Midwifery… Deja vu all over again?

Well, I see that midwifery is back in the news again, so I thought I’d revisit the issue -my last look at it  was in November, 2012. Its not that I’ve changed my opinions -I haven’t; nor that I have since discovered something new and compelling about the role of midwives in pregnancy -I continue to support them as I always have. Its more that I am surprised that there should still be any lingering doubt as to their value; that we should still be treating midwifery as if it were an Alternative Medicine -you know, like Huckleberry leaves for indigestion, or something. Midwives have proven their worth over millennia; their extensive and practical experience has helped countless women over the centuries -especially those who couldn’t afford, or even access doctors with their often unhelpful and sometimes misguided medical beliefs and practices -some dating back to Aristotle… It occurs to me that perhaps I am  being too harsh, too revisionist -too reductive- in my recollection of Medical History, but until quite recently there didn’t seem to be much advantage accruing to the involvement of a doctor in the care of a woman in labour.

A predictably Canadian stimulus -the CBC News- got me thinking about midwives again. They reported on a recent issue of the Cochrane Database of Systemic Reviews which looked at 13 studies that included more than 16,000 women comparing various models of obstetrical care with midwife-led care. This model is different from what has traditionally been known as the Medical Model in which a doctor is in charge and a midwife is (maybe) part of the team, but not the leader. In it, she was a useful accessory perhaps, but really just a doctor’s helper: someone who could see the simple and uncomplicated cases and therefore ease the doctor’s burden. I almost said ‘was allowed to see’ these, but I caught myself.

So the meta-analysis tried to put midwife-led care into perspective: was it as good as doctor-led care? Was it merely a niche product serving women with unusual needs and attitudes, or more mainstream in its goals and aspirations? Were they just two Majesteria staring at each other from afar, as incapable of comparison as the proverbial apple and orange?  Well it turns out that one can compare them, and after allowing for the more complex and sicker women that are more likely to find themselves assigned to the medical camp, it seems that there are definite benefits to seeing a midwife… Surprise!

Of course one could argue about some of the touted advantages of midwife-led care mentioned in the article: the use of fewer epidurals for pain relief in labour, for example. I’m not sure I understand why a procedure that truly does relieve pain -and which, if used in a timely and appropriate fashion, has minimal effects on the outcome of labour – can not be judged to have a positive effect on the experience. Labour doesn’t need to equate to running a gauntlet; there are no prizes for enduring the most punishment; no moral or societal penalties for actually enjoying it -in other words, being open to pain relief without a sense of guilt or failure. Or at least cherishing the opportunity to choose. Epidurals aren’t for everyone, but its nice when they’re available. Options are good. Maybe its the man in me wondering what all the fuss is about natural labours; can any labour that results in the birth of a baby -perhaps apart from circumventing it entirely with a Caesarian Section- really be unnatural? Unplanned, maybe; not living up to expectations or desires, perhaps; requiring interventions one would rather have avoided, possibly -things happen… All of us -doctors included- would like to see events unfurling as the mother had hoped, and honestly try our best to achieve this. But above all, we want a satisfying, but safe delivery of a healthy infant.

Fewer episiotomies is another benefit to midwife-led care apparently… Uhmm, I’m trying to remember the last time I -or my colleagues- had to resort to one of these! But I understand the point: there are some things doctors may do that could be construed as unnecessary intervention.  I take exception to a comment the CBC reported from a Guelph, Ontario midwife, though. She apparently felt that the fewer midwife interventions noted in the studies made sense “given how midwives view birth as normal.”  [italics are mine]. However, she does go on to say that “There’s more time in the visit to really address their concerns, so my expectation is we would really care for the whole person, address problems early, refer problems early and that allows women to be healthy.”  No Us and Them in that follow-up statement;  no aspersions cast there. Indeed, she’s managed to encapsulate just why I feel so comfortable with midwives. But I would like to suggest that even doctors are capable of considering the whole continuum of conception-pregnancy-birth as normal, too.

Choice in pregnancy care is the important issue, I think. Midwives, like general practitioners, refer to specialists when there is a need. Some pregnancies are known to be at higher risk than others right from the start -an older woman with hypertension, or diabetes, for example- but even there, as long as the midwife, mother, and specialist are comfortable with each other and with the probability of more intensive and perhaps more frequent testing, shared care between them is still an option if the patient wishes to continue with the midwife. Its a beautiful compromise that dips a toe in both rivers without being swept away by either.

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