Stacey A. Tovino, who teaches at the Health Law and Policy Institute at the University of Houston Law Center and has written on midwifery and the law, said prosecutions of midwives almost always started with a tragedy.Every birth is a potential disaster! So is every car trip. Lots of us assume we will be lucky, especially when the odds are in our favor. That's why when we lose we say "Why me?" We rarely think to say "Why not me?" The question is whether the state ought to save us -- and our children -- from our relentless optimism.
"No one complains until a baby dies or a mom dies," Professor Tovino said. But once the issue arises, she said, legislatures often become involved as well, with doctors and midwives engaging in a bitter struggle over the proper regulation of midwives, one driven by a mix of motives that are difficult to disentangle....
"Midwifery is an autonomous profession," [a midwife, Mary Helen] Ayres said. "It's an art and a science that predates the medical model of care. Midwifery sees birth as normal and basically safe.
"It's made safer by reliance on the woman's power," she continued. "The medical model assumes the woman is passive and her body needs to be acted upon. Every birth is presented as a potential disaster from which every woman needs to be protected and potentially rescued."
April 3, 2006
"It was the most cozy, lovely, lush experience."
That's a description of childbirth, accomplished at home, by candlelight, with the help of a midwife. It's pretty when it's pretty, but what if the baby dies, and it wouldn't have died in the hospital? Indiana is prosecuting a midwife:
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I personally think the wiser choice is a hospital, but I also think it should be up to the parents.
No mention is made of the cause of death. Would a hospital birth have made a difference here?
Why would they publish a story with such a gaping hole?
My two were born in a hospital, but with a midwife for the second.
People choose to not use medical services all the time, whether the child who is at risk matters, I would say yes and that should be a factor. But not everyone feels that way.
(the Health committee chairwoman is a nurse and very opposed to midwives)
I really enjoy the little tidbits one learns in a blog.
Dear Professor Althouse,
I can't say if mortality rates are the same for home-birth of an uncomplicated pregnancy v. hospital birth. It certainly makes sense though since hospitals are notorious for their nasty antibiotic resistant bugs and my impression is that complications are fairly rare in routine pregnancies.
My wife had our first two children in a hospital with midwives and we were happy with the experience. Our third daughter was born at home, but not on purpose. Other than the terror of actually having to perform the delivery myself, the third birth experience was far better than the first two. The quiet privacy and familiarity of our own home and the lack of idiot orderlies constantly bursting in made for a memorable and moving experience.
If it is the case that the risks are the same for home-birth v. hospital birth, then there is a good arguement for home-birth.
Best regards,
dbp
"It's made safer by reliance on the woman's power."
Invoking the "it's okay because a woman is superior" rule again.
Should the state save us from our relentless optimism? I guess the question is where should the state draw the line. It allows pregnant women to get in a car as often as they like despite the fact that two-thirds of pregnancy trauma is the result of car accidents.
I wonder if more babies would be saved by disallowing pregnant women from the use of a car than would be saved by disallowing home births.
I wanted to have my second child at home. Not because of the cozy, lovely, lush experience, but because the hospital where I had to give birth had killed off and permanently disabled a jarring number of babies and mothers in the six months before my due date. Killed off, mind you. Actually caused the deaths and disabilities through the stupid mistakes of its own staff.
However, as a military dependent, I didn't get to make the choice.
Although this is beside the point, those of you who advocate for government managed centralized healthcare might want to consider this anecdote.
I have friends whose baby died during a home birth from causes that probably would not have resulted in death had the birth taken place in a hospital. The state prosecuted the unlicensed midwife, against the wishes of the parents. That process horribly complicated their grief, which was already bad enough. Their marriage did not survive the experience. It was a nightmare, and enough to put me and everyone who knew them off home birth once and for all.
eye doc, on your question about the parents' knowledge -- my friends, at least, were fully aware of their midwife's unlicensed status. They wanted a home birth, disagreed with the state's position on license requirements for midwives, and took the risk. There were no legal consequences to them, but their identity was made public in the course of the proceedings against the midwife, and their judgment was called into question -- so it was all quite painful.
I am not normally a fan of the state interfering in decisions of this kind but I agree with the commenter who pointed out that there is a baby involved in this decision who does not get a voice. In this case, it seems to me, reasonable state regulation may be justifiable.
One reason I believe in hospital deliveries is that you never know. One kid I know went into distress during her delivery. It was, of course, picked up immediately on the fetal monitor, and was solved by giving her mother oxygen. If that had not worked, they were ready for a C-section. But in most home deliveries, it would have gone unnoticed, and the baby born with potentially some brain damage. Most likely not noticable, but there.
Then, upon birth, a complication was discovered than ended up with her in the infant ICU for a day or two. Two pediatricians were there immediately. Yes, she could have been rushed to the hospital, but this was much, much, better.
So, how many home deliveries do end up with some minor damage to the babies that is not readily detected? I know another kid who was delivered at home by midwife, and has the emotional maturity of a kid 4 or so years younger. It could be fetal-alcholol syndrome, or it could be an undetected problem with the birthing - something that would routinely have been detected in a hospital.
Having a baby is a pretty big deal. I can't imagine not wanting the full resources of a hospital at your disposal in case complications should arise.
That said, having a baby is not, in itself, a complication. Giving birth or assisting someone who is giving birth is not practicing medicine.
I'd keep the state out of it.
Trying to either "empower" or "pamper" yourself by experiencing childbirth without all available medical technology at hand, is dangerously, stupidly self-indulgent, to my mind.
Sure, most childbirths come off without a hitch, but why take that sort of risk?
I think if the midwife is being prosecuted, the parents should too, though I'm sure they're suffering horribly for their decision already...
"a woman who entered a hospital to give birth and was subsequently transferred to another hospital where both her arms and both her legs were amputated"
Oh, gimme a break.
gj: That's horrible. I note that it happened in Florida. Personally, I would dread medical care in Florida, based on my family's experience. Doctors can do some terrible things. It's true! But staying away from them can be even more devastating. The trick is to find good doctors and good hospitals!
I must say that when I had my second Caesarean, I went into a state of hypotension, and I never learned how serious it was, but I was in a situation where I was wondering if I was dying. I wasn't allowed to move, and medical personnel were walking about talking about my condition in a way that I couldn't quite understand. Afterwards, I had the question, so was I sort of dying back there? But they never gave me a straight answer. The fact is, I didn't die, so what's the good of knowing?
Trying to either "empower" or "pamper" yourself by experiencing childbirth without all available medical technology at hand, is dangerously, stupidly self-indulgent, to my mind.
Knoxgirl: I think you're probably right that some women are pampering themselves by giving birth at home. But, I think there are many women who believe that its a safer and healthier option.
I think the research posted in the comments here bears out their belief.
I think its clear that some people would have been much better off steering clear of a hospital. Others should not have given birth at home.
I'm not sure its stupid and self-indulgent to weigh the particulars of your own situation to make a decision.
Most insurance does not cover labor and delivery. Hospital births are very expensive.
Still, I think it depends on the age of the mother since older mothers are at greater risk for complications.
Women are having babies at an older age today, and probably need the services of traditional obstetrics more than, when the average age of childbirth was a woman in her 20s....and a midwife would suffice for that back then.
Peace, Maxine
"People have them in the tub, on birthing stools, on their hands and knees, even standing up."
Oh, good lord! How about standing on their head? Is this really the time to be showing off?
"...many women who believe that its a safer and healthier option. I think the research posted in the comments here bears out their belief."
If the hospital(s) you are restricted to are butchers, by all means, have the baby at home! But I seriously doubt this is the norm. Trying to scare women with gorey, if true, stories about hospitals is just wrong.
Having a baby is not a complication---nor should it be a political act of woman power! -- like a lot of feminists want to make it.
What a vaginal birth does to a baby's head -- if you did anything like that to your child after it was born -- with your hands, I mean, not your vagina -- it would be horrific child abuse. You can say it's "natural" -- but it's an extreme thing to do to a baby and it can cause permanent damage. To treat it as a spiritual experience for the adults is creepy.
But those who are doing home births to save money -- I really feel sorry for them.
Those who are impressed by posh "birthing rooms." You do realize the reason hospitals dump so much money into this? They know it influences women choosing their insurance plans. You're then stuck with the rest of the hospital. But they know you'll notice this.
If the hospital(s) you are restricted to are butchers, by all means, have the baby at home! But I seriously doubt this is the norm. Trying to scare women with gorey, if true, stories about hospitals is just wrong.
I think you're being a wee bit obtuse here. The research I was referring to was the posted evidence in this thread that home births don't result in a higher rate of injury or death than hospital births.
Trying to guilt women into using hospitals by calling them stupid and self-indulgent is no less wrong than scaring them with gory stories.
Those who are impressed by posh "birthing rooms." You do realize the reason hospitals dump so much money into this? They know it influences women choosing their insurance plans.
Ann: Exactly! And we fall for it, don't we?
For the same reason, hospitals for those of us who don't have a choice don't bother with the luxury. I still had to do the stupid exam room, labor room, recovery room progression. And I got to share my recovery room for two days with another couple and their child. Good times!
Knoxgirl: I should clarify that I wouldn't have thought I would consider home birth for myself either. It's not something that would have been my "style".
I just think its a kneejerk reaction to summarily dismiss the option for other people based on your own preferences when evidence supports their decision.
Jennifer:
I'm not trying to guilt anybody! There are real risks involved.
1. If your childbirth goes smoothly and you're at the hospital, chances are overwhelmingly good that you and the baby will be safe. Same with home birth.
2. If your childbirth does NOT go smoothly, at the hospital there are medical personnel and equipment to address the issue. At home, there is nothing but 911.
I cannot find the evidence in this thread you are referring to?
Anyway, FWIW, if we had universal health care, I'd be the first one having babies at home, believe me.
Re me being my own troll...
Interesting idea!
I do act a little different in my comments persona.
(sorry...)
raisa,
I've yet to meet anyone expressing the interest or desire to have their baby at home who says it's for "safety reasons" ...but ok!
I'm sure if you're "low-risk" then it is indeed relatively safe to have your baby at home. But the key word is "risk". As in, "still risky."
I was actually expressing agreement with Jennifer in my comment about universal health care....
so, my question is why would someone want care from someone who barely has the time for them?
I *can* see this point of view. Doctors are VERY into inducing labor these days. I always thought the high rate of c-sections was attributed to doctors getting nervous about being sued when complications arose.
Raisa,
"The embattled status of the obstetric profession does no service to women or babies."
I remember hearing a piece on NPR about how there weren't enough OBs in Nevada--maybe it was just Vegas, not sure--to deliver all the babies, and there were pregnant women who had no doctor to go to, because of malpractice insurance rates there.... yikes
NY Times story on Indiana prosecution of home birth midwife RE: The question is whether the state ought to save us -- and our children -- from our relentless optimism.
I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth. I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.
After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.
I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.
I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.
My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care “in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother.
Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.
Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.
One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.
Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada. The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.
Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives.
In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves. This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.
In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.
More info is posted at www.sciencebasedbirth.com. See ‘April 06 Info for Bloggers – midwife controversy’.
NY Times story on Indiana prosecution of home birth midwife RE: The question is whether the state ought to save us -- and our children -- from our relentless optimism.
I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth. I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.
After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.
I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.
I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.
My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care “in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother.
Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.
Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.
One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.
Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada. The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.
Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives.
In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves. This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.
In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.
More info is posted at www.sciencebasedbirth.com. See ‘April 06 Info for Bloggers – midwife controversy’.
I am impressed by the thoughtful, informed and informing responses to my April 4th comments. Usually I am talking to myself when addressing any aspect of this unpopular topic. I have to admit that this is the first time I’ve ever posted anything to a blog, as my handlers usually keep me chained up in the basement, nose to the grindstone, and won’t let me ‘waste’ time with such foolishness. But the NYT article on the Indiana midwife had a link to Ann Althouse’s blog and I clicked just to see what it was all about. Imagine my surprise! Cherrie and Elfanie’s replies are so good and worthy of being quoted. So I’m officially asking – may I quote you both?
The actual hot issue of the day is not the prosecuted midwife in Indiana but the draft report by the National Institute of Health subsequent to their “State-of-the-Science Conference on Cesarean Delivery on Maternal Request” (which they kindly reduced to ‘CSMR’ for the keyboard challenged). The conference was held March 27-29 in Bethesda. One of the most interesting aspects is that a government agency officially released a report at 5pm on March 29th, the last day and last minute of a conference. [www.consensus.nih.gov] Obviously, the report had already been written, which means the input of the participants was just a feel good move and window dressing for a predetermined agenda.
The NIH draft report concluded that mothers are demanding C-sections in greater numbers (good data says not true!), which ‘explains’ the 29% percent C-section rate for 2004 (and the projected 33% C-section rate for 2005!). The report went on to infer that there isn’t really any good data to determine if C-sections are better or worse than vaginal birth, but if you’re only planning one or two children, the odds are about even.
The illogical conclusion was that if you want to, go ahead and have all your babies by scheduled C-section (something about consumer convenience and giving mothers ‘control’ over their birth), never mind that it doubles maternal mortality and costs twice as much. Rumor has it that one of the things fueling this conference was a push for a CPT code (Current Procedural Terminology) for patient choice CS. This would permit them to hide a lot of poor obstetrical practices under the banner of women’s reproductive freedom and a woman’s ‘right to choose’. How poetic.
The NIH’s official conclusions are a great way to distract the American public from the real issue, which is physician fear of normal birth, spurred on by lack of education or experience in physiological management of spontaneous labor and birth, hospital policies that make physiologic process hard or impossible for either mother or physician to use in an institution, run away litigation, pressure on doctors from malpractice insurance carriers not to ‘allow’ mothers with VBAC, breech and twin pregnancy to deliver vaginally (docs get a ‘good driver’ discount if they agree) and astronomical malpractice premiums. This is all wrapped up in the notion that Cesareans (referred to as ‘vaginal by-pass surgery') are safer and better than normal birth (referred to as “delivery from below” – uck!). All these spurious ideas come to us courtesy of a dis-information campaign by many spokespersons within the obstetrical profession, who go on the Today show and NRP and assure us that vaginal birth is very bad for the mother’s pelvic floor (under anti-gravitational obstetrical management I agree!) and the baby and that “Cesarean is safer for the baby”.
Mind you, I’m not anti-obstetrician or anti-hospital. I have several physician friends that are obstetricians, even ones that are politically active in ACOG. They are all honest dedicated people. I am however ‘anti’ the politics of organized medicine, which includes methods of mass deception and the ill-informed idea that the best way to prevent complications is the “pre-emptive strike” -- routine use of potentially injurious interventions on healthy women and a form of malpractice insurance referred to by OBs as “when in doubt, cut it out”.
American mothers don’t have a “C-section deficiency”. The most important issue is not maternal choice Cesarean, it is how and why the mismanagement of normal birth has been systemized by the entire obstetrical profession to become the 20th century ‘standard of care’. Abandonment by the medical profession of physiological management in 1910 has brought us, in 2006, to the brink of the “tipping point”. For the lay public, post 9-11 political & economic overload, normal human inertia and the blind spot and prejudiced reporting that the media treats this topicwith, combined with the relentless lobbying pressure of ‘special interests’ groups and especially the loss of ‘institutional memory’ within the medical profession for normal birth management, has us tittering on the brink of a precipice. In some ways, the NIH document represents that exact point of the “tip-over” into no man’s land.
The NIH’s went off track because they started with the idea that the ‘normal’ CS rate is and should be one out of three or higher. Since no one can tell which one of the three patients will have a C-section and since the other two mothers will be subjected to so many injurious interventions that the rate of sequelae will be as high as it is for scheduled C-sections, then why shouldn’t we retool the behemoth of obstetrical care into a 9-5 M-F walk in C-section assembly line, which is already how its done in Mexico City (95% CS rate, with surgery scheduled at 15 minute intervals).
Throughout the entire 20th century, organized medicine has been free to build a relentlessly ambitious system to replace normal childbearing with a new and improved version, orchestrated by institutional medicine but never exposed to scientific methods. This unofficial medical experiment required that the principles of physiologic process be ridiculed and discredited and that infrastructure for physiological management dismantled. In the obstetrical model the integrity of childbirth is broken up into two separate sub-systems. Normal labor is conducted as a medical condition managed by nurses (no directly billable units, just routine hospital charges). Normal birth is renamed as the ‘delivery’ and given its own special professional status and economic base. Delivery is considered to be a surgical procedure that can only be ‘performed’ by a physician-surgeon in an institutional setting and which generates an itemized professional fee to be billed on top of normal hospital charges.
After 96 years of this new world order, physiological management has become invisible, a total non-entity (aside from the practice of community midwives) and was of course, missing-in-action in the 2006 NIH scheme of things. The federal government’s rubber stamp for maternal choice cesarean simply gives the obstetrical profession the green light to continue on with business as usual. That business is the death of normal birth via the total replacement of spontaneous vaginal birth with various forms of Pitocin accelerated labors and assisted vaginal delivery under epidural anesthesia and what they'd like us to think of as the Rolls Royce of OB care -- Cesarean surgery. The ultimate goal is the obstetrical dream machine – 9 to 5, Monday thru Friday walk-in assembly line C-section as the 21century standard of care.
The NIH panel did not report anything that is technically in conflict with "the literature" at the most base level of interpretation. Its faults, of which there are many, are subtle instead of simple and easily apparent. What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart. I wish it were true.
Faith: We discussed the NIH study here.
Thanks to all who are bringing the pro-midwife perspective.
Personally, I'm skeptical of everyone, not just midwives. Being pregnant is quite a predicament, and you need someone to help you out of that jam. I didn't like anyone I had to deal with. But the reality was, with modern nutrition, the babies' heads were completely out of proportion to the pelvis. I had no real choice.
Good luck to all. I don't have the answer myself, other than to say I'm glad I lived through the supposedly "natural" phenomenon of childbirth. Millions of my sisters did not.
Ann, thank you for the kind words and the link to your blog on the NIH draft report. I wish I’d read it before my own post; I feel a bit foolish now.
I’d feel even worse if anything I said about the politics of physiological childbearing and the need to reform our national maternity policies that were interpreted by you or your readers as a criticism of your informed choices or birth-related medical necessities. Nor do I mean to ignore real dangers such as maternal mortality. My objection is only to the systemized and often non-consensual use of potentially dangerous drugs, interventions and operative delivery in the absence of a medical necessity, without first employing science-based physiological principles and without first obtaining true informed consent.
I do not mean to cast aspersions on any of the lovely women who require or desire medically appropriate interventions or make light of the ability of modern obstetrics to successfully treat life and limb-threatening complications. My eldest grandson was born by Cesarean. It never occurred to me to judge his mother (my beloved first daughter) based on an accident of biology or the route of delivery.
As a young married woman, I was diagnosed with Stein-Leventhal syndrome (polycystic ovaries). At that time the only treatment required major abdominal surgery. I was and still am eternally grateful to my wonderful OB doctor, who made such an astute diagnosis more than 40 years ago (before modern infertility technologies) and skillfully performed surgery that permitted me to have 3 lovely children and 2 grandchildren. I love obstetricians and continue to grieve that they no longer love me.
However, I also remember waking up in the recovery room after abdominal surgery, feeling like I had been kicked in the stomach by someone wearing a pair of ice skates, retching and desperately in pain. I pondered long and hard on what such intense pain and prolonged debilitation would be like as a new mother also trying to meet, get to know, breastfeed and care for a newborn. Thus was born my dedication to preventing *unnecessary* cesareans.
I have been an advocate for childbearing women since I was an 18 year old nursing student. I define that as meeting the mother’s practical needs with the right amount and right kind of care – timely, not too little, not too much. I was taught to baby the new mother so that she was empowered to mother the new baby. My entire professional life has been a quest to secure the right of healthy, mentally-competent women to have control over the manner and circumstance of their normal childbirth.
My father, my husband and more recently my son were all in the armed forces, fighting (and risk dying) for our democratic way of life. But despite my ability to vote for the politician of my choice, my mother, myself and now my daughters, did not / do not have the ability to say no to medically unnecessary obstetrical procedures we didn’t want or need. Obstetrical care is often provided on a basis similar to pediatric care, in which the adult experts make the fundamental decisions while the childlike patient is expected to be good and to be grateful.
I know of these realities because I was the labor room nurse who carried out the doctor’s orders and the hospital policies, whether or not the mother wanted or needed or even legally consented. This is still as immutable for the majority of childbearing women in America today as it is for woman living in third world countries who can be forced as children to submit to female circumcision and required as a married woman to submit to unwanted sexual encounters.
Only in America, if a pregnant woman in a hospital should object to a treatment perceived by the staff as ‘necessary’ or refuse to cooperate, the obstetrical version of unwelcome bodily invasion will be accompanied by threats to call a juvenal court judge for a court order. If the baby is already born, the non-compliant mother will be told that if she doesn’t quickly agree to the proposed medical procedure for her newborn, Child Protective Services will be contacted.
Occasionally this is justified for an acting-out teenager on crack cocaine or mentally ill adult woman, but ask around and you will find many reports of being coerced into treatments because mothers couldn’t hold out against the sustained professional pressure or they feared retaliation. The prestigious Maternity Center Association of NYC just published their second “Listening to Mothers Survey” conducted by Harris Interactive of 1,500 healthy women with a single fetus who gave birth in the last 12 months. Only 1 mother identified herself as voluntarily (with true informed consent) choosing an elective Cesarean, but 9% of women described being ‘talked into’ a cesarean which they didn’t believe was medically necessary and didn’t want. (www.maternitywise.org)
True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Interventionist obstetrics is an “expert” system that has failed most in the very area it was supposed to have the most mastery and expertise -- "the optimal conduct of the many normal cases". This dysfunctional system creates an asymmetrical burden of that risks falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of litigation for the obstetrician and hospital.
As a mother myself, this breaks my heart. But one of the most intractable issues I face as a birth activist (second only to the vitriolic rhetoric of lobbyists) is that attempts to widen and deepen the public discourse on this topic inevitably triggers an avalanche of protests from (yes, you guessed it) other mothers. Usually these women needed or wanted medical interventions and feel that I am judging their use of medical procedures as unnecessary, and inferring that they are bad. Most people I talk to are also misinformed about physiological care, believing that it means NOT doing anything at all, denying the laboring woman access to effective pain management, putting the baby at risk because no one is monitoring its well-being, refusing to offer medical help if labor stalls or gravity fails to bring about a spontaneous birth.
This instantly negative reaction specifically applies to career women, many of whom are the movers and shakers in my political world -- women legislators, members of the medical board, attorneys, members of NOW, newspaper reporters, TV journalists, etc. This is a major, if not insurmountable, stumbling block to effective political action. America needs to question the fundamental premise of a surgical specialist routinely using a medically and surgically interventive model to provide care to healthy childbearing women with normal pregnancies (70%). There is real danger in permitting obstetrics to adopt Cesarean section as the 21st century standard of care. Already the new maternity unit at the Ann Harbor University Hospital (Michigan), scheduled to open in 2011, is replacing 50% of its LDR with ORs in anticipation of a 50% C-section rate by 2010. It is “build it and they will have no other choice”.
Heaven help us all if there were to be a dirty boom, bio-terrorism or a pandemic of the avian flu. Precious hospital services would have to be divided between the gravely injured or the contagious, critically ill AND providing customary but medically unnecessary high tech interventions to healthy pregnancy women because none of our OB doctors know how to physiologically manage a normal birth any more (the midwives will all be in jail). I Googled the words “obstetrical research on normal childbirth” on March 31, 2006. The search results said it all in a single digit: “Number of results: zero. Sorry, your search for Obstetrical Research on Normal Birth has found no results.”
So my question for you lovely women is what can I and other birth activist say or do that would not inadvertently insult the 99% of the childbearing public that did not have un-intervened with childbirth and among that cohort, the 30% who had a Cesarean? Unless we can avoid this pitfall, it will be impossible to would elevate the public discourse and reform our national maternity care policies.
A rehabilitated system would integrate the classic and scientifically sound principles of physiological management with the best advances in obstetrical medicine, to create a single, evidence-based standard for all healthy women used by all maternity care providers and in all birth settings -- family practice physicians, obstetricians, and professional midwives, providing care in hospitals, independent birth centers and homes.
But without rigorous public debate, we will never have maternity care that is safe, cost-effective, family-friendly, physiologically-sound and able to keep on keeping on, even during a Katrina-like civil disruption.
Any constructive feedback would be most welcome…. Faith ^O^
Halojonesfan: I don't think anyone is advocating for home births in high risk situations. Given that, it doesn't make sense to lump high risk statistics in.
They wouldn't really figure in to the home birth numbers and they would drag down the hospital numbers. So, yes the picture would look less rosy - for hospital births. But it wouldn't be a fair comparison.
Halojonesfan: I don't think I've ever heard "home-birth people" advocate that every birth should happen at home. That's a really irresponsible position.
The studies quoted in this thread do not exclude births that had complications. They exclude high-risk pregnancies. Very very very very few women with high-risk pregnancies attempt a home birth. Thus, those numbers skew the hospital statistics and don't affect the home birth statistics. That's why they are excluded.
It is not a case of "ignoring statistics you don't like". Nor is it impossible to identify which pregnancies are likely to lead to complications in birth.
If the statistics are cherry-picked, then there's your answer….. Now the picture doesn't look so rosy.HaloJonesFans post:
I continue to be interested in how to talk about this topic in a way that does not inadvertently insult 99% of the childbearing public. So far, no one has responded to my question. However, I see the catch-22 aspect of my inquiry. If you believe that all the studies on planned home birth (PHB) are poorly done or cherry picked, that assumption would automatically prevent anyone from addressing my question.
I am particularly motivated to hear from women because the D.C. office of American College of Obstetricians and Gynecologists (ACOG) is currently gearing up to rebut the BMJ paper on PHB and (they hope) discredit its conclusions. ACOG has formed a national committee to develop a uniform policy on how best denigrate PHB and (they hope) eventually eliminate both home-based birth care and non-nurse midwifery (naturopathic doctors who attend PHB as well as direct-entry midwives).
Organized medicine already implemented this type of campaign once before, in1910. It resulted in a precipitous drop in the number of midwife-attended births from 60% to 13% in a single decade. Regardless of what one thinks of midwives and PHB, I’m assuming that most people would agree that a one-party political system, a one-church national religion or a total monopoly over other aspects of American life is not such a good thing.
None of you don’t know me from Adam’s house cat, but I’m not joking when I say that I know the scientific literature backwards and forwards So just for the sake of argument, I’m asking readers to be temporarily willing to believe me. I am one of a tiny handful of published historians on the practice and politics of midwifery and its interface with the medical profession, especially in 20th century American and the state of California.
I live about five minutes from the Stanford University campus and medical center and have logged about 3 calendar years in its medical library doing research on this topic. For the last 13 years I have also been a liaison between the Medical Board and California licensed midwives. To answer the Medical Board’s questions about the relative safety of PHB, I put together a 2-volumn set of the research on planned home birth as attended by midwives published since 1976. Together these two books weighs 71/2 pounds.
The consensus of the scientific literature over the last 30 years is always remarkable the same. For low and moderate risk women who give birth either at home or in a hospital, the perinatal mortality rate is between 1.9 and 2.3 per 1,000 or approximately one out of 500 normal births, *regardless of location or category of care provider*. All out-of-hospital statistics include outcomes for women or babies transferred to the hospital during labor or after the birth.
As for mothers, the medical and surgical intervention rate is between 3 and 10 times *less* for physiological management in free-standing birth centers and client homes than for hospital delivery. For example, the C-section rate in the BMJ study for PHB (including transfers to hospital) was *3.7%*. For a similar cohort of hospital birth, it was *19%*. PHB with an experienced midwife, in combination with access to appropriate obstetrical services for complications, is a responsible choice for healthy women who want a physiologically-managed labor and birth and do not plan on using labor stimulating drugs or pain medications.
Next I want to provide a basic fact about biology. It is a missing piece of the puzzle for most people.
The childbearing pelvis is shaped like a lower case letter ‘ j ’. If the mother is standing, the long stem of the ‘j’ tracks with her spine, then a 60-degree bend occurs as the curved foot sweeps the last few inches of the pelvic outlet and birth canal. For the baby to be born spontaneously, it must negotiate that 60-degree bend and be born going forward (not down as one might imagine). When a mother gives birth in an upright position, the baby is born going forward into her own hands or those of the birth attendant. Under these circumstances the weight of the baby is a force that aids in its own expulsion. In physiologic terms, this is known as the right use of gravity.
If the mother is laying down during the pushing stage of labor, the big triangular bone in the back of the pelvis (the sacrum) naturally encroaches somewhat on the pelvic outlet (the curved foot of the letter ‘ j ‘). The ability of the baby to negotiate this turn and get past this bone can be seriously limited by the mother’s own weight on her sacrum and the pressure from the mattress when she is lying down. If she gives birth while lying down in the lithotomy position, she must push the baby around that 60-degree bend and then push it up hill (towards the ceiling), against gravity. The baby’s size and weight work against its ability to be born under these anti-gravitational conditions.
If the baby is bigger than usual or the mother’s pelvis is smaller usual or her ability to push has been impaired by the effects of anesthesia, then it may be necessary to perform an episiotomy and use forceps or vacuum extraction to rescue the baby. If that doesn’t work, a Cesarean will become necessary. Episiotomy and instrument-assisted vaginal birth are both associated with pelvic floor/pelvis organ damage and maternal incontinence. Cesarean is associated with a number of intra-operative, post-op, delayed and downstream complications that don’t occur in spontaneous births under physiological management. The reason for using physiologically-based management it is to reduce the trauma to both mother and baby.
So I’m asking again if anyone out there can articulate for me what the road blocks are, at least as they see them, to having this type of conversation in a public forum without making women feel unduly anxious (or judged) and cutting off debate. Physiological management should not be about hospital vs. home, neither should it be a debate about pain management.
The ‘perfect’ solution is the ‘relocated home birth’ in which mothers can be in the hospital and still get science-based physiologically-based care under the primary management of a midwife or physician. Should the mother want or need drugs or interventions for any reason, primary care would be transferred to an specialist in obstetrics (now days a perinatologist), while the midwife continued to provide social and emotional support. It’s a win-win solution.
Faith: I don't know how you frame the debate without seeming to disparage those who choose differently. Babies and mothering are touchy subjects.
Just look at breastfeeding. Try to put out a factual message like "breast is best" and automatically you set anyone who chooses bottle on the defensive. But how else do you advocate for breastfeeding without pointing out its inherent advantages?
My only guess is to frame the debate in terms of new information that most of us don't have access to. Most people are unaware of the evidence supporting home births.
Wow, I’m impressed. This is public discourse at its best. Everything I was going to say has been said eloquently by other knowledgeable and articulate souls.
HaloJonesFan said (and rightly so) that my original post was *not one* conversation but many. As pointed out by Cherrie, it is so hard to talk about just one circumscript aspect of this complex subject. But up front, I am NOT saying that “anything goes”. I am no more promoting irrational, “feel good” but potentially injurious choices by childbearing women than I am for the obstetrical profession.
The crux of my commentary is not even about midwives or home-based midwifery per se. This only gets into the fray because there is absolutely no place for physiological management in public consciousness or in mainstream obstetrics. Healthy childbearing women in the US are not suffering from an “obstetrical-intervention deficiency”; instead it is American obstetrics that suffers from a deficiency in its knowledge of and respect for and experience in physiological management. The powers-that-be wwould like to distract us from their unproven, unscientific practices (resulting in a 30% C-section rate!). So they turn the story around and make it about irresponsible midwives using false ideas about 'normal process' to lead gullible young women astray. Not true.
So here is the pearl of great price.
The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is the safer and most cost-effective form of care for a healthy childbearing population. This leads us to the natural and compelling conclusion that our current intervention-based maternity care system must be reexamined and rehabilitated.
A newly formulated national maternity care policy would integrate the standard, science-based physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. That standard must be based on criteria arrived at through an interdisciplinary process that includes the all the stakeholders.
In addition to obstetricians, public health experts and economists, the traditional discipline of midwifery as an independent profession and *the input of childbearing women and their families* must be integrated into the political process.
Once identified as the foremost standard for normal maternity care, the principles of physiological management would apply equally to all birth attendants – physician, obstetricians and midwives – and in all maternity care setting – hospital, home and independent birth centers. Physiological care ALWAYS defaults to medical care whenever medical and surgical interventions become the *more appropriate* treatment for a complication or are requested by the childbearing woman.
Reform of our national maternity policies is also vital to the ability of the US to maintain its place in a global economy. To meet the practical needs of childbearing families while remaining competitive in the world marketplace, the US must utilize the *same efficacious form of maternity care as the countries with the best, most cost-effective outcomes*.
Just from the standpoint of economics, that can never be a system based on escalating medical interventions and scheduled C-sections. Only an improved and cost-effective system can permit limited health care dollars to be properly used so as to meet the medical needs of the ill, injured and elderly. Effective and affordable maternity care based on scientific principle of physiological management is to the mutual benefit of mothers, babies, fathers, families and society in general.
As a practical matter, most normal births would actually be best managed (from the doctor's and the mother's standpoint) by the professional midwives that would normally staff the L&D unit. This saves OB doctors all those sleep-destroying middle of the night trips to the hospital for a simple delivery, thus allowing obstetricians to do what they do best and are trained for – treat the diseases and disorders of reproduction and complications of pregnancy and birth.
Were our national maternity care polices to reflect this change, the unbelievable tension and acrimony between midwifery and medicine would be naturally resolve itself, based on the genuine merit of both disciplines.
How could this happen? Actually, it is easy at the practical level but frankly unlikely at the political level. The answer is simply that ACOG itself acknowledges that physiological management is the appropriate standard for healthy women, that medical interventions should not be used “prophylactically” and instead be reserved for actual complications or if requested by the mother. The would instantly shift the landscape of our tort law in relationship to obstetrical "malpractice".
I have pasted in an operational definition of physiological management, since it is somewhat elusive in the minds of most people. Anyone who is also interest in how midwives apply these principles (at least as defined by the standard of care for members of the California College of Midwives), I have pasted in this link:
www.collegeofmidwives.org/Standards_postHearing_Feb2005/Standards_of_Care_Dec2005.pdf
Stedman’s Medical Dictionary definition of “physiological” – “…in accord with,
or characteristic of, the normal functioning of a living organism” (1995) ©
Physiologically-sound practices* include:
Continuity of care
Patience with nature
Social and emotional support
Mother- controlled environment
Provision for appropriate psychological privacy
Mother-directed activities, positions & postures for labor & birth
Full-time presence of the primary caregiver during active labor
Recognition of the sexual nature of spontaneous labor
Upright and mobile mother during active labor
Non-pharmaceutical pain management such as showers & deep water tubs
Judicious use of drugs, anesthesia, medical and surgical procedures when needed
Absence of arbitrary time limits as long reasonable progress, mom & babe OK
Vertical postures, pelvic mobility and the right use of gravity for pushing
Birth position by maternal choice unless medical factors require otherwise
Mother-directed pushing - no Valsalva Maneuver (prolonged breath-holding)
Physiological clamping of umbilical cord-- after circulation stopped (avg. 2 to 5 minutes)
Immediate possession and control of healthy newborn by mother and father
On-going & unified care and support of the mother-baby for postpartum
Access to appropriate social and psychological services for the 'second nine months' relative to breastfeeding advise, infant development, parenting and psychological adjustments to postpartum stresses, other children, spouse and employment outside the home, etc
**One does not have to be a midwife to appropriately use physiological (i.e. "midwifery") management.
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