively aborted). In California 6 out of a 1000 pregnancies carried past 20 weeks ends in a stillbirth (usually prematurity). In 7 out of every 1000 live births the baby dies with in the first 28 days of life – that is 1 out of every 149 births. In Japan, Sweden and the Netherlands the ratio is about 4 or 5 per 1000, or one out of 200 - 250 live births. In spite of genetic testing, ultrasound and liberal abortions policies, 3 out of every 100 babies will be born with a mild to serious congenital anomaly. Future brain functioning cannot be visualized on ultrasound and there are no predictive blood tests. 

This is not to say that obstetrical care is never “life-saving” – in the face of certain complications it is and we are all extremely grateful for these skills. But interventive obstetrics is also associated with an increase in operative deliveries and maternal complications, including postpartum depression and decreased levels of self-esteem and satisfaction in motherhood. Labors that are induced or augmented with Pitocin produce higher rates of children with autism and associated learning disabilities and behavior disorders. The physician-director of a clinic in New York for autistic disorders reports that 60% of the children he sees were the product of a Pitocin accelerated labor. About these topics obstetrics is uniformly silent.

The “usual and customary” practice of obstetricians often remains 5 to 50 years behind the scientific evidence. This is particularly a problem in the area of Cesarean surgery, considering its potential mortality and far-reaching health consequences. For example one published study reported that that a significant percentage of Cesarean Sections done for “failure to progress” or “arrested labor” were performed before the mother was in active labor and were therefore medically unjustified. Another study reported that a significant portion of Cesareans done for fetal distress were performed without first utilizing the simple fail-safe criteria published years ago by ACOG to assure that the baby really was distressed and the surgery was truly necessary. This article noted that it takes many years for simple scientific adjustments in practice to be voluntarily adopted by ACOG members. In the mean time, obstetricians continue to use out-dated or inadequate criteria, and even harmful methods, with impunity.

A Cesarean every 39 Seconds - the politics of an epidemic

Twenty percent of our entire healthcare budget is spent on maternity services. Forty percent of obstetrical services are paid for out of Medicaid funds from federal and state governments and yet only 3 out of 10 mothers or babies has a “medical condition” that warrants obstetrical management.  In US 23% of births (about 900,000 per year) are via cesarean section out of approximately 4 million annually. It is the single most frequently performed major surgery in the US. Or as the enclosed product advertisement from an obstetrical journal proclaimed in 1995, “a scar is born every 39 seconds”. That’s 80 Cesareans every hour, round the clock, 365 days a year. The percentage of Cesarean surgeries has risen since 1995 to about one Cesarean every 33 seconds.

Cesarean surgery is currently being promoted by organized medicine as protective of the pelvic floor when it actually is a risky procedure that fails to achieve this purported goal. ACOG has always promoted the idea that the “perfect” birth was a medically induced, medically managed delivery. Now obstetricians have come up with an even better idea – to totally eliminate the unpredictably of normal birth via “Cesarean on demand”. This also permits doctors the luxury of practicing “daylight obstetrics” and maximum billing per unit for their time. Cesarean surgery is now being promoted as “safer”, “better”, “maybe should even be routine” and simply as a matter of a “woman’s right to choose”.

On the national news show “Good Morning America”, the president of ACOG, Dr. Harer, claimed that pelvic floor damage was an expected “collateral damage” of normal birth and hense could be totally avoided if women would just choose an elective cesarean delivery before labor. Dr Harer answered Diane Sawyer’s question on the relative safety between normal birth and elective CS by saying: “For the mother, the immediate risks for a cesarean section are a little higher, but.. over the long time I think that the risks balance out … there really is no big difference.” Obviously Dr. Harer is unfamiliar with his own professional literature. However, the most chilling aspect of his recommendation is that there was no descent from the public at large – it was accepted at face value as safe, reasonable and the “enlightened” thing to do.  But not every knowledgeable doctor agrees.

According to Dr Elaine Waetjen, an ob-gyn with the University of California at Davis, “the evidence does not support the effectiveness of prophylactic C-section in preventing uterine prolapse or urinary incontinence” later in a woman’s life. This non-solution for protecting the mother’s pelvic floor function fails to acknowledge that the wrong use of gravity, which is the routine in medicalized births, prolongs both first and second (pushing) stage labor and increases instrumental delivery rates. Pelvic floor damage is not “collateral” to normal birth but directly associated with the elements of medical (rather than physiological) management and its subsequent need to do episiotomies and use forceps or vacuum extraction to overcome these deficiencies. Right use of gravity and the other elements of physiological management, rather than Cesarean surgery, is a more effective way to preserve the pelvic floor integrity.

Dr Waetjen reports that Cesarean section causes more maternal morbidity than vaginal birth and doubles or triples the risk of maternal death. It triples the rate of infection, hemorrhage and emergency hysterectomy, blood transfusions and blood-born diseases, increases the risk of potentially fatal blood clots 2 to 5 fold and causes surgical injury in about 1% of cases. It interferes with breastfeeding and the mother’s enjoyment of her baby. In the long-term, cesarean surgery increase the maternal risk of future placenta previa, accreta, percreta (fatal in 10% of cases), uterine rupture (in VBAC labors), emergency hysterectomy, surgical injury, the need for blood transfusions, spontaneous abortions and ectopic pregnancies while decreasing fecundity. Babies delivered by cesarean section have a higher risk of lung disorders and operative lacerations. A study published in the UK found that adults that had been delivered by CS had a one-third increase in asthma. Cesarean surgery associates with increased rates of postpartum depression. Surgical delivery is twice as expensive as vaginal birth and that does not account for cost of surgical complications or increased deaths that are its unfortunate result in one out of 3,225 deliveries (vaginal birth rate is one maternal death out of 16,666 spontaneous deliveries). 

An example of how far the perspective and the agenda of the medical community is from the expectations of the public and interests of childbearing women is offered in an article published in the New England Journal of Medicine in May 1985, by George B. Feldman, MD, Jennie A. Feldman, MD entitled Prophylactic Cesarean Section at Term? This article brings into sharp contrast how much we need to publicly expose and explore these conflicts of interest. As did the ACOG president on Good Morning America, the Doctors Feldman made the “case” for Cesarean on demand and seriously promoted the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women. This drastic idea was seen as a preemptive strike to protect the baby from the “dangers” of childbirth and would change the professional focus of doctors from the wellbeing of the mother to determining when fetal lung maturity was achieved so that the CS could be scheduled before (gasp!) the mother went into spontaneous labor (a mistake of course!) and (gulp!) gave birth naturally!

The Doctors Feldman make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality” and opine that the “low cost of excess maternal mortality” may be a price worth paying. Here is a short excerpt:

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean* section at term would be 5.3 per 100,000….  This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality. 

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? ….  Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure?  

 

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached?  If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?  (*emphasis mine)

I think it is safe to say that there is no “ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure”. That is a choice ONLY the mother and father can decide to take and only after truly fully informed consent and full knowledge of the benefits of physiological management versus medical interventions and surgical delivery. 

If you acknowledge the fundamental facts of normal biology – immutable facts that are true world-wide and throughout all time, you would have to look askance at “business as usual” interventionist-obstetrics, which costs 3 to 6 times the money and has a 3 to 10 times greater rate of operative deliveries and maternal-fetal complications. That is a lot of money spent for healthcare services that offer a far less satisfactory outcome. It also brings on an astounding rate of malpractice claims that further the cost, difficulty and long-term medical complications – all things that people and politicians don’t favor. If American planes landing at US airports crashed 3 times more often than when they landed at airports in the UK or Japan, we would demand an inquiry of our air traffic control system, since the laws of aerodynamics are the same worldwide. As a concerned citizen I would be most interested in why there is no public scrutiny of this situation or inquiry into organized medicine’s propaganda pronouncements (such as promoting medically-unnecessary Cesarean-on-demand) or request that they explain the high rate of Pitocin accelerated labors and Cesarean surgeries. As an obstetrician, I would be most interested in ways to keep this kind of detrimental information from ever seeing the light of day.

The Contrast ~  ~ Physiological Management

Healthy mothers have a biologically based need for personal psychological assurance, privacy and social support in order for the spontaneous physiology of childbirth to work. Hormonally speaking, parturition is a sexual function of a woman’s body, incorporating aspects of biology, sociology and psychology. Healthy mothers benefit greatly from the philosophy of midwifery, which identifies birth as both a normal, and yet a “unique” process that is different for each mother and does not fit on the doctor or hospital’s timeline. Midwives prepare parents for labor by teaching them about the “preamble” phase – the 4 to 48 hours of warm-up or practice labor, during which it is far better for the mother to be at home, going about her business,

psychologically supported by her family and  checked on regularly  by her midwife. This usually includes a house call once or twice a day until active labor commences.

However, the obstetrical system and its malpractice protocols are locked into a medically defined standard of care that has no method for monitoring early labor at home. Obstetricians are required to hospitalize the woman when she calls reporting any labor pattern or leaking membranes. In the hospital, where her insurance company is being charged by the hour, the mental clock immediately starts to tick in everyone’s mind and it becomes a race to the finish line.

Once labor begins, irrespective of where (home or hospital) mothers and unborn babies both benefit from maternal mobility and upright postures and right use of gravity. This addresses the mother’s pain without resorting to narcotics and anesthesia and facilitates the spontaneous dilation of the cervix (gravity!) without the intravenous use artificial hormones. Gravity also facilitates the advancement of the baby’s head in the pelvis without episiotomy and the use of forceps, vacuum extraction or CS.

The gift of non-intervention is both the enhanced experience of the mother and in avoiding the dangers of medical interventions. Research on a million California birth certificates documented that 70% of all births occur to healthy women with normal pregnancies who give birth vaginally. That means only 30% of mothers and babies are sick, premature, have multiple gestations, etc and will eventually need and benefit from medicalization and obstetrical interventions. However, obstetricians deliver 95% of all mothers, which means that about 65% of the time their talents are being grossly underutilized.

However, “normal” obstetrical care is “one size fits all”, the same whether the mother is sick or well. This can be seen these days on cable TV programs such as Maternity Ward and Baby Story. It is what I have observed since becoming an L&D nurse in 1962. I see an increasingly aggressive interventionist pattern today in 2001 when I accompany women who are having planned hospital births. Typically women are either scheduled for induction for dubious medical or non-medical reasons or told to come to the hospital at the first sign of labor. They are put to bed in very early labor, hooked up to IVs and electronic fetal monitors that keep them still and lying down. Slow labors or very early labors are routinely augmented with IV Pitocin.

Then the downhill slide speeds up. The mother’s increased pain, caused by Pitocin accelerated contractions and artificial immobility, requires the administration of narcotics and/or epidurals. The logistic demands of several IV lines, epidural pump, blood pressure cuff, pulse oximetery lead, continuous electronic fetal monitoring cables and a urinary bladder catheter requires laboring women, with rare exception, to be prone and stay still in their beds for 10 to 20 hours in a row. The weight of the pregnant uterus on the large blood vessel that traverses from her heart to the uterus and feeds the placenta is interfered with in this position. The combination of unnaturally forceful, close-spaced (every 2 ˝ minutes) Pitocin-induced contractions, the prone posture, maternal narcotics, epidural anesthesia and immobility of the mother, all reduce blood flow to the baby and can causes or exacerbates fetal distress. The mother must to be given oxygen by mask (the 8th tube tying her to the bed!), while everyone in the room becomes more anxious and the labor is designated as “high-risk”.  An emergency CS may be required any minute to rescue the baby from the meddlesome nature of obstetrical medicine.

In second (or pushing) stage, these same anti-gravitational postures result in weight bearing on the mother’s lower backbone. This moves her sacrum forward a couple of centimeters into the pelvic outlet, thus closing the pelvic aperture by 30%. The direction of the birth canal, referred to in obstetrical textbooks as the “curve of carus”, is steeply angled. After the baby passes over the sacral promontory, it must dip backwards into the deep hollow on the inside of the mother’s sacrum and then turn its head sharply upward and rotate out under the pubic bone during the actual birth. If the mother is upright, either standing or squatting, the baby’s head will be born straight forward. If the mother is lying on her back the baby will emerge aimed upward, toward the ceiling. If the mother is prone or semi-sitting while trying to push her baby out, this wrong use of gravity means she must push the baby’s head uphill through a partially closed door and around a 60-degree angle. This contributes to both fetal distress and maternal exhaustion. The birth-retarding effects of immobility, anti-gravitational positions and anesthesia will need to be overcome by the use of episiotomy and forceps or vacuum extraction. An emergency Cesarean is frequently required due to DPD (cephlo-pelvic disproportion, which is the 2nd stage labor equivalent of “failure to progress”) or due to complications caused by these interventions.

Whether the mother delivers vaginally or by CS she may well suffer from a postpartum hemorrhage as a side effect of surgery or an artificially accelerated labor. If forceps or vacuum extraction were used she may have arterial bleeding from a deep tear in the vaginal wall from forceps or vacuum extraction. This will requires more Pitocin and sometimes many blood transfusions. When this is all over, the doctor will comment on the risky-ness of normal risky birth and opine that “if she had been at home, she would have bled out before she could get to the hospital”. Aren’t we lucky that she wasn’t at home laboring under the non-interventive care of a midwife, exposed to the ‘risks’ of gravity and natural birth instead of those nice safe forceps. Aren’t we doubly lucky that the doctor was around to save her life. Who could possibly question his motives or his methods?

The more things change, the more they stay the same!

"The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong". [Dr. Joseph De Lee, 1915]

"If we want an increase in cerebral palsy, mental retardation, extended hospitalizations for mothers undergoing infections, fistulas, hemorrhages, and other severe and disabling results of neglected childbirth, only then could one endorse [this midwifery] bill..." [Dr Heinrichs, Chief of Ob-Gyn, Stanford Hospital, 1977]

“In my opinion issuing a license to a (non-nurse) midwife is giving away a license to kill.   ...  I think licensing this activity in the name of competition is wrong. In the name of quality of care it’s wrong. In fact, it’s just plain wrong” [Contemporary obstetrician on an Internet user group, ob-gyn-l@obgyn.net , January  17, 1997]  

The driving need of organized medicine to continue to make midwifery “wrong, wrong, wrong” lies in the twisted logic that this makes interventive obstetrics “right, right, right”.  Hitler used Jews as a foil to hide the inherent lack of substance in his politics and I firmly believe (having studied the law and political history in detail and knowing the politics personally from the handcuff marks on my own wrists and hours in solitary confinement cell!) that obstetricians use midwives as a foil for the same reasons.

One extraordinary example that comes to mind are the efforts by organized medicine for the last 100 years to keep midwives from registering the births they attend, thereby hiding any comparable statistics contrasting physician and midwife outcomes. This reflects the great desire to prevent any unbiased scrutiny of medical practices while aggrandizing obstetrics without fear of being called to account for an excessive number of preventable deaths. This is “social status” insurance for obstetricians. The hubris in these actions is crystal clear in the comments published in the Boston Medical and Surgical Journal, Feb. 23, 1911, page 261 on the “midwife problem”:

"What we must first do is arouse public sentiment and first of all we must have the enthusiastic support and united action of the medical fraternity.... We feel that the most important change should be in the laws governing the registration of births. The word "midwife" as it occurs, should be at once erased from the statute books. ...

 

We believe it to be the duty and privilege of the medical profession of American to safeguard the health of the people; we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth. The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public."

The agenda for ACOG continues to be dominated by attempts to keep midwifery methodology hidden under a bushel basket because interventionist obstetrical methods cannot even begin to compete with physiological management. There is just too much “collateral damage” resulting from its complications. When talking frankly between themselves, obstetricians have frequently acknowledged the shaky ground that their profession stands on when providing heavily medicalized care to healthy women. A midwife-complimentary example of this recognition can be seen in a statement by Dr. P.W. Van Peyma of Buffalo, NY in 1915. He had 40 years of experience working with midwives and was a member of the Board of Examiners in Midwifery for 25 years:

"The essential difference between a midwife and a physician is that (physicians) are free to hasten delivery by means of forceps, version, etc. This, in my experience, results in more serious consequences than any shortcomings of midwives. ..Time is an element of first importance in labor, and the midwife is more inclined to give this than is the average .. physician. ..The present wave of operative interference is disastrous. .. The situation would not be improved by turning (the clients of midwives) into the hands of such medical men ...".

In contemporary time an Internet communication by obstetrician Garry E. Siegel also acknowledges the wisdom of non-intervention while questioning just how valuable obstetrical training is as a foundation to care for healthy women. Dr Siegel was a participant on the ob-gyn-l@obgyn.net user group and his comment was part of the same dialogue on licensed midwives as the “license to kill” quote on the previous page.

“As an obstetrician, I have learned that when things are left to themselves, things usually turn out ok.  In essence, we represent expensive "insurance policies" to those giving birth in a hospital under our care. ... how could we ever get enough numbers to compare outcomes with .. midwives, given the infrequent .. complication rate of childbirth, especially seemingly low risk .. ones”. ~ 1/17/97 

In response to vitriolic criticisms of community midwives by other physicians on the ObGyn.Net User Group, obstetrician Dr Beverly Miller responded:  

“all major studies EVER done (see the literature) support the fact that trained ... midwives (i.e., pass a licensure exam .. etc) has as good or better stats in out-of-hospital settings than OBs do in hospital. 

               

The morbidity/mortality rates are lower in comparable pregnancies, the midwives frequently do a better job of risk reduction management, score higher in perceived quality of care (time element and rapport development count a lot here).  I've heard physicians say that if one of the midwives they backed up lost a baby, they were convinced that they too would have lost it.  There are rotten apples in every barrel, my friend.  Pluck them out and go on.  Don't sacrifice the benefits of utilizing the rest for the well-being of community maternal-child health. Find a good midwife in your area and give her some support”.  ob-gyn-l@obgyn.net  1/31/97 

Last Sunday our minister was recounting one the many scrapes JC had with the Jewish leaders of his day and I especially noted the similarity of strategy between organized medicine and the Sanhedrin. When Jesus healed the blind man, the chief priests complained bitterly that Jesus was guilty of a crime against God by healing on the Sabbath. Doctors want to make public dialog about midwifery be one of complaining that midwives are “guilty” of safely delivering healthy babies without a physician supervisor – a “crime” against ACOG, every bit as egregious in their minds as healing on the Sabbath.

To sue or not to sue, that is a good question

The issue for society (thus for litigation) is the relative wisdom of interventive obstetrical medicine as the unchallenged and perpetuated “standard of care” for every healthy woman versus the preventive

practices of midwifery      for well women. European and Asian countries that use the midwifery model as their standard maternity care system have better perinatal outcomes and higher rates of breastfeeding along with vastly reduced rates of maternal interventions such as epidural, episiotomy, infection, operative delivery, neonatal intensive care for babies. Every jurisdiction that properly registers midwife-attended births can clearly document that midwives overall have equal or better outcomes with 1/10 the rate of interventions (for mothers transferred to hospital care) and a perinatal mortality rate of approximately 3 per 1000. It goes without saying that this system spends far less money for far better outcomes. This is the real “no brainer”.

This cognitive dissidence is what the medical association wants to keep under wraps at all costs. Midwives have been forced to cover their faces with a metaphoric burka under the repressive regime of a medical Taliban, who vowed a jihad against midwives in 1910 and have not let up since. The midwife problem is wider that just who “catches” babies.  Pregnancy produces a mother as well as a baby. The current system not only drastically disturbs the birth process but also the socializing process for the new mothers. We are wasting the considerable gifts of midwifery as a social support structure for mothers and to assist in the development of parentcraft skills. Midwives are superb sources of parent education and emotional support to help women cope successfully with the intimate issues of motherhood such as breastfeeding and infant care, family relationships, sexuality, child development, disciple, childhood nutrition, etc. In order to do that, we first have to stop prosecuting midwives. Then we need to authorize them to do what they do so well – provide care and nurturance to childbearing families.

      

I say we sue the bastards for a century of  “false claims” (consumer fraud!) and failure to implement corrective actions when corrective information was presented to them. Or we agree to negotiate a truce that permits midwives to practice, mothers to choose community-based maternity care and eventually elevates the practice of obstetrics so that women can be assured of physiological management, regardless of whether they are cared for by doctors or midwives and give birth at home or in hospitals.  

Right Use of Gravity!

     

      

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Here is what the world would look like if ACOG had
a really good reason to cooperate with midwives:

Consent to legislative remedy & recognition of the wisdom of voluntarily accepting collaborative relationships between midwives and physicians: This would permit the malpractice equivalent of a firewall between the professions in regard to the very controversial topic of domiciliary birth services.  The most straightforward example of this is reflected by the UCSF Stanford “Consent for Patients Planning Home Birth” (copy enclosed). It reflects a caregiver-relationship between the mother and the medical institution and does not purport to provide any professional relationship with the midwifery practitioner. It serves the basic need and is an OK a place to start.

Corrective Information programs for the Medical Community:  The efficacy of professional midwifery in all settings has

been established beyond all reasonable doubt.   Information in numerous studies is widely available and was reiterated in the recently published UCSF Center for Health Professions-Pew Report “Charting a Course for the 21st Century: The Future of Midwifery. Just this October, the American Public Health Association passed a resolution supporting independent licensed midwifery and home-based birth services for healthy women. And yet, this preponderance of evidence is virtually unknown in the physician community. Institutionalized ignorance has perpetuated resistance and non-cooperation to the determent of childbearing families.

The established safety record of midwifery services assumes easy access to medical care when appropriate and so it becomes a matter of utmost importance that physician prejudices be addressed so that physician cooperation can be gained. Cooperative and complimentary relationships with physicians are impossible in the milieu of historical prejudice and misinformation that currently dominates the thinking and policy making of the medical establishment. The bias resulting from this disinformation campaign must be reversed through informational programs. 

(1) The Medical Board of California is in a position to influence physician opinion and has a duty to public safety as well as to its 130 licentiate midwives to responsibly address this issue with the considerable resources it has at hand. We suggest that informative articles in the MBC’s quarterly publication, the Action Report, as a first step. In addition, organizationally sponsored programs for the membership of CMA & ACOG will also be necessary.

(2) Shared Educational Opportunities:  Ideally medical and midwifery students should train side by side in both undergraduate studies and in clinical rotations. Interns should be exposed to normal childbirth via midwifery care

   as provided by hospital midwives before being exposed to the pathology of obstetrics.

(3) On-going in-service education should maintain the dialog between physicians and professional midwives as both have specialized knowledge that should be shared with the other on a regular basis. 

Professional Liability Concerns: It is well established that the dangers of over-treatment of healthy populations via obstetrical intervention is greater than those of under-treatment via the midwifery model of care. This means professional liability issues for obstetricians can be greatly improved by integrating midwifery standards & protocols (physiological management) for a healthy population into the standards of obstetrical care. This care can be provided by the physician himself or by employing professional midwives to care for healthy women.

Shared Authority and Control between physicians and midwives regarding obstetrics and midwifery protocols. Physicians need to equitably share control over midwifery protocols as related to potential medical risks as part of a reciprocal process in which midwives share control over those aspects of maternity care falling within the midwifery model, i.e. healthy women with normal pregnancies.

Full time Practitioner presence (physician or professional midwife) when hospitalized women are in active labor:

Labor and delivery units should be primarily staffed by professional midwives who are present and awake in the immediate area of the laboring woman during the time women are in active labor or hospitalized due to complications requiring “intensive” intrapartum care or observation. Nursing staff should be present to assist the practitioner and not instead of a qualified practitioner. Only practitioners are formally educated and trained to detect the full spectrum of possible complications and likewise skilled and legally authorized to deal immediately with the emergent situations that sometimes befall women in active labor. The scope of practice of the nursing profession does not include either the formal education or authority to make many of these crucial decisions. Regardless of how well trained or experienced L&D nurses may be, they do not have the legal authority to make independent medical judgments or independently carry out necessary remedial actions. Only a practitioner -- the mother’s attending physician, a professional midwife in the employ of the physician or one with independent status or employed by the hospital has the requisite training, skill and authority to identify and respond immediately to potentially problematic situations. The full-time presence of a practitioner reduces bad outcomes and subsequent litigation.  [See accompanying information from Dr. David Rubsmen, MD, LL.B. author of the Professional Liability Newsletter and The Obstetrician’s Professional Liability -- Awareness and Prevention and list of “Risk Reduction Strategies”]

It is this capacity for immediate medical response that is one of the primary reasons that families choose hospital-based obstetrical care (rather than community-based midwifery) and why they bear the added expense, discomfort and inconvenience of those arrangements. Malpractice litigation occurs with greater frequency when the unmet expectations by the family for immediate medical response are coupled with a problematic outcome that would conceivably have been avoided through the immediate intervention of an on-site practitioner.

Documentation and  Resource List

A – text-based historical documents ~ As you know from our conversation on December 4th, I have been doing university-based research on these historical records since my arrest 10 years ago. I have Xerox copies of vital statistics throughout the last century, peer-review journal articles, transactions of the American Association for the Study and Prevention of Infant Mortality, papers presented at meetings of other professional groups (Am Public Health Assoc, etc), historical and contemporary obstetrical and midwifery textbooks (one from 1830!) and the entire California Medical Practice Act from 1876 to 1981, cataloged by section and topic. I have rare books on the history of the AMA (Merchants of Medicine and Your Life is Their Toy by Dr Josephson) and anthropological sources on really ancient history of medicine and midwifery (Egyptian era 3500 BCE) and more recently antiquity, such as practices in the 16th  and 17thth  century Europe.

B – Contemporary, peer-reviewed practice parameters ~ I also maintain extensive contemporary files in 3-ring binders of obstetrical peer review articles, abstracts from the Internet and synopsis of the peer-review research as published in the trade paper “Ob.Gyn.News”. The synoptic of articles published in Ob.Gyn.News (now available on the Web) clearly demonstrates that obstetricians are continually being made aware of evidence-based practice parameters that directly contradicts the “business as usual” practices of the majority of obstetricians. This includes the iatragenic risks and deficiencies associated with electronic fetal monitoring, routine induction at 40 or 41 weeks, induction for suspected macrosomia (a large baby), routine episiotomy, long-term complications of Cesarean surgery such as placenta previa and accreta, etc. In spite of access to timely information from an insider source respected by physicians, the “usual and customary” practice of obstetricians are continue to be years behind the scientific evidence.