Midwives take a stand

The nation’s leading midwifery organizations–the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA),  and the National Association of Certified Professional Midwives (NACPM)– recently issued a statement titled: “Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM” 

Despite that rather sedate-sounding title the statement is remarkable, both for what it says and because of the politics that went into its making.

The purpose of the statement is to define “normal physiologic childbirth,” and to identify the factors that  promote–and interfere with–such a birth. The intent is to serve as a guide for providers, decision-makers, and pregnant women who wish to “protect, promote, and support human childbearing physiology and to avoid overuse of interventions, thus achieving better care, better health, and lower costs.”

It’s hard to argue with that.

Some definitions from the statement:

Normal physiologic birth

•             is characterized by spontaneous onset and progression of labor;

•             includes biological and psychological conditions that promote effective labor;

•             results in the vaginal birth of the infant and placenta;

•             results in physiological blood loss;

•             facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and

•             supports early initiation of breastfeeding.

Factors that disrupt normal physiologic childbirth

•             induction or augmentation of labor;

•             an unsupportive environment, i.e., bright lights, cold room, lack of privacy, multiple providers, lack of supportive companions, etc.;

•             time constraints, including those driven by institutional policy and/or staffing;

•             nutritional deprivation, e.g., food and drink;

•             opiates, regional analgesia, or general anesthesia;

•             episiotomy;

•             operative vaginal (vacuum, forceps) or abdominal (cesarean) birth;

•             immediate cord clamping;

•             separation of mother and infant and/or

•             any situation in which the mother feels threatened or unsupported.

The statement’s authors call for systemic changes in clinical practice, education, research, and health policy to support physiologic birth whenever and wherever possible. It’s a measure of how glacially slowly progress comes in the field of obstetrics that this statement isn’t much different from one issued by the World Health Organization in 1996.

Given that 16 year-old WHO report, a reader might well ask: So what’s new about this? Hasn’t vaginal birth always been the “norm”?

Yes, for the vast majority of human history vaginal birth was the only viable way for a baby to leave the womb. But things have changed dramatically in the last few decades, as technological intervention–particularly cesareans and labor induction–has become so pervasive as to blur the boundaries of what constitutes the healthiest way for a low-risk woman to give birth.

Don’t get me wrong–I love medical technology when there’s an emergency or a complicated patient at hand. It’s just that the use of technology tends to beget the use of more technology, often in less and less urgent situations. An example: if elective cesareans (i.e., those performed without medical need) are performed frequently, at some point it becomes “normal” for healthy, low-risk women to opt for elective cesareans.

The joint statement is an effort to put a stake in the ground, to define “normal physiologic birth” even as the slope toward technological birth becomes ever slipperier. The goal is the promotion of low-intervention vaginal birth and the appropriate use of technology, not its elimination. For healthy, low risk women that means ready access to the kind of care that promotes “normal physiologic birth.”

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A word about politics…

I think that most casual observers would assume that the conflict over American maternity care practices exists mainly between midwives and doctors, facing off over a Great Childbirth Divide—a battle between the Forces of Nature and the Techno-People, if you will. Yet there have long been disagreements within the field of midwifery itself, as reflected by the fact that there are three professional midwifery organizations in the U.S.

Most of American midwifery’s internal disagreements have revolved around issues of training, certification, and governance–questions of what qualifications a midwife should have, for example, and how midwifery as a profession should interface with the larger medical-obstetrical  world. The lack of a unified midwifery voice has sometimes made it easier for professional obstetrics organizations to downplay, and sometimes ignore, the very legitimate concerns raised by midwives.

This joint statement is a major step toward the goal of unifying that voice, a process that will ultimately be of great benefit to mothers and babies.