Midwives shilling for themselves in The Lancet

The big shill

Ever notice how midwives can’t seem to write a paper that does not involve shilling for midwifery jobs?

The latest series on midwifery in The Lancet is no exception. The entire focus of the series is on midwives and their employment opportunities, not on women and babies and their needs.

It’s all the more remarkable when you consider the series of stunning midwifery failures in industrialized countries.

Multiple studies in The Netherlands, the country with the highest proportion of homebirths, have shown that Dutch perinatal mortality is among the highest in Europe. Moreover, Dutch midwives caring for low risk patients have a HIGHER perinatal mortality rate than Dutch obstetricians caring for HIGH risk patients. That is an incredible indictment of midwifery.

Over in the UK, the situation is so dire that the government has released a scathing report:

The Health Service Ombudsman examined the supervision of midwives after a series of reports into a scandal at University Hospitals of Morecambe Bay Foundation trust involving the deaths of 14 babies and two mothers…

The damning report is fiercely critical of subsequent investigations into the deaths by the trust and the local health authority – which it found guilty of “maladministration” for failing to properly probe the deaths.

Under the current NHS system of regulation, local midwives in were asked to investigate their peers following a series of deaths at Furness General Hospital.

Despite clear evidence of serious mistakes made, they found their colleagues did nothing wrong.

There were long delays investigating the deaths, and failures to highlight obvious lapses in care – such as babies not having their heart rates monitored and not being given antibiotics despite being very poorly, the report found.

Not surprisingly, the amount of money paid for bad outcomes and the cost of insurance coverage have skyrocketed in the wake of midwifery incompetence. Indeed, a fifth of maternity funding is spent on insurance.

Australia has had its own problems with midwives, and the US has an entire second class of midwives (CPMs) who are grossly undereducated and undertrained and leave a trail of tiny dead bodies in their wake.

Yet as far as I can tell, there has not been a single paper in any midwifery journal investigating the deadly lapses or suggesting stricter standards and greater midwifery accountability.

In contrasts, midwives in general, and midwifery papers in particular, are constantly shilling for midwife employment opportunities.

The new papers in The Lancet appear to be no exception. The focus of the series is squarely on midwives and their employment opportunities, NOT on women and their babies.

The first sentence sets the tone:

Midwifery matters more than ever

That is complete and utter bullshit.

Women and babies have been dying in droves since the beginning of recorded history. Traditional midwives tried, but were not able to do much to stem the tide. ONLY modern obstetrics has been successful in saving lives. Indeed it has been spectacularly successful, saving literally millions of lives each and every year around the world.

Too many women and babies continue to die for lack of obstetric care. The solution is more hospitals, more obstetricians, more medications, more interventions in general, and more C-sections in particular. Well trained midwives, as avatars of modern obstetrics, have an important role to play in providing obstetrical services. They are not the solution to the problem, nor should their employment goals be a focus of a series.

Look at the following list of key findings from the series:

• These findings support a system-level shift, from maternal and newborn care focused on identification and treatment of pathology, to a system of skilled care for all, with multidisciplinary teamwork and integration across hospital and community settings.Midwifery is pivotal to this approach.

• Future planning for maternal and newborn care systems in low-income and middle income settings can benefit from using the evidence-based framework for qualitymaternal and newborn care (QMNC) for workforce development and resource allocation.

• The views and experiences of women themselves, and of their families and communities, are fundamental to the planning of health services in all countries.

• Midwifery is associated with more efficient use of resources and improved outcomes when provided by midwives who are educated, trained, licensed, and regulated, and midwives are only effective when integrated into the health system in the context of effective teamwork and referral mechanisms and sufficient resources.

• Promoting the health of babies through midwifery means supporting, respecting, and protecting the mother during the childbearing years through highest quality care; strengthening the mother’s capabilities is essential to longer term survival and wellbeing for the infant.

• Strengthening health systems, including building their workforce, makes the difference between success or reversal in maternal and newborn health. Since 1990, the 21 countries most successful in reducing maternal mortality rates—by at least 2·5% a year—have had substantial increases in facility-birthing, and many have done this by deploying midwives.

• Effective coverage of reproductive, maternal, and newborn health (RMNH) care requires three actions. These are: facilitating women’s use of midwifery services, doing more to meet their needs and expectations, and improving the quality of care they and their newborn infants receive.

• Although evidence from more settings is needed, evidence so far shows that midwifery care provided by midwives is cost-effective, affordable, and sustainable. The return on investment from the education and deployment of community-based midwives is similar to the cost per death averted for vaccination.

• Quality improvements in RMNH care and increases in coverage are equally important for achieving better health outcomes for women and newborn infants. Investment in midwives, their work environment, education, regulation, and management can improve the quality of care in all countries.

• Efforts to scale up QMNC should address systemic barriers to high-quality midwifery— eg, lack of understanding of midwifery is and what it can do, the low status of women, interprofessional rivalries, and unregulated commercialisation of childbirth.

More bullshit!

A system-level shift, from maternal and newborn care focused on identification and treatment of pathology to a system of skilled care for all? Why on earth would be turn our focus from the mothers and babies dying of pathological conditions to a system that gives greater emphasis to women who don’t need life saving care?

To increase employment opportunities for midwives, mothers and babies be damned.

The typical woo-mongering of midwives is given pride of place. Women and babies are dying hideous deaths, but midwives want to talk about “strengthening the mother’s capabilities.” (For what? They don’t say.) There’s a lot of talk about “respecting” mothers, investing in midwifery, integrating midwifery more fully into healthcare, reducing interprofessional rivalries and stopping the “commercialisation” of childbirth, EXCEPT when it is midwives who are doing the commercializing.

They seem to be entirely ignoring the actual causes of maternal and perinatal mortality.

According to the World Health Organization, the leading causes of maternal death are:

  • severe bleeding (mostly bleeding after childbirth)
  • infections (usually after childbirth)
  • high blood pressure during pregnancy (pre-eclampsia and eclampsia)
    complications from delivery
  • unsafe abortion

WHO data

What can midwives do about these problems? Not much.

According to the WHO, the leading causes of neonatal death are:

  • prematurity
  • infection
  • intrapartum events (asphyxia, shoulder dystocia, etc.)
  • congenital anomalies

Neonatal deaths

What can midwives do about these problems? Not much.

Indeed the report itself provides only paltry evidence that increasing midwifery services will have an impact on these problems.

What do women and babies really need?

They need access to forceps, vacuums, C-sections, D&Cs for miscarriages, surgical services for ruptured ectopics, and skilled surgeons capable of repairing obstetric fistulas.

They need access for medications like anti-seizure meds for eclampsia, Cytotec for obstetric hemorrhage, antibiotics for infections, Rhogam to prevent erythroblastosis fetalis, Vitamin K to prevent hemorrhagic disease of the newborn.

They need access to contraception and pregnancy termination so women can control their own fertility.

They need more obstetricians to supervise midwives, care for patients, and provide care that midwives are incapable of providing. They need more MEDICAL facilities to care for every aspect of women’s and children’s health, NOT birth centers which care only for childbirth related issues.

They need more neonatologists to save premature babies, more neonatal intensive care units, and more supplies with which to run them.

But midwives cannot provide these services, so who cares?

The Lancet series on midwifery is an extended advertisement for midwifery services, despite the fact that those are not the primary services needed.

I have a question for the folks at The Lancet:

Now that midwives have been allowed to run their giant ad, when can we expect to see a series on what women and babies need, as opposed to merely what midwives can provide?

  • Homebirth problem Dad

    Planned home birth. Midwife sleeping on sofa for hours before late night delivery after more than 24 hours labor. Baby not breathing on delivery. Manually resuscitated. Transferred barely breathing to hospital (20 mins) then to NICU. 17 day stay. Ventilated. Seizures. Phenobarbital. Gtube. HIE 2. Infarct of left cerebral artery. Baby now ‘on spectrum.’ Permanent damage. Could have been prevented if more vigilant and better equipment available. I want to sue midwives for malpractice. Was against home birth from beginning. My wife insisted. Now she’s suffering from severe depression, we have a baby that is in and out of hospital, and I can barely work full time because of the issues. Love to talk to someone about retaining council.

    • Trixie

      I’m so very sorry.
      Do you mind sharing what state you’re in? Or, you could always email Dr.Amy privately. Her email address is in the top right corner.

    • Young CC Prof

      I am so sorry for what’s happened to your family.

  • Rebecca

    “QMNC” is the part that really jumps out at me. Once the baby is a “newborn” it’s deserving of Quality Care. Before that, no so much?

  • Rigi Vbac Saunders

    Another way to save lives is affordable effective birth control for proper family planning. That saves a lot of lives too. Good article

  • pettelly

    I like a lot of what you say about the fetishisation of vaginal birth in rich countries but in this case your criticism is really unfair and not substantiated in any way.

    Have you ever seen what happens in RMNH care in low income countries?? Have you met midwives working in these countries?? These are NOT ‘woo’ midwives. There is nothing they would love more than being able to refer women who need it for c-sections/OB care or whatever but the resources are so limited that they’re often on their own. We all know what women NEED, we all know what will save lives. That’s not controversial. The problem is when resources are extremely limited, how do you get the drugs, the facilities etc to the women who need them most. Midwives can provide the first level of care. In Niger, fewer than one in five women deliver with ANY kind of skilled birth attendant, let alone in hospital with an OB! Your wishlist is nice but hardly practical for Niger.

    This is a completely different kettle of fish to both the US and Europe.

    I know and have worked with a few of the authors of these papers. They are highly respected professionals who know what they’re talking about and, no, they are mostly not midwives or have any vested interest in midwifery. What they are interested in is improving outcomes for women and babies in the poorest countries in the world. Why don’t you critique the evidence which is presented in these articles rather than launch into an substantiated diatribe about an ‘advertisement’ for midwifery just because you don’t like what they say.

    • Amy Tuteur, MD

      If what you say is true, why didn’t these midwives write a series of papers about everything that underserved women need instead of writing a series of papers about why women need what midwives provide?

      This is shilling, pure and simple, and midwives do a lot of it. Their blogs, websites and Twitter feeds are extended advertisements for their services. They write only about their success and bury (literally and figuratively) their failures. That natter on about the “dangers” of interventions when interventions aren’t dangerous. Their professional organizations appear never to have met a problem that can’t be solved by hiring more midwives, and they are ideologically committed to process over outcome.

      • pettelly

        But they’re not midwives!!!! The majority of the authors are MDs, PhDs etc. They’re not midwives!!!! They have no vested interest in midwifery. Why do you insist on calling them midwives? I think there’s one midwife in there (Petra ten Hooper), maybe another of co-authors is, I don’t know, but the vast majority aren’t midwives, for sure.

        The evidence is that midwives provide the most appropriate and cost-effective first line of care. OF COURSE, it’s not the only thing. If they have nowhere to refer a woman for pre-eclampsia, no NICU so she can deliver prematurely, no OB to provide a c-section then of course maternal mortality rates will be higher. But the first line of care they can and do provide and often HAVE to do more than midwives in developed countries are allowed to do, out of necessity. These midwives WANT to refer patients, you won’t get a midwife in Niger telling a woman ‘to trust her body’, that midwife wants access for her patients to blood transfusions, c-sections. These things cost money though. Where is this money going to come from? If all the resources go in to best practice care, how many women will benefit?

        There are other articles and series about which interventions can save lives as well – for example, contraception and access to safe abortion – but this is a series about midwifery care. Critique the evidence, that’s always good to do, but you’re makign unsubstantiated accusations here. You haven’t provided a shred of evidence against what was written.

        Improving and expanding midwifery is crucial in low-income countries and this series presents the evidence why. Of course you need more midwives in these countries – you also need more doctors, more nurses, more of almost any healthcare professional. It’s not the only solution, far more is needed, and as far as I can see, that point is also made.

        Here’s the Lancet series on cost-effective interventions for newborns: http://www.thelancet.com/series/everynewborn

        Here’s the Lancet series on maternal survival:
        http://www.thelancet.com/series/maternal-survival

        Here’s the Lancet series on stillbirth
        http://www.thelancet.com/series/stillbirth

        You can see that everyone is aware that midwifery is but one part of the solution, it’s not the cure all and no-one has say it is.

        • Amy Tuteur, MD

          No, they’re midwives. Having a PhD in Midwifery means you are a midwife.

          Out of the dozens of authors, how many are obstetricians?

          • pettelly

            No, they’re not. James Campbell is not a midwife. Zoe Matthews is not a midwife. Richard Horton is not a midwife. Ingrid Friberg is not a midwife. Linda Bartlett is not a midwife. Helga Fogstad is not a midwife. These are just the people whose work I happen to know professionally (other issues with Richard Horton but a midwife he is not). I’m not going to go through the CVs of the whole list of authors but the authors I know are NOT midwives. They are well-respected health economists, statisticians, demographers, development experts, epidemiologists, all of whom specialise in RMNH in low income countries.

            Not that there’s anything wrong with being a midwife by the way. Or having a PhD in midwifery.

            Instead of slandering the authors with unsubstantiated accusations of ‘shilling’, why not focus on and critique the evidence? What do YOU think would be the most cost-effective way to improve RMNH in low income countries (with evidence of course) if midwives are to be excluded? That’s what’s important if you have a problem with what was written.

          • Amy Tuteur, MD

            How many obstetricians are there? You know, the folks who are experts in birth complications?

          • pettelly

            How is Jim Campbell, an internationally respected health economist who specialises in global health workforce planning (including but not limited to midwives) ‘shilling’ for himself? What has he to gain from this, for example? You keep on repeating yourself but not substantiating it.

            You might not agree with the statement in the executive summary so please share your arguments about why the evidence on which it is based is wrong.

            Or is this just a fit of pique that there weren’t enough obstetricians involved for your liking? That’s what it sounds like to be honest.

          • Amy Tuteur, MD

            You haven’t answered the easiest question: how many obstetricians, the people who are EXPERTS in childbirth complications and saving the lives of women and babies, were involved?

            Why on earth should we accept a prescription for treating childbirth complications and preventing deaths from the people who are “experts” in normal birth? What possible basis exists for shifting the focus away from pathology except as a full employment plan for midwives? Even I’m amazed at the cynicism and blatant self interest that is on display.

          • pettelly

            I don’t think you understand the situation in these countries. Do you know that Niger spends $36 per capita per annum on health care? In Niger there are 2 physicians for every 100,000 people (presumably even fewer OBs). There are 14 nurses and/or midwives for every 100,000 people. This is the kind of situation we’re dealing with. Your wishlist is nice but unrealistic. The evidence shows that scaling up midwifery will most certainly save lives (this was modelled using the Lives Saved Tool developed by JHU, not just someone’s opinion – you can look and see the assumptions made if you don’t like it).

            I already said I don’t know how many obs were involved, only that you accused all the authors of being midwives and having a vested interest. If you have the time, you could trawl through Cvs and find out who is who, I only pointed out the people I know who happen to be extremely well-respected non-midwife professionals.

            I’m not sure why you think that is what makes such difference that obs were or weren’t involved – this isn’t a clinical study but a population level one and it’s one which focuses on the contribution of midwifery to RMNH outcomes. If it were one on the contribution of obsetricians, would you be upset that a midwife wasn’t involved? If you look at the series on maternal survival in general in the Lancet, you’ll see that obstetricians were involved such as the wonderful Professor Wendy Graham (who, by the way, is fully supportive of expanding midwifery as you can see from her articles).

            We know what works with saving maternal and newborn lives in low-income countries, the question is how to best implement given the constraints. It’s not a clinical question.

            Your blog post was completely inappropriate and even slanderous.

          • Amy Tuteur, MD

            I can think of no more damning statement than the grossly unethical claim that received pride of place in the executive summary:

            “These findings support a system-level shift, from maternal and newborn care focused on identification and treatment of pathology to a system of care for all”

            That is clear evidence that they are shilling for themselves, not considering what is best for women and babies.

        • Young CC Prof

          Yes, low-income countries can benefit from more well-trained midwives with at least basic supplies.

          However, the series also recommended using midwives to promote natural birth and reduce interventions, which is the nutty part.

          Low-income countries: More midwives will save lives.

          Countries that already have a good health system do not need to reduce interventions by adding more midwives!

          • pettelly

            That’s fine. I have no problem with someone critiquing the findings based ont he evidence presented. I don’t like the slanderous and dismissive tone of the whole blog post, ignoring the enormous contribution of midwifery to improving RMNH outcomes in low and middle income countries.

          • araikwao

            So as I have been informed, the three biggest contributors to reducing global maternal mortality are, in descending order: timely access to emergency obstetric care (basic and comprehensive,can give details if anyone’s interested), legalised abortion, and skilled birth attendants. (Source: lecture from RANZCOG ?president. A professor, anyhow!)
            So yes, midwives absolutely make a big difference, just not the biggest difference.

  • Dr Kitty

    In a place where labour wards are understaffed, there is a 3 day wait to be seen at the early pregnancy clinic unless you have severe pain or bleeding or a suspected ectopic and women often cannot get epidurals in a timely manner during labour, the local policy is to try and replace GP initial pregnancy visits and postnatal visits with midwife appointments.

    Grrr…I do those appointments because I am damn good at it, and it is more appropriate IMO for a Generalist who knows a woman’s entire medical hx and social circumstances to see her at the beginning and end of her pregnancy than for a midwife to do so….especially since they are stretched enough providing the ESSENTIAL services that only they can offer!

  • Ob in OZ

    How the midwife agenda has hijacked modern medicine is beyond comprehension. It seems that these “articles” are given a free pass as not to offend the midwife community. There is just too much to critisize of the article pointed out on this blog, that if I went and read the entire article I might put my head through my desk.

    • Sue

      In Oz and the US at the moment, it seems to be PC (or ideologically correct) to juxtapose nursing-feminine-feeling-based with medicine-masculine-technology-based tribes as if they weren’t BOTH caricatures.

      Give me a smart hospital nurse-midwife who understands the anatomy, physiology and pharmacology of pregnancy and delivery, with a team to consult for pain relief or complications, any day.

  • pinkyrn

    ” from maternal and newborn care focused on identification and treatment of pathology, to a system of skilled care for all….”

    I am thinking skilled providers of care need to be focused on identification of pathology in order to treat the problem. How would that ever need to change? In nursing school we learn about signs and symptoms in order to identify them in patients and then initiate treatment. We do this because some pathology has a tendency to escalate until it kills the patient. And a dead patient is the ultimate fail, unless DNR. Often that is calling the Doctor or Midwife or NP in order for them to come initiate a treatment plan.

    I don’t think this sentence really makes any sense at all.

    • Elaine

      IMO it’s basically riffing on the idea that medical providers view pregnant women as “patients” and “pregnancy is not a disease” so it should be viewed as basically a normal healthy stage in a woman’s life rather than “medicalized” and women should get, I suppose, just supportive care which acknowledges how “normal” it is. Which is true and not true, because it is true that pregnancy is a normal stage of life that many women will go through, and that many women will have healthy pregnancies and births, but it still carries its own sets of risks and potential pathologies that care providers need to be watching out for.

      • fiftyfifty1

        Exactly. Pregnancy is not a disease and most pregnancies end in a healthy mother and baby AND ALSO pregnancy is a huge killer of young healthy women throughout all of history and the day a baby is born is statistically the most dangerous day of its entire life. What is wrong with the current midwifery ideology that they cannot keep both these truths in their heads at the same time?

  • Maya Manship

    Hello Dr. Amy. I’ve been reading your blog for several weeks now. I’m expecting my second child in November. I’ve never considered a home birth but your blog has made me appreciate my OB-GYN and her practice more than ever. She delivered my first baby by emergency C-section. I was allowed to labor for 15-18 hours in the hospital. Of course, I was monitored at all times along with my baby. My daughter turned sideways and her heart rate dropped and off we were sent for an emergency C-section. That was the only complication. She was born at 8lbs 14oz, didn’t even had jaundice. Thinking back on her birth, another woman and baby in the same situation during a home birth may have died. The thought gives me chills. Home Birth advocates like to say “trust birth, your body knows how to give birth.” Well, the mother’s body is not the only body involved. How is my daughter supposed to know that she should not turn in the womb during labor? I know other doctors and medical professionals read your blog. I’d like to say thank you. Thank you for the years of study and professional practice. Thank you for all the research, for everything that you’ve learned and are continuing to learn. Thank you for saving so many lives. This is one mother that will never trust birth or allow a lay midwife near any baby of mine. Sorry if I hijacked the comments…

    • The Bofa, Being of the Sofa

      Home Birth advocates like to say “trust birth, your body knows how to give birth.”

      And you can stand there, tell them your story, and ask, “How can you still say that?”

      Clearly, turning your daughter sideways was not your body being so darn smart about knowing how to give birth.

      Thanks for your comment.

      • Hannah

        Their reply will be that she wasn’t trusting or they were obstructing her from progressing, or some other nonsense.

        • The Bofa, Being of the Sofa

          True, they can just insult her.

      • Certified Hamster Midwife

        They would blame interventions.

        • Hannah

          Exactly.

        • Medwife

          The baby was clearly squirming away from the Doppler ultrasound waves.

    • pinkyrn

      Go Sox!

  • Sue

    Hospital midwives and obstetricians are both collaborating in the specialty of obstetrics, just as nurses and doctors collaborate in cardiology, oncology or NICU. Midwifery is a role, not an independent discipline. The evidence within obstetrics applies to all its providers. Skilled hospital midwives use sophisticated knowledge, drugs & technology every day.

    • Ob in OZ

      But Obstetrics is the only field in which the collaboration is completely one-sided in the wrong direction. In all other fields the collaboration is respected, but ultimately the Doctor will make the final decision. In Obstetrics the Doctor is told over and over again to collaborate with the midwives and respect their professionalism, but I am still waiting for the day that the midwives comes up to me and says they appreciate that my opinion is different to theirs on this occassion and they are happy to go in that direction.

      • pinkyrn

        Actually, doesn’t the patient have the final decision? Unless the patient consents to treatment, there will be no treatment or it can be viewed as battery.

        • fiftyfifty1

          Of course the patient has the final decision. But wouldn’t it be weird if, say, cardiac NPs or oncologic NPs or psychiatric APNs came out of an entirely different “philosophy” of their fields? That when you became a patient for one of these conditions you had to wade through dogma to try to figure out what course of action would be healthiest for you?

          • guest

            Exactly. Imagine a surgical nurse telling a surgeon they can’t operate on a patient with a burst appendix and to let the patient trust their body while they hold the space.

          • pinkyrn

            Nice analogy. However, CNMs working in the hospitals I have worked at, do not behave like that. Doctors and nurses in hospitals do not behave like that. If they did, they would be held accountable.

            The education of a CNM is full of classes on pathophisiology. Neonatal patho, Maternal patho, pharmacology. There are no classes on “holding the space,”

          • sameguest

            I am in Australia and the woo is starting to infest University midwifery education. Sadly midwives in hospital do behave in this way, sometimes even physically preventing a doctor from entering a delivery room. This is a well known manoeuvre in NZ birth suites too.

          • pinkyrn

            Wow, that is shocking to me. And that is not right. Obstetrics is a team sport. You cannot do a stat c-section without 5-6 people in the room. You should not do a no-frills vaginal birth without 3 people in the room.

          • Ob in OZ

            This is why I made the original point. Also, the midwife has one or two patients. We have all of them plus covering ED and Gyn and clinic etc, so our 5-10 minutes with a patient every few hours is a battle when they are being told woo for hours and hours.

          • sameguest

            I know exactly what you mean.

      • guest

        Well said Ob in OZ. My experience exactly.

      • Sue

        Point well made, Ob in Oz. Even in non-procedural specialties like Psychiatry, nurses, doctors and allied health staff seem to accept the same body of evidence, even if they take different perspectives to care.

        I suspect that the large majority of competent, hospital-based midwives and RNs do so for obstetrics too, but their voices are drowned out by the zealots.

      • areawomanpdx

        I will say that I have seen nurse midwives in the US have very collegial relationships with physicians, and respect that goes both ways.

        • Ob in OZ

          I would agree that the majority are in pretty much every country. It is the vocal minority that scar me for life.

  • AussieAcademic

    The Lancet is a prestigious journal but has become extremely ideological. I am disappointed but not surprised to see this latest piece of advocacy posing as science.

    • Medwife

      Yeah that’s one journal I don’t bother to read anyway.

  • Deena Chamlee

    So it discusses addressing the midwives work environment, management, and removal of barriers to high quality midwifery care. The report states midwifery is only successful when integrated into the larger healthcare system. So the report is not a total loss. Only CNMS and CMS can be integrated in the UNITED STATES. It also addresses education, regulation and association. You can’t regulate any so called midwife when regulation will not improve safety.

    It also staes providers must be trustworthy…..hang in there AMY, it’ s not a total loss.

  • no longer drinking the koolaid

    We also need more maternal special care units. Michigan has an excellent one at Harper Hutzel, but it is the only one in this state.

  • Maya Markova

    In my country, which definitely hasn’t state-of-the-art health care, nevertheless (nurse) midwives are considered assistants of OBs, rather than independent providers.
    I have a broad pelvis and both my babies were well positioned. I was considered low risk and, I guess, other health care systems would allocate to my birth only a midwife. Happily, I had both an OB and a nurse midwife.
    During my 1st birth, the midwife was wonderful and did most of the work, telling me when to push etc. However, when I had unexpectedly severe tears, it was the OB who stitched them. It would not be good for me if he had not been there.
    During my 2nd birth, the OB first let the midwife do the same as before, but at some moment took full control. I learned later that there had been meconium in the amniotic fluid. Apparently, after seeing it, he decided to take the driver seat and monitor the birth and the baby closely. I wonder what can midwives do if, presiding alone over a “low-risk” birth, they face a red flag in the middle of the process.

    • Karen in SC

      Exactly.

      • guest

        It’s called practicing “maternity care by Obstetric rescue”. Apparently it is cheaper than proper medical care.
        It’s catching on everywhere because people are fooled into thinking it is “women centred”.

    • Hannah

      In the UK, it seems that they avoid bringing in a consulting OB until the last possible minute, with detrimental results. Similar in Canada and Australia.

  • Young CC Prof

    If every pregnant woman in the world had ready access to a well-trained midwife with some useful drugs, instruments and supplies, maternal mortality would drop a lot.

    Replacing obstetricians with midwives wouldn’t help terribly much.

    • Trixie

      I kind of see this through the same lenses as other recommendations for less developed countries. Like BF til 2 — makes great sense if you don’t have clean water and live in an area with rampant diarrheal illness. It’s a way to save lives right now. Of course the long-term goal is to improve sanitation and economic situations so women can have the choice to FF if they want, just like we can.
      Well-trained nurse midwives with basic drugs and equipment can save lots of lives in certain areas right now. But the long-term goal is not to have to rely on frontier midwives, but instead to give everyone access to the same medical care we enjoy.

      • Young CC Prof

        Exactly. It’s a great plan in the poorest areas, but applying third-world solutions to first world (real) problems usually doesn’t work well.

        • Hannah

          Exactly! I get so frustrated when people twist it like this – it’s the same as a government of a first world nation saying ‘well you have it better than Africa’, so that’s good enough. It’s like, no, it’s not. That should be the standard in the developed world and we should be aspiring for better in developing nations.

  • Mel

    I think I fell asleep in the middle of the list because it is so freaking similar to our “5-year-plans” that my school district used to write yearly.

    To wit:
    *No real problems are addressed; instead, problems are alluded to in a jargon-stuffed way.
    *Large, important, external root causes are blatantly ignored in favor of finger-pointing at smaller (and often imaginary) problems within the system.
    *The ‘solutions’ to the smaller systemic problems don’t actually address the systemic problems let alone the ignored root causes.
    *Since everything up to this point is imaginary, no one needs a timeline for completion – or – “We’ll work on that later.”
    *Lots of back-patting on a job well done.

    To keep my sanity, I would give the 5 year plans a name from either a Stalin 5-year plan or a Mao 5-year plan. I therefore give the Lancet series the name “Let a thousand flowers bloom.”

    • guest

      your post would be hilarious if it weren’t so painfully true! brilliant!

      • Mel

        Thanks. I’ve left the secondary education system to return to school to move into post-secondary education. I fully expect the same problems there – but at least there I can partially pick my own curriculum and there are options for part-time/evening/weekend work.

        I loved working with my teens – even the behavior problem, academically unmotivated ones. What was killing me was the unending stream of “initiatives” that involved me re-writing my curriculum (all 4 subjects plus project-based learning class) to a new, insane educational fad that would be replaced each. freaking. year. Being told yearly that I had $75 dollars for supplies while being introduced to the newest math/science/reading guru who was hired at double my salary and had no previous teaching experience got old. Being told that we shouldn’t let poverty, violence, discrimination, lack of mental health services, lack of supplies, and students who were learning English “get in the way of authentic learning” made me wonder what universe my administrators lived in. When I realized I was fantasizing about working at a local gardening store as a cashier as I drove to work every day, I realized it was time to leave.

        • Amy M

          Yep. My husband was a teacher for the better part of a decade, and he wasn’t even in as bad conditions as you describe, but all the red tape and NCLB stuff was preventing him from really teaching, so to speak. Now he’s in school to become a guidance counselor, so he can work more directly with the kids, and not be tied to a curriculum.

        • Lisa from NY

          Why don’t you start a petition for a “back to basics” curriculum that works for all students. Asking to have the same basic academic curriculum (starting with phonics in elementary school) and putting the money into incentives to motivate students to learn instead of paying for stupid consultants.

        • pinkyrn

          I feel your pain. I met the woman from JACHO who is working on Ob initiatives, she has no experience in Obstetrics. None. The initiatives we are tasked to complete sometimes interfere with each other. It is a comedy of errors. We have to keep a good sense of humor. Because another things about these initiatives is that new ones are always coming along so the hospital has a tendency to get distracted by new initiatives. So just wait it out and they will forget.

    • Lisa from NY

      The real problem with schools is that students with major behavior problems are kept in mainstream classrooms, thanks to the “No child left behind” act. So now every child is “left behind”.

      • pinkyrn

        Sounds like nobody left behind means some kids will be pushed ahead and others will not excel.

        • FormerPhysicist

          Oh no, no child is pushed ahead. There’s no bonus for that. Bright children are used as teacher extenders. Despite no training. It’s called “peer teaching”.
          It isn’t quite as bad as untrained midwives, but there actually are some similarities. Untrained extenders, ideology over outcomes …

      • Hannah

        My mother runs into this all the time in Australia, too.

    • pinkyrn

      Public relations and Politics.

  • Amy Tuteur, MD

    The tl;dr version of this piece:

    To a hammer, everything looks like a nail.

    Midwives are hammers, but most causes of maternal and perinatal morbidity and mortality are not nails.

    • Cat10

      I agree with you. However, midwifery is not created equal in all countries (as you have pointed out multiple times on your blog). In my home country, for example, the standard of maternity care is to have both a doctor and a midwife. The midwives have admitting privileges at hospitals and they encourage hospital deliveries which they accompany as part of a medical team. As the article below (see link) shows, they also provide valuable care to women in rural areas but alas, they know their limitations and they understand that they cannot and should not replace a medical doctor: http://www.spiegel.de/international/germany/midwife-crisis-reforms-needed-to-stem-shortage-of-birth-caregivers-a-766195.html

      • Hannah

        The problem is that in countries like the UK, Canada and Australia they are being used to replace medical doctors and the introduction of an OB consultant is at *their* discretion. That, combined with dogmatic shift towards NCD ideology in mainstream midwifery, means that we’re going backwards, not forwards.

        • Ob in OZ

          Exactly right. The next step backwords is approaching the New Zealand model of care, wich has resulted in worse Obstetric outcomes (common knowledge, don’t ask me to reference). I assume their healthcare budget is more manageable, which is the only explanation for accepting worse outcomes. I am also willing to bet they don’t have the liabilty issues of the US,UK and catching up quickly Australia.

          • Michelle

            “Common knowledge” doesn’t mean that is what is happening and it’s certainly not about just accepting or ignoring worse outcomes for mothers and babies, there is the Perinatal and Maternal Mortality Review Committee looking at any issues that might contribute and could be preventable and recommending improvements. That’s not to forget those working in obstetrics here too – as said in the article it is modern obstetrics that saves lives and I don’t think obstetricians here would think it acceptable to have a system that simply tolerates worse and worse outcomes. The liability issues are there but in NZ ACC covers anyone harmed by medical misadventure/malpractice so there isn’t lengthy law suits to try and recover costs.

            The figures for 2011 show 6.7/1000 perinatal mortality, 3.5/1000 stillbirth, 2.6/1000 neonatal mortality. Maternal death rates are stable, with little change since 2006.

            In 2009 the figures were 7.5/1000, 4.7/1000, 2.9/1000. 1996 NZ figures: 9.1/1000, 6.6/1000, 3.4/1000. Some improvement there in rates over the years. UK figures for 2009 were 7.6/1000, 5.2/1000, 3.2/1000 as a contrast.

        • guest

          A prime example from Australia is the intellectual genius (sarc) spokesman of the College of Midwives, Hannah Dahlen.
          Remember, she is the one arguing for a non-rational view of risk and other such gems.

    • fiftyfifty1

      Or perhaps this: If you don’t have a hammer, nothing looks like a nail.

      i.e. if you can’t do surgery, forceps, vacuum, and other high skill interventions in the face of deadly risks, you will convince yourself that those deadly risks aren’t really there at all.

    • pinkyrn

      ~ 20 years ago, I was walking through the hallowed halls in one of Harvard Medical Schools teaching hospital. I was a nurses aid, so I could walk around undetected. Sort of like a ghost with scrubs on. The conversation went like this, “I realize Dr. X has told you that your husband needs a pacemaker. I am telling you that is not the focus for your husbands care at this time…….” I knew Dr. X, he was a hammer and every one with a heart needed a pacemaker. He also had a tendency when he removed the dressings he would throw them across the room. Very flamboyant guy. So not only was he narrow minded, he was a grade A jackass.

  • theadequatemother

    quite a few of the full text articles in this series (as opposed to editorials) are behind a pay wall. For those of you with access to university libraries you will be able to get the full text. I would encourage the rest who are intersted to consider joining your former university library as an alumni (here its $50 a year and in some places free and you get access to tons of online journals). The full texts are an intriguing mixture of information and ideological commentary. Quite a job. Impressive, but not in a good way.

    • LibrarianSarah

      Not necessarily, a lot of colleges and university do not offer use of the databases to alumni because of cost concerns. Database providers make you pay out the ass for that kind of thing.

      • theadequatemother

        many of the major universities in Canada offer their online journal content to alumni and community members. I’ve attended three and they all do.

        • Elaine

          I’m in the States. I wish mine offered this. My husband worked for a community college while I was in pharmacy school, and he used to borrow my institutional access because it was better than his. I graduated and can’t get the access anymore, and then he lost his job, so now we really can’t access anything at all. Boo. And I attended a large public university. I haven’t checked what I can access through my undergrad school, but considering they don’t have a program in anything related to my field, I doubt they have the specialized medical journals either.

          • doctorex

            Worth checking. Also worth checking if your association memberships (if you have any), come with access. Remember that health policy folks, biologists, and a lot of other folks need access to specialized medical journals, too.

    • moto_librarian

      Inter library loan from a public library is also a possibility for those without access to an academic library.

  • DoulaGuest

    Also I understand the argument of Dutch midwifery, but *is* it a fair indictment of midwifery? It is one country’s midwifery outcomes, and they educated differently from AMCB midwives.

    • Amy Tuteur, MD

      It’s an indictment of exactly what I wrote about the other day: the hijacking of midwifery by ideologues who value their autonomy and employment prospects above the well being of women and babies.

      • Lisa from NY

        Maybe these midwives have no other job prospects.

      • pettelly

        Except most of the authors aren’t midwives. Ah well, don’t let the truth stop a good story.

  • DoulaGuest

    What are the outcomes for CNMs/CMs? I thought they were comparable (looking at the same populations) to that of OBs (if not better in some cases?). Please correct me if I am misinformed in this regard. Also, in terms of physician supervision….most states do not require this. CNMs/CMs consult and refer with physicians, just as OBs consult and refer with MFM/endocrinologists/etc. and I don’t believe that their outcomes differ from states with written practice agreements.

    I haven’t read the Lancet, but with the political moves that APRNs in general (not just midwives!) are making it isn’t a surprising thing to have happen. Now that baby boomers are getting older, and dollars tighter, there will inevitably be more competition for the dollars that go towards L&D.

    • Amy Tuteur, MD

      Midwives have comparable outcomes for LOW risk women. They do not have comparable outcomes for everyone else.

      • DoulaGuest

        But CNMs/CMs are (supposedly) only managing low-risk, yes?

        • Ash

          I’m involved with a bit of data collection for women in a high risk pregnancy clinic. Not all of them are managed by an OB upon admission for delivery

        • Stacy48918

          My Type I diabetic, trying for a VBAC sister-in-law was managed by a CNM for both pregnancies. She did achieve her VBAC…but baby was 10#. High risk all over the place. My family couldn’t understand why I was so worried for her. Oy.

          BUT she was delivering at the hospital at the University of Kentucky so high risk docs and services were readily available. I doubt that she would have been allowed to attempt the VBAC in a rural hospital with a CNM.

          • Medwife

            Huh. That patient would be considered out of my scope.

          • Stacy48918

            Yea…I was kinda freaking out her entire pregnancy….

        • Medwife

          I independently manage low risk patients and consult my OB as issues arrive. I co-manage patients with certain problems, and the most complex patients belong to the OB. Some women I can’t manage while they’re pregnant but I can manage the birth, or vice versa. It’s not cut and dried.

          • Sue

            But “Medwife” – that sounds dangerously like ”collaboration”! The bete noir of the HBMW!

          • Medwife

            The homebirth midwives, including cnms, definitely do not seem to be team players.

        • guest

          But they don’t. That is the point.
          They take on TOLAC, breech, twins and call them “variations of normal”.

    • Therese

      In the U.S. the outcomes for hospital CNMs are better than OBs. .3 something out of 1000 instead of .8 something out of 1000. (You can look in the CDC database for infant mortality if you want the exact numbers.) Homebirth with a CNM is pretty comparable to hospital birth with an OB.

      • Amy Tuteur, MD

        No, they aren’t. All the higher risk cases plus all the transfers are recorded in the MD group.

      • fiftyfifty1

        “Homebirth with a CNM is pretty comparable to hospital birth with an OB.”

        Wow, that’s an indictment of homebirth if I’ve ever heard one. Women choosing homebirth can brag to their friends that they are choosing a way to birth that puts them at the same risk level as the group that contains women with underlying heart problems, insulin dependent diabetes, innercity teens, and drug addicted moms!

        • Young CC Prof

          The neonatal death rate at home birth is NOT comparable to hospital birth unless you include all the preemies in the hospital group.

          Once you exclude the preemies from both groups, the death rate at home birth is the same as the death rate at hospital birth among women who recieved no prenatal care at all.

          • fiftyfifty1

            Even better! I want to give my baby the same start in life as the baby of the homeless woman who got no prenatal care and wandered into the hospital when she was about to deliver. Sign me up for a homebirth!

  • Amy M

    I would guess that highly trained midwives would be able to diagnose many of those problems, and handle some of them (in the hospital). Probably they could deal with hemorrhage (to a point), administering abx to laboring women in an effort to prevent neonatal infections, they may be able to do some maneuvers to relieve shoulder dystocia also. They should also be able to recognize when a problem has gone beyond their scope and then refer the patient to an OB, whether that’s prenatally or in labor, or post-partum. If the midwives can do that, and are willing to do that, then sure, they have a place in the care of pregnant women.

    • DoulaGuest

      I don’t think they are saying in any way that midwives should replace OBs. In fact I find this article a bit confusing, since CNMs/CMs have great outcomes and (as you pointed out) have the ability to diagnose and treat many of the issues stated above. Is Dr. Amy stating that *all* midwives….not just the CPMs….need to be done with?

      • Amy M

        I can’t speak for her, but she’s said in the past that she worked with CNMs and thought they were excellent caregivers.

        • DoulaGuest

          I’m not exactly a fan of the ACNM, nor do I think that they have shown stellar ethics, but it seems like her arguments are becoming more and more that all forms of midwifery are unnecessary.

          • Amy Tuteur, MD

            No, my argument is that midwives are NOT the answer to the most pressing problems in obstetrics. It’s difficult to think of a more pressing problem in obstetrics than preventable perinatal and maternal deaths.

            What I object to most is the focus on the employment prospects of midwives. I can’t recall any articles in medical journals whose main focus is to promote doctors. The appropriate focus for healthcare papers is how to identify and address the problems that PATIENTS have.

          • Amy M

            I clicked the link you provided and looked at the titles to the articles in the series. I’m not sure I have access to read them, I don’t have time right now, so I’ll just ask: do the problems you’ve outlined in your post here come up in any of the articles? Are the authors of the series even recognizing what the problems are?

          • theadequatemother

            well one of the articles said maternal and perinatal M&M dropped in a few countries after they increased pre-deployment training for midwives and moved more births into facilities but their final sentence stated that the care wasn’t women-centric and that “overmedicalization” wasn’t addressed. (!)

          • Amazed

            Give me an overmedicalization please! I’d very much like to be alive, with a healthy baby, so I could get to complain about all those zealous medics to my hearth’s contentment.

          • pettelly

            When you have very limited resources, over-medicalisation is a problem as it’s wasteful.

          • Amy Tuteur, MD

            Where’s the evidence that over medicalization is a problem in low resource countries? There isn’t any, is there?

          • Student/Doula

            Typically I agree with 99% of your posts, but this one baffles me. I surely think that training more midwives in third-world countries will help complications be identified, therefore referred for treatment by MD (where available), therefore lower rates of death from complications in childbirth.

            I believe that the Lancet series focuses on the need for and promotion of midwives because it is hard to promote more physicians in countries that do not have the training/resources available. I also think that the patient IS the focus when more midwives = more care. Hadn’t you recently posted about how when you were practicing you always respected the CNMs you worked with and the care they provided? Training a CNMs is a lot cheaper than training an MD. And wouldn’t it be better than no care at all?

          • Amy Tuteur, MD

            If it were more patient centric, it would focus on what patients need. Instead it focuses only on what midwives can provide, which is often not what patients need.

            The bottom line is that midwives are doctor extenders, not doctor substitutes, and certainly not substitutes for surgery, medication, equipment, etc.

          • Deena Chamlee

            Amy we are not extenders, we are midwives. CNMS and CMS need to be the only pathways because they are the only pathways that can be integrated. It should not be an interprofessional battle.

          • Stacy48918

            I don’t think she means “extenders” in a negative way. OBs simply can’t see all the pregnant women out there. They’re already over-extended. Having a group of highly trained, competent care providers that can manage and deliver low risk patients, allowing OBs to concentrate their time and training on high risk patients improves outcomes for ALL women.

            I think in very similar terms of my support staff (I’m an emergency veterinarian). The more highly trained support staff (LVTs, CVTs, etc) I have the more work we can ALL accomplish and the better, more efficient care I can provide. There are a LOT of things that I am “over-qualified” to do. My nurses/techs should be doing it while I do “doctor” stuff.

            In the obstetrics world, CNMs are even MORE important than that because, in many cases, they can practice independently without an OBs direction or direct involvement.

            “It should not be an interprofessional battle.”
            Where did she say it was?

          • Deena Chamlee

            By implying we are extenders. PAs are extenders, not midwives. And Amy knows I adore her and her work.

          • Rph

            As a pharmacist, I absolutely view midwives as physician extenders (see the less complicated, send the more complicated on, take care of the day to day bread and butter stuff). I don’t see why you would be offended by this, it isn’t an insult but a complement.
            -rph

          • Carrie Looney

            It should be considered a compliment to be considered a complement? 🙂

          • Young CC Prof

            Yes. You win a prize for that one.

          • Carrie Looney

            Wooho!

          • fiftyfifty1

            Being an extender isn’t an insult. As a family physician, a large part of my role is as an extender and an organizer. I’m happy with that. It’s ok to acknowledge the limit of your skills. I’m not lobbying to extend my scope. No patient needs me trying to manage their cancer, psychosis, kidney failure etc. on anything more than a stop-gap extender basis.

          • Deena Chamlee

            Fifty I got booted out and severly abused for standing up against this stuff. So in a sense I really dont care because everything I was indoctrined to believe isnt true. It is just terminology anyway and in the beig scheme of things it doesnt really matter .

          • pinkyrn

            And you are still here. That shows merit. This board can be brutal.

          • Deena Chamlee

            Out of my profession by the hiarchy.

          • pinkyrn

            I am confused, you lost your license? How can CNMs boot you out for not agreeing with NCB ideology?

          • pinkyrn

            Agreed Deena.

          • pinkyrn

            I have seen CNMs first assist in one of the hospitals I did a per diem job in. It seemed to be a good model.

          • Hannah

            The problem is that this isn’t just being applied to third world nations. Obstetric care in a lot of socialised medicine nations is increasingly midwife-led – to the extent that a woman can go through an entire pregnancy and birth and never see an obstetrician. Given that NCB ideology has infiltrated mainstream midwifery in many of these nations for a variety of reasons and the tendency to define *anything* as a variation of normal, this is worrisome.

          • The Bofa, Being of the Sofa

            No, my argument is that midwives are NOT the answer to the most pressing problems in obstetrics.

            How can “experts in normal birth” solve the problems in obstetrics? Are “normal births” resulting in serious problems?

            Remember, the “expert in normal birth” is the midwife mantra, so that’s not a strawman.

          • Elaine

            Maybe more low-risk patients being managed by midwives will free up more OBs to focus on higher risk patients? That’s the only merit I can see to this whole argument. It would work if OBs being spread thin is an issue. I don’t know if it is or not.

          • Young CC Prof

            Oh, definitely some areas even within wealthy countries lack sufficient obstetricians, and midwives can help them cover more patients. As long as the midwives’ goal is improving outcomes, rather that avoiding interventions, that is.

          • The Bofa, Being of the Sofa

            True, by definition, the low-risk pregnancies need the least amount of attention.

          • pettelly

            Then you need to read a bit more. There are many articles which discuss employment prospects in low-income countries for doctors, mainly how to deal with the brain drain to rich countries because doctors in poor countries get such bad money and how to get doctors in to rural areas and out of the cities. No, these aren’t clinical papers.

      • Jenny_from_da_Bloc

        She has never said that midwives need to be done away with, Dr. Amy is advocating for education and licensing standards.
        The fact of the matter is that the statistics are appalling and midwives need to be held accountable for their patients and the babies they deliver. CPMs need to be banned or at the least have education standards and licensing requirements in place to prevent unlicensed practice. It is appalling tha low risk women and babies are dying because these natural birth midwives have something to prove to themselves. Giving birth is dangerous business and midwives should be advocating for their patients and for more access to medical care, interventions and medications to prevent injury and death, not advocating for themselves and natural birth. Natural is not always better and women should not be prevented from accessing real and safe medical care or fed baseless lies based on some midwives personal beliefs.

    • Anj Fabian

      I think that’s exactly what they are saying.

      Use the cheaper midwives to provide more of the basic care.

      The problem is that you need someone skilled in sifting out the high risk and complicated cases from the low risk, uncomplicated cases. For this to work, the mantra would have to be “When in doubt, send the patient out.”. In other words, if you aren’t sure – refer the patient to an OB and have them make the call.

      If you aren’t sure and you continue to treat the patient as an uncomplicated, low risk patient with only the basic tests and monitoring, there will be complications that will be missed.

      • pinkyrn

        I am currently in a program of study for a CNM degree. I do not believe the CNMs are trying to replace OB Docs. There are not enough Ob docs at present to cover all the pregnant women.

        Also a few years ago some regulatory agency mandated that the Interns and residents can only work X amount of hours. So those missing hours in most specialties are being filled by Advanced Practice Nurses. I have asked the floor nurses how they like working with the APNs and whether they thought the patients were safe being covered by someone with out a medical school degree. I was skeptical about a NP covering in an acute care hospital. The floor nurses told me the NPs bring a sense of continuity to the floor and they had not noticed a huge difference in practice other than it was easier for them to get an NP to come down and see the patient.

    • pettelly

      You do realise that the vast majority of births in many low-income countries take place outside of hospital? This is not a choice. Many women live too far from hospitals or can’t afford them or have other barriers to access.

      It’s a question of what improves outcomes the most. Take Niger when 80% of births take place completely unattended by a skilled birth attendant. There’s a huge lack of midwives, obstetricians, nurses – and whatever health care professional you care to mention. $36 is spent per annum per capita on health.

      Just getting midwives with clean birthing kits to women, basic antiobiotics, basic resuscitation kits, magnesium sulphate and other basic meds (I’m talking cheap stuff here) would save lives. It doesn’t happen in the poorest countries. Talking about increasing OBs is almost laughable, who will pay for this exactly?

  • Alexandra

    I’m partway through this excellent article, but have spotted many, many typos. I think an updated, thoroughly edited version would be a good idea.

  • Amy M

    Dr. Amy, can you comment directly at Lancet?