Midwives are the guardians of normal birth; obstetricians are the guardians of mothers’ and babies’ lives.


Midwives love to claim they are the “guardians of normal birth.”

Type “guardians of normal birth” into Google and you get page after page of midwives declaring their commitment to a specific vision of birth.

I’m not sure why they’re boasting because it’s actually an unwitting indictment of the moral rot at the heart of contemporary midwifery theory. It highlights the difference in ethics between midwives and obstetricians. Midwives are the “guardians of normal birth,” while obstetrians are the guardians of the health and lives of mothers and babies.

It is fundamentally unethical for any health provider to pose as a guardian of a procedure. It would be wrong for a surgeon to pose as a guardian of appendectomy; it would call into question his or her ability to successfully and ethically treat abdominal pain when he had a clear bias toward removing appendices. It wouldn’t matter if the surgeon claimed to believe that appendectomy was the appropriate treatment for abdominal pain, and we would quite rightly suspect that the surgeon has his own self-interest (the surgical fee, the opportunity to hone skills, the enjoyment of performing surgery) at heart.

Similarly, if a dermatologist claimed that she was a guardian of Botox, it would call into question his her ability to recommend appropriate treatment for her patients. It wouldn’t matter if the dermatologist claimed to believe that every patient could benefit from an injection of Botox. We would quite rightly suspect that the dermatologist had her own self-interest (her fee, gifts from the drug company, opportunity to serve as a paid consultant for Botox)at heart.

When a midwife claims to be a guardian of normal birth, it calls into question her ability to successfully and ethically care for pregnant women. It doesn’t matter if the midwife claims to believe that normal birth is beneficial for nearly every women. We would quite rightly suspect that she had her own self-interest (her fee, professional autonomy, the enjoyment of assisting an unmedicated vaginal delivery) at heart.

Obstetricians, in contrast, are the guardians of the health and lives of mothers and babies. Their commitment is to the patients they treat, not to a particular method of treatment. Their commitment is to delivering healthy babies to healthy mothers, regardless of what it takes to make that happen. Their commitment is to people, not process.

Over the past few decades we have come to understand the pernicious influence that outside forces can exert on providers. Even something as simple and trivial as small gifts to doctors from pharmaceutical companies can affect a doctor’s choice of therapy (which is why pharmaceutical companies engage in the practice in the first place). Ideology is a far more powerful source of influence than pens and calendars. It, too, can sway a provider’s judgment to use decision making criteria other than the best interest of the patient. That’s why ideology has no place in medical care.

The central questions in caring for pregnant women should be: how can I help each individual women to remain healthy during pregnancy and childbirth and what can I do to ensure the health of her baby?

Midwives, as guardians of normal birth, view the central question as: what can I do to make this woman’s birth conform to my ideal of unmedicated vaginal delivery?

Not surprisingly the different approaches lead to different responses in the event of complications. Since the obstetrician is committed to health, complications are acknowledged, treatments instituted based on specific circumstances, with all options avaiable to achieve the desired outcome.

Midwives’ commitment to unmedicated vaginal birth means that complications are more likely to be ignored or denied (a “variation of normal). Treatment options are rated by whether or not they are compatible with normal birth, not based on their likelihood of ensuring the health of mothers and babies. A particularly distasteful consequence of privileging unmedicated vaginal birth is that failure to achieve a live baby is often unacknowledged, dismissed with the callous words “some babies are meant to die.” Instead of investigation, root cause analysis and questioning of the approach taken, midwives committed to normal birth may supress investigations and root cause analysis and to ban questioning of the approach taken since that would call the commitment to normal birth into question, which is intolerable.

Midwives need to take a long hard look at the moral rot of a philosophy that privileges birth process over healthy mothers and healthy babies. Rather than patting themselves on the back for being guardians of normal birth, they should be embarrassed to be caught out promoting a philosophy that places how a baby is born on an equal or greater footing than whether that baby lives or dies.