Birth Stories


From Our Bodies Ourselves, written by Judith Rooks
(Read full article here)

Midwifery and medical obstetrics are seperate but complementary professions with different philosophies and overlapping but distinct purposes and bodies of knowledge. Physicians are experts in pathology and should have primary responsibility for the care of pregnant women who have recognized diseases or serious complications. Midwives are experts in normal pregnancy and in meeting the other needs of pregnant women - the needs that are not related to pathology. In most countries, midwives have primary responsibility for the care of women with uncomplicated pregnancies.

Midwifery focuses on the normalcy of pregnancy, and its potential for health. Birth is viewed as a natural process that has profound meaning to many people and should be treated as normal until there is evidence of a problem. The possibility of complications is not allowed to preempt all other values associated with the woman’s experience of bearing and giving birth to a child. Midwives are experts in protecting, supporting, and enhancing the normal physiology of labor, delivery, and breast-feeding.

The medical management model focuses on the pathologic potential of pregnancy and birth. As a specialty of medicine, the main focus of obstetrics is diagnosis and treatment of pregnancy complications and management of diseases that affect pregnant women and the fetuses they carry. Attention to the pathologic potential of pregnancy is vital because, although most pregnancies would proceed healthfully without any medical intervention, serious complications and diseases are not uncommon and can be deadly. The importance of medical care for pregnant women with serious complications was dramatically shown by a study that documented extremely high mortality among well-nourished American women who belong to a religious sect that does not allow any kind of medical treatment (eg, deaths equaling a maternal mortality rate of 872/100,000 births among members of the Faith Assembly in1983). Acknowledging the essentialness of medical care for women and newborns with serious complications, the American College of Nurse-Midwives (ACNM) requires all certifiednurse-midwives (CNMs) and certified midwives (CMs) to maintain a safe mechanism to obtain medical consultation, collaboration, and referral. But, physicians have expanded the proportion of pregnancies considered abnormal or pathologic by using monitoring devices that over-diagnose complications, basing diagnoses on overly narrow definitions of normal, and treating variation from those definitions as evidence of a pathology. The desire to identify complications early has led to use of a sequence of preemptive interventions (to prevent complications or to treat them before there is evidence that they exist) and a focus on “risk factors” (conditions that are not pathologic but are associated with an increased incidence of complications). In many instances, the distinction between risk factors and actual pathology has been lost, and women with “high-risk factors” are treated as though they have actual complications.

Since an unexpected complication can happen to any woman at any time, the medical management model prepares for the worst. For example, an intravenous infusion (IV) or “hep-lock” (placement of an IV cannula to ensure rapid access to a vein) are often provided just in case the woman needs blood or drugs in an emergency. And, substantial oral intake is discouraged or not allowed just in case she needs anesthesia for an emergency cesarean section. Although an IV is not necessary for a woman having a normal birth, establishing an IV early in labor is a routine practice in many United States hospitals. In contrast, IVs are used relatively rarely in birth centers, which were specifically designed for the midwifery model of care.

The midwifery model establishes the pregnant woman as an active partner in her own care and recognizes her as the primary actor and decision-maker. A major part of the midwife’s role is providing the information and support the woman needs to make her own decisions. A midwife helps the woman identify problems and gives her information, options, and the authority to make her ownchoices. Many midwives avoid saying that they “deliver babies”; rather they “attend” the laboring woman and “catch” the baby, recognizing that the woman herself, through her labor, delivers her own child into the world. Physicians are more likely to see themselves as the key decision-makers, and most say that they “deliver” babies.

Continuous Presence and Hands-On Assistance During Labor

The midwifery model of care is time-intensive and relationship-intensive. Midwives use their own physical and emotional energy to encourage, support, and comfort women during birth; the medical management model, in contrast, tends to substitute more use of medical technology for more use of professional time. Researchers studying the impact of caregiver support for women during childbirth have noted that nurses who work in obstetric units with a high use of technical obstetric interventions may have little time to provide support to women in labor. That description seems to fit American obstetric care in general. More than 80% of women who gave birth in the United States in 1997 had EFM during labor (whether internal or external, continuous or intermittent), more than a third had their labors either induced and/or stimulated by oxytocin, and more than 40% had epidurals. Use of both oxytocin and epidurals is increasing rapidly. Recent studies have reported a doubling in use of both interventions during the previous 10 years, and there are anecdotal reports of epidural rates of 90% or higher in specific hospitals. Nurses in many hospitals watch fetal monitor tracings from several patients at a central nursing station. Careful observational studies conducted at some hospitals have found that labor-and-delivery-unit nurses spend only about one-fourth of their time in a room in which there is a patient.

Use of Obstetric Interventions

The midwifery model of care is based on respect for the intricacy of the natural physiology of childbirth and belief that women’s bodies are well designed for birth. Midwives try to protect, support, and avoid interfering with the normal processes; thus they try to avoid unnecessary use of obstetric interventions. The medical management model, in contrast, views women’s bodies as very imperfect at giving birth and calls for close monitoring and control of the process.

Physicians tend to manage labor using relatively narrow criteria for what is normal and intervene when a woman’s labor falls outside those criteria. Midwives may accept greater variation as within the range of normal, so long as both the woman and fetus tolerate labor well. Labors that deviate from these norms are cause for increased vigilance for early signs of actual complications, but not for automatic use of interventions.

Medical management often calls for applying treatments as preventive measures. The midwifery model recommends waiting until there is evidence that the intervention is needed. Treating more labors as normal may help them stay normal; some of the interventions applied because a woman is high-risk cause actual complications. For example, using oxytocin to increase the frequency and strength of contractions can interfere with the supply of blood going to the placenta and thus cause fetal distress. Oxytocin also tends to increase the pain of labor, sometimes making it necessary to give an epidural to a woman who would not have needed it if she had not had the oxytocin. Epidurals, in turn, tend to increase the need for either a cesarean section or use of forceps or vacuum extraction to actually deliver the baby.

Most CNMs and CMs use some obstetric procedures, including electronic fetal monitoring (EFM), and some of their clients have episiotomies or receive oxytocin, epidural analgesia, or anesthesia, and other procedures that are needed sometimes. But, except for EFM, midwives’ clients are less likely to have these procedures, in part because midwives specialize in the care of women without serious complications, in part because women who want to avoid unnecessary procedures seek the care of midwives, and in part because midwives have other, less invasive methods to assist women, such as warm water baths and counter-pressure as measures to relieve and help women cope with pain.

Goals and Objectives of Care

The health and safety of the mother and baby are of paramount importance in both the midwifery and medical models. But, they are not the midwife’s only goals. Midwives value childbirth as an emotionally, socially, culturally, and often spiritually meaningful life experience - something to be experienced positively, with potential for making women feel stronger, and be stronger, and for strengthening bonds between the mother and father, as well as the other siblings and the newborn.

In addition, the baby is not the only important outcome of the pregnancy. Pregnancy, especially every first pregnancy, is a critical developmental process for a woman. Pregnancy results in a mother as well as a baby. It is important that the woman’s transition into motherhood is a positive experience, that she and all members of her family make emotionally healthy adjustments to each pregnancy and birth, and that she has the means to acquire the necessary information, skills, support, and self-confidence needed to successfully assume the roles and responsibilities of motherhood. Breastfeeding and mothercraft are part of the focus of midwifery.

This article was written by Judith Rooks and originally published in the July/August 1999 edition of the Journal of Nurse-Midwifery (now the Journal of Midwifery and Women's Health). It is posted here with permission from the author and the publisher.


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