Midwives are wrong to fight fear in childbirth; it’s a lifesaving gift.

True fear is a gift copy

The meme of the moment in UK midwifery is “fight fear.” It is both hypocritical and immoral.

It’s the keystone of today’s piece in The Guardian by an anonymous midwife, I loved being a midwife, but bullying, stress and fear made me resign and at heart of the new book by UK midwives Sheila Byrom and Soo Downe, The Roar Behind the Silence.

I’ve already written about Byrom’s personal hypocrisy in editing a book about kindness, compassion and respect in maternity care, when she is on public record as treating with utter contempt a parent whose baby died at the hands of her colleagues. But the book itself is an example of the hypocrisy that is at the heart of contemporary UK midwifery theory. UK midwives are among the biggest fear-mongers around.

Before we look at what UK midwives mean by “fight fear,” it is worth considering the advice of security consultant Gavin de Becker who wrote the book The Gift of Fear.

True fear is a gift.
Unwarranted fear is a curse.
Learn how to tell the difference.

Or as this post on a Psychology Today blog explains:

Fear is helpful and safety-oriented whereas worry and anxiety are not helpful and related to phantom ‘possible’ events that often don’t happen. To that degree, worry and anxiety are distracting away from real fear signals that could help …

In other words, fear can be extremely beneficial in helping us avoid danger, while anxiety, generally related to possible events that don’t often happen, is harmful and may actually impede our ability to avoid real harm.

Indeed, fear of death (of the baby or mother) in childbirth has been the impetus for the interventions that have saved and continue to save hundreds of thousands of lives each and every year. In contrast, anxiety about interventions, from epidurals to C-sections, ruins the birth experience for many women and puts them and their babies at risk of injury and death.

What do UK midwives want to fight when they say “fight fear”?

Do they want to fight fear of epidurals?

Absolutely not. They encourage women to fear epidurals, wailing, “Drugs!” and emphasizing complications that are in reality less likely to occur than being killed by a lightning strike.

Do they want to fight fear of childbirth interventions?

Absolutely not. They encourage women to fear childbirth interventions by constantly invoking the dreaded “cascade of interventions.”

Do they want to fight fear of C-sections?

Are you kidding? Their efforts to demonize C-sections are notorious, and they don’t consider themselves restricted to the truth. From “C-sections interfere with bonding” (they don’t) to “C-sections change neonatal DNA” (they don’t), to the supposed “crisis” in maternity care represented by a C-section rate over 30%, no one can touch midwives when it comes to inspiring and creating fear.

So what do UK midwives really mean when they claim they want to fight fear?

Here’s what Sheena Byrom and Soo Downe have to say in the section ‘Fear as a driving principle of maternity care design and delivery’:

…For midwives and obstetricians, fear of recrimination, litigation, negative media exposure and loss of livelihood potentially contributes to defensive practice…

Of course, none of these things — recrimination, litigation, negative media exposure and loss of livelihood — occur UNLESS a baby or mother is injured or dies in childbirth.

The fear that UK midwives want to fight is PROTECTIVE fear of death of a mother or baby in childbirth.

They lament:

In maternity services in England, this issue has been exacerbated since the publication of the Mid Staffordshire Trust public enquiry, with a subsequent increase in internal and external service reviews and a fear of bad publicity of imposed special measures.

Why was the Mid Staffordshire inquiry undertaken?

According to The Guardian:

An estimated 400-1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report being published on 6 February 2013 of the public inquiry chaired by Robert Francis QC will be the fifth official report into the scandal since 2009, and Francis’s second into the hospital’s failings.

The often horrifying evidence that has emerged means “Mid Staffs” has become a byword for NHS care at its most negligent. It is often described as the worst hospital care scandal of recent times. In 2009 Sir Ian Kennedy, the chairman of the Healthcare Commission, the regulator of NHS care standards at the time, said it was the most shocking scandal he had investigated.

What did the Mid Staffordshire Trust report (Francis Report) find?

The very first sentence of the Executive Summary lays it out quite plainly:

Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area.

Byrom and Downe don’t lament the hundreds of unnecessary deaths that occurred in “conditions of appalling care.” They don’t even mention the hundreds of people who died unnecessarily, enduring horrific suffering. No, Byrom and Downe lament the extra supervision and scrutiny that were put in place to prevent another similar episode.

Byrom and Downe’s book went to press before the recent publication of the Morecambe Bay Report, often compared to the Mid Staffordshire report, which found that 11 babies and one mother died preventible deaths at the hands of midwives:

[M]idwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… [W]e heard that midwives took over the risk assessment process without in many cases discussing intended care with obstetricians, and we found repeated instances of women inappropriately classified as being at low risk and managed incorrectly. We also heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care…

Why did this happen? Because the midwives did NOT fear the inherent deadly dangers of childbirth. It is this fear that they are fighting.

Toward this end, they recognize no limits in encouraging fear of epidurals, fear of childbirth interventions, fear of C-sections (all of which, not coincidentally, they cannot provide), but they abhor fear of the very real risk of DEATH and serious injury in childbirth (which, not coincidentally, they can’t prevent).

UK midwives’ desire to “fight fear” in childbirth is both grossly hypocritical and stunningly immoral. They want women to fear everything they can’t provide and they want women to ignore the legitimate, protective fear that they or their babies will be injured or die in life threatening emergencies that are all too common in childbirth.

UK midwives are the equivalent of an auto manufacturer touting a car that doesn’t have seat belt, air bags or other safety devices:

It costs less!
Crashes are rare!
Seatbelts interfere with freedom of movement!
Seatbelts could trap you in the event of a car fire!
Fight fear of being killed in a car crash!

Most of us are savvy enough to recognize that such an auto manufacturer would have only its bottom line in mind and would be encouraging anxiety over unlikely possible events while discouraging the protective fear that saves lives by being prepared for a car crash.

Similarly, we should be savvy enough to recognize that UK midwives have only their own benefit in mind when encouraging anxiety over epidurals, interventions and C-section, while discouraging the protective fear of death and injury that saves lives by being prepared for life threatening events in childbirth.

As de Becker said, fear is a gift, unwarranted fear is a curse and everyone must learn how to tell the difference.

UK midwives discourage life saving fear, substitute unwarranted anxieties in its place, and women and babies die because midwives cannot or will not recognize the difference.

  • Jen

    I will admit that I was not afraid of birth, nor was I fearful during either of my labours. That is because as soon as I realised that I was in labour, I got myself to my hospital and settled in to birthing suite with the midwives and my Ob right there with me.

    Can’t wait to do it all again later in the year – with my wonderful Ob there to take care of me!

  • CharlotteB

    I’m so over this “Birth without Fear!” BS that is the mantra for NCB-types. When I was in labor, I was TERRIFIED–the pain was far, far more intense than anything I had imagined, and I’d planned a natural birth! All I could think was that I had to get to the hospital where they could help me. I told my husband later that it was a good thing I hadn’t planned an out-of-hospital birth, because I would have made him take me to the ER because I was that scared.

    Everything was fine–turned out I had precipitous labor. After the first contraction, all I wanted was bright lights, medical professionals, and drugs. I didn’t get the drugs, but once I was at the hospital I knew everything would be ok, because they could take care of me. Who are these midwives to deny a woman’s intuition just because it doesn’t fit their agenda??

  • Kazia

    I posted a while ago about getting a breast reduction at the age of 21. I just wanted to update everyone who supported me. I’m 10 days post op, and feeling fabulous. Other than nausea and vomiting the first few days, my recovery was very smooth. I would still be suffering if I hadn’t read Dr. Amy’s blogs on breastfeeding. I finally understood that while it is beneficial, it is not as great as is claimed.

    • Dr Kitty

      Great news! Here’s to the remainder of your recovery being easy and quick!

    • lawyer jane

      Congratulations!! Not sure if back pain was one of your symptoms, but when you have a baby one day, you will be *very* glad you don’t have to deal with that. I still carry my 35lb chunker around!

      • Kazia

        Yes, I had awful back and neck pain. It’s already better. Not gone, but significantly improved. I suspect I’ll have to go back to physical therapy for my remaining issues, but they shouldn’t take too long to sort out. I haven’t beenkept up from pain since my surgery, and it’s not because of the drugs (I haven’t needed them in over a week).

    • demodocus’ spouse

      Awesome!

    • Amazed

      That’s great! Take care and swift recovery, or what is left of it!

    • Wombat

      Congratulations and I’m so happy your surgery went well. It is something I have seriously considered (and in some ways probably should have done already) so I know where you are coming from to at least some degree.

      Your positive outcome and feelings are so good to hear c: I am sorry I missed the original post, but glad I saw this one!

  • Amazed

    OT (not really). I can’t BELIEVE it! An official body saying that… homebirth is unsafe. Thanks, Dr Grunebaum, Your Holiness, for making it known to me and conducting the study that the Australians took into account.

    http://www.ranzcog.edu.au/documents/doc_view/2051-home-births-c-obs-2.html

    “The Australians seem to have gotten it correctly,” indeed! I love your no nonsense style, Dr Grunebaum.

    http://www.babymed.com/blogs/dramos/australian-college-obgyn-ranzog-against-homebirth

    • Michelle

      Just to clarify though, it’s not the Australian College of OBGYN, the NZ bit in RANZCOG refers to New Zealand in addition and was first put out in 1987 and has been under continuous review since then to include the most up to date information.

      Next Australia will be claiming pineapple lumps thus erasing NZ as a nation again, oh wait, yes, they did that too.

      Interestingly enough, I was doing a bit of research as to why home birth is funded in NZ but not officially encouraged (and wasn’t even mentioned as an option to me when I was pregnant x 3) and it turns out funding is part of the issue, as this is done per capita. NZ has a smaller, much less urbanised population and a significant rural population compared with Australia and other countries and to keep services viable, maternity units providing services are
      funded for a certain level of patients. If too many choose not to
      deliver at the units, this threatens their viability, and the option of
      having no services at all is untenable as there are and will be women that need them.

      “The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does not endorse planned homebirth. Fewer than 1% of deliveries in Australia, and a greater proportion in New Zealand, are planned homebirths.The true incidence of planned homebirth is somewhat difficult to accurately assess, particularly in New Zealand. While supportive of the principle of personal autonomy in decision making, RANZCOG cannot support the practice of planned homebirth due to its inherent risks and the ready availability of safer options
      for labour and delivery in Australia and New Zealand.”

  • Elizabeth Neely

    it is sad how twisted the use of fear has become….

  • The Computer Ate My Nym

    So who is Caroline Flint? I must admit that the name doesn’t ring a bell and google was a little too informative: there are several Caroline Flints including an MP, a midwife possibly responsible for a baby’s death and several MDs. Why was someone who was arguing with you bringing her (whichever her it is) up?

  • Dr Kitty

    So, Midwives are just replacing a Gom Jabbar with the threat of a CS in a weird humanity test where an unmedicated labour takes the place of sticking your hand in a box.

    “I must not fear.
    Fear is the mind-killer.
    Fear is the little-death that brings total obliteration.
    I will face my fear.
    I will permit it to pass over me and through me.
    And when it has gone past I will turn the inner eye to see its path.
    Where the fear has gone there will be nothing.
    Only I will remain.”

    Apologies for the Dune reference.

    • Amazed

      They sure fight their fear. They fear that they’re inferior to doctors and their way is to take insult when called mid-level providers. Yes, I saw the poster’s reply to you in the Guardian. You know, if wifey takes such offense at being called a mid-level provider, perhaps wifey should have graduated from a problem giving her the right to be a high-level provider.

      • Dr Kitty

        🙂

        Guardian commenters are a special bunch.

        GROLIES is one of those medical acronyms like FLK that you don’t see on notes anymore, but was developed because it was useful.
        Guardian reader of low intelligence in ethnic skirt.

        • Joy

          Or NFN. If you are from my area of England.

      • Sarah

        I just don’t understand that attitude. Mid level providers are important, hugely so. Providing care to women experiencing straightforward births, understanding when more is needed and taking steps to ensure a patient gets it, looking after them once baby is born, providing support with feeding, visiting postpartum women at home- this is honourable, vital work. It doesn’t need to be defined in relation to anything else.

        • Amazed

          Which attitude? Mine or theirs? I do not degrade the importance of being a mid-level providers, they do by taking insult at being called so.

          I suppose you could say I am a mid-level professional in the writing world. I am a translator. I feel that my work is very important – but I am not an author and I usually take the time to explain it to those who think that I am “the second author of the book”. I am not. And it’s important that I recognize it because it’s so easy to slip and make changes – minor ones, just a touch here and there – that suit the way *I* think the book will be better. You know, the person who *didn’t* write the book.

          Midwives don’t seem to think that their scope is important enough, that’s why they encroach on doctors’ scope.

          • Sarah

            Theirs.

    • Medwife

      Never apologize for a Dune reference.

      Weird though, I’ve said “the litany” to myself many times! I always thought of it as not letting fear freeze me up and render me useless. You have to listen to what your fear is telling you but not be paralyzed by it. Shoulder dystocias for instance are scary as hell but you have to take away that emotional response, so as not to be a blubbering idiot. You just face it, drill for it, and when it happens, you do what you need to do.

  • JJ

    YES! The Psychology Today quote is right on as well. The homebirth/altmed communities make me angry because they cater to anxieties. They made me terrified of epidurals/C-sections and vax when I should have been afraid of death and disease! It’s like opposite day everyday with them. In the warped world of NCB a c-section, not death, is the worst thing that can happen! What I needed was help getting over my anxieties of needles and medical practices in general. Instead I was told that homebirth would protect me when in truth it was endangering me and my baby even more!

    Plus, I suffered in multiple ways needlessly just to endanger ourselves more. I really needed an epidural with my first. Hours of feeling like my back was being crushed by an 8 1/2 pound posterior baby while I scream in my living room. (So much for a peaceful birth). Then my 3rd pregnancy where I developed an unrelenting cough for my last month of pregnancy and was given a herbal blend to take. I was coughing so hard that I would cry from the pain and I had a rib on each side that I could move around (I think they dislocated). I could not sleep either because of pain in my ribs and coughing! For my 9th month! Now I know I could have had cough medicine and a strong pain reliever instead if some unregulated ineffective herb syrup!!! All just to make my pregnancy and birth closer a 3rd world one. Yes, I am angry.

    My former midwife recently posted on facebook that basically said don’t listen to anyone who makes you afraid of birth and your body is not trying to kill you. Well that is magical thinking and my body/nature has no feelings for me. I should have a healthy fear of something going wrong in childbirth so I can make good choices to help keep myself/baby safer. Thank God I escaped the woo with the help of a therapist and blogs like these. Now I am able to work through what is a healthy fear and what is just anxiety. Thanks again Dr. Amy for spreading awareness of these dangerous ideologies.

    • nomofear

      Amen, same here. Well, you suffered worse than I did. At least I only had PUPP in the last few weeks with my first pregnancy, and then a quick delivery (though, with pain meds, three hours of pushing could have been shortened significantly). I’m so glad I found this, and other, sources of reason during this second pregnancy.

  • FrequentFlyer

    I guess I’m just not as smart as the NCBers. Here I was thinking that if a person was in a painful and/or dangerous situation fighting the pain or danger woold have the amazing side effect of fighting the fear. I never realized that fighting the fear alone was the key to a perfect outcome. Dumb me. I’m so ashamed.

    • Well you see, fear and ignorance is what causes pain. By understanding what happens during each phase of labor, you know what’s going on and therefore aren’t afraid.

      Which is why only stupids whinge about things like “broken legs” or “glass embedded in faces after crashing through a windshield”.

      • FrequentFlyer

        Yes, I understand now. I have to find some way to atone fo my csections and for the terrble ordeal we put Younger Son through when his arm was broken. Instead of explaining that a broken bone was a perfectly normal part of life and would be fine if we let nature take its course, I gave in to the fear and took him to the ER. T hat was followed by visits to an orthopedist(the horror) and weeks in an uncomfortable cast. What was I thinking?:p

        • There’s a very easy way to fix this!

          Just have another child, the normal way of course, break his arm, then proceed to medically neglect him. Kids are just props for this parenthood thing anyway, it’s super easy to make new ones.

          • FrequentFlyer

            Great advice, but the baby factory is closed!

      • Hannah

        Husband and I were at the British Museum yesterday; in the Egyptian mummy room, they had various bones on display showing various health problems; one was a leg fracture that hadn’t healed properly. It looked seriously painful, even to my untrained eye. It was like… the two pieces had overlapped and fused together. All I could think was how much that must have HURT. But of course, I don’t trust nature, so that’s my own fault.

        • Oh shit, ancient Mesopotamia is my JAM.

          They did use painkillers though, including opium, which makes me want to birth in ancient Egypt more than with the average under-qualified midwife.

          • Sarah

            And they had Tawaret.

  • The Computer Ate My Nym

    Semi off topic rant about medicine in general…

    I don’t like this trend towards having less well trained caregivers provide care. Taking OB care as an example: OB care is getting more complicated. We have more high risk women getting pregnant than ever. Part of it is that more women are having children in their 30s and 40s than before. That makes for high risk pregnancies, especially when it’s a first pregnancy. Part of it is that we’ve got more people surviving childhood illness and growing up to want to have families like everyone else. That’s great, but a woman who survived Hodgkin’s disease or neuroblastoma as a child or who has sickle cell disease or type III von Willebrand’s is going to be high risk. And then there’s the woman who survived a previous pregnancy complicated by eclampsia, gestational diabetes, severe pregnancy related thrombocytopenia, and a post-partum PE. We used to tell women like that “just don’t get pregnant again” (if they were lucky enough to survive the first time). Now we don’t even always tell them it’s dangerous.

    So, we’ve got more sick women getting pregnant and pregnant women getting sick. So what do we do? We (as a society) start hiring or encouraging women to hire less well educated providers to care for them. A CNM is a good option for a woman with an uncompliated pregnancy, but a woman like the one I mentioned above (not a real patient but, well, I’ve seen close enough…including the thrombocytopenia and PE: yes, they can occur together) needs a high risk OB, hematologist, endocrinologist, and a GP to organize it all and watch out for the organs no one else is paying attention to! But she might well end up with a midwife. Because she doesn’t have insurance and can’t afford real medical care. Because the NHS doesn’t want to bother paying for a lot of OBs and calls her “low risk” for “cost-containment”. Because she believes the NCB movement when they say that all her problems are due to the “cascade of interventions”.

    It’s not limited to OB. From hospitals trying to provide ICU care with essentially unsupervised NPs (nothing against NPs and PAs, but their scope is limited for a reason) to GPs in remote areas struggling to figure out how to give chemotherapy to patients who just flat out can’t get to a specialist, there’s a problem throughout medicine with people not getting the best care they can.

    We’ve simply got to admit that medicine is what we need to spend money on right now. It’s a growing industry. Ok, so we spend more now on medicine now than we did in 1990. We spend more on cell phones too and no one talks about the “cell phone crisis” (well, at least not in the economic sense). The money is there, it just has to be extracted from the pockets of the wealthy who are sitting on it without using it to add anything to the economy. Medicine is a people heavy field and spending more on medicine means more people employed, more people living longer and healthier lives, more people who can keep giving to society and the economy. It’s where the money needs to be spent right now. Forget trying to get care on the cheap, spend whatever is needed to get well educated people into the right positions and make it possible for them to work there.

    Ok. I’ll settle down now.

    • Ash

      Write and ask your local US elected officials to propose increases in the federal funding allocated towards medical residencies…and watch your request be ignored! ;P

      • The Computer Ate My Nym

        Heh. Yep. They won’t listen until it inconveniences them.

    • Guest

      But if you look at statistics, CNMs have better outcomes for low-risk women than OBs.

      • The Computer Ate My Nym

        I’m not sure that a direct comparison of patients with the same risk level has ever really been done. Do you have some data to the contrary? I’d like to see it.

        • Guest

          Sure! I am doing some work/school things, but I can grab it for you later today/tomorrow if that is ok? I’m not bashing medicine by any means. I have a ton of respect for doctors, and a healthy respect of what midwives (in hospital) can and cannot do for patients. I believe the data was from the CDC. There was even an article (maybe it was babymed?) that showed a comparison chart of providers and location for an article about HB, and it very clearly showed CNMs/CMs had the lowest mortality rates.

          Also, I want to point out that in the hospital many CNMs/CMs do induce, augment, order epis, and even first assist. They aren’t scaring patients away from these things because they can’t do them. In fact, most of the ones I know aren’t scaring them away at all. I also feel like OBs have become less specialized. The truly high risk seems to go to MFMs, fertility is referred out to specialists, same with oncology. You don’t see forceps much any more, nor vaginal twins or breech (which is a good skill to have IMO).

          • Amazed

            Is there a clarification that those were patients who actually ended up delivering with a CNM? Because in the hospital, when complication arise, CNMs usually call the obstetricians in and transfer care, as they should, so the result, good or bad, goes into the obstetrician’s stats.

            You don’t see forceps much anymore because c-section is now much safer than it used to be. Same with breech and twins. I feel no grief because an unsafer practice has fallen out of favour to a new, safer one. I do think that it’s a good thing to be trained in vaginal breech delivery, for one, just in case a c-section isn’t possible. But I really cannot see why women wouldn’t say, “Screw your getting practice, I am here to choose wisely for me and my baby, not be your school project as you better youself.”

            I think it’s meaningful that so many women choose the safer option. For the doctor, it might be one vaginal breech birth out of 500; for the woman, it would be the vaginal breech of her own baby. One of… certainly not 500. Given the fact that she’s the one who’ll live with the consequences, it’s no wonder that she goes for safer.

          • Medwife

            I don’t think it was organized by intent to treat. So yeah, then, obviously our outcomes would be better (assuming appropriate consultation and referral). If things are happening that increase odds of a bad outcome, an OB takes over.

            I refuse to take credit away from our wonderful back-ups.

          • EmbraceYourInnerCrone

            I think you might be thinking of the study mentioned here: http://www.medscape.com/viewarticle/823091
            Except the numbers they are comparing are all births NOT just low risk.
            From the article:
            “The total neonatal mortality risk was significantly higher for babies delivered at home by midwives compared with those delivered by hospital midwives (1.26/1000 births; risk ratio [RR], 3.87 vs 0.32 per 1000 births; P < .001).
            The risk for infants delivered by physicians in the hospital was higher than for those delivered by hospital midwives but lower than for home midwife births (0.55/1000 births; RR, 1.69).

            The risk for infants delivered by physicians in the hospital was higher than for those delivered by hospital midwives but much lower than for home midwife births (0.29/1000; RR, 2.04)."

            "The higher neonatal mortality rate for hospital physicians when compared to hospital midwives almost certainly reflects the fact that hospital physicians deliver a higher-risk population than hospital midwives and deliver patients with complications transferred from the hospital midwifery service to the hospital physician service," the authors write.

          • Insider

            Guest, you wrote: “CNMs have better outcomes for low-risk women than OBs…. I believe the data was from the CDC. There was even an article (maybe it was babymed?) that showed a comparison chart of providers and location for an article about HB, and it very clearly showed CNMs/CMs had the lowest mortality rates.”

            You may be referring to this babymed.com article:

            http://www.babymed.com/blogs/lana-muniz/safer-home-birth-requires-educated-regulated-midwives

            As you say, the article is about homebirth, uses CDC data, and includes a chart that compares outcomes according to provider and location. However, the provider comparison is between CNMs and “other midwives,” not between CNMs/CMs and OBs.

            The CDC data show the following:

            * Birth attended by “other midwives” is 3-4 times more deadly than birth with a hospital midwife.

            * CNM-attended birth at home is 2.5 times more deadly than a CNM birth-center birth.

            * CNM-attended birth at home is just as risky as birth with “other midwives” (home or birth center).

            * All of these groups had worse outcomes than birth attended by midwives in hospitals.

            The article does not consider OB-attended birth.

            The article goes on to note that, compared to CNMs, “other midwives” lack education and regulation.

      • The Computer Ate My Nym

        In any case, I agree that CNMs practicing within their area of expertise and with appropriate backup can be excellent practitioners. I had a CNM attend my kiddo’s birth–up to the point where things went wrong and she promptly and appropriately called in the OB. What I object to is the expansion of the role of the CNM and especially non-CNM midwives to areas where they are not qualified. This might happen either at the midwives’ instigation because they want to take on more patients or as a cost cutting measure by the NHS, insurance companies, etc. Often it’s some combination of both: the midwives start pushing for a larger role and the insurance companies see this as a way to cut costs and push with them.

        Again, I used OB as an example, but it’s by no means the only area of medicine where less experienced or trained practitioners are being asked to take on more and more complicated patients. And that’s just not good practice.

    • Liz Leyden

      That will only work when facilities start hiring adequate staff.

  • Amy Tuteur, MD

    Miwives are the guardians of normal birth; obstetricians are the guardians of safe birth.

    • Who?

      How about a small refinement:

      Midwives are the guardians of natural birth; obstetricians are the guardians of safe birth.

  • lawyer jane

    That Guardian piece by the anonymous midwife is sort of incoherent. The example she gives of the birth ending in a c-section seems to suggest that the mother needed more intervention, the attention of an OB, and better standards for how to assess fetal heart tracings. But then at the end she suggests that the problem is that midwives are not free to protect “normal” birth. Which is it? And the part about the stillbirth is sad, but seems unconnected to the overall point of risk management etc, unless again, there was a problem prenatally that did not get detected, or it could have been prevented by an earlier induction? Ultimately it is unclear what she thinks the problem is in maternity care, except for that she doesn’t like the fact that people have to “tick boxes.”

    • lawyer jane

      Or what the Computer Ate My Nym already said 🙂

    • Dr Kitty

      I loved that the only hypothetical Dr she could find was a male GP trainee (over 70% of GP trainees are female) who was there to “tick boxes”…but it was somehow his fault that the strip didn’t improve and the birth didn’t go normally….

      I think the whole thing can be summed up as “I really just wanted to be at normal uncomplicated, straightforward natural births, and real life isn’t like that.”

      If she thinks SHE has too much paperwork, when she’ll be spending 8-12hrs with just 2 or 3 patients, she should come and do my job.

      Did you know that in the UK the council needs a letter from your GP to say that you are too frail to take your own rubbish bin to the kerb and need the bin men to take it out for you?
      Even if said bin men can see that you are a wheelchair bound nonagenarian with their own eyes?

      Medical reports for life insurance/job application/driver’s licence/mortgage…
      letters to say you can take your insulin in your hand luggage when you fly…
      letters to say you should be able to cancel your gym membership because you broke your leg in six places…
      letters to say your child’s teacher can administer their inhaler in the event of an emergency…
      letters to ask for extra time or special consideration in an exam because you have dyslexia or your granny died…
      letters saying your’re really stressed sleeping on your sister’s sofa and could the council find you a flat faster…
      letters to say your paranoid schizophrenia makes jury duty impossible…

      The answer to many of life’s problems appears to be “get a letter from your GP”.

      I can charge for the letters, but I’m doing it on my own time (because my working day is actually already filled to the brim doing actual medical stuff).

      • The Computer Ate My Nym

        I wonder what she says when the GP does say, “Yep, that strip looks bad. We need to move the patient to the high risk side and have an OB take over.”? Does she accept it with a “yay! the patient is being taken care of!” or does she argue that the strip isn’t really “that bad” and doctors just want to take over everything?

        • Hannah

          “I wonder what she says when the GP does say, “Yep, that strip looks bad.
          We need to move the patient to the high risk side and have an OB take
          over.”? Does she accept it with a “yay! the patient is being taken care
          of!” or does she argue that the strip isn’t really “that bad” and
          doctors just want to take over everything?”

          My impression was that she was already in a mixed risk setting. The “SHOs” referred to stand for Senior House Officer (although technichally I think they’re called something different now), and are one of the most junior grades of hospital doctor. The fact that they’re referred to as GP trainees just means that they’re on the GP training track, and on rotation to Obs/Gynae, rather than on the Obs/Gyn training track.

      • Joy

        My office now has a counselling system so if you get too high a score on the absence system you MUST go speak with someone. Get the flu and then sprain your ankle? Off to the counsellor. Have bad morning sickness? Off to the counsellor. It is such a waste of time and money for 99.9% of people at my office.

  • Mel

    When I taught, fear helped me protect myself and my students when a new student turned out to have a violent temper.
    When working with cattle, fear helps me get the hell out of the way before I get hurt.
    Caroline Lovell was afraid she was dying after her baby was born. Her midwife worked at easing her fear. Since Ms. Lovell was bleeding to death, her fear was very reasonable and if her midwife had heeded that fear, she’d still be alive today.

  • Michele

    Dr. Amy – typo – “It’s the keyston of today’s piece in The Guardian by an anonymous midwife” I think you mean keystone

    • Amy Tuteur, MD

      Thanks!

  • Bugsy

    Completely off-topic: a humorous take on the all-natural crowd: http://www.nwedible.com/tragedy-healthy-eater/

    • namaste863

      Priceless! Thanks for the best laugh I’ve had in a while.

  • NoLongerCrunching

    The second I saw the title of the post I thought of Gavin de Becker. His books are gamechanging IMO.

    • Daleth

      I’ve met two people who told me that that book saved their lives. So yeah… it’s hard to be more game changing than that.

  • dbistola

    Great article, Dr. Amy. I think this would be a nice addition to Sheila Byrom’s review page on Amazon, because it quotes portions of the book itself. I also love the way you tied in The Gift of Fear. This book is a gold medal standard when assessing anxiety, fears and risks.

  • The Computer Ate My Nym

    Automobile manufacturers did try to stop mandatory air bags–successfully–in the 1970s using much the same arguments as Dr. Tuteur described for the hypothetical case above: promoting fear of them (they might go off accidentally), making the case for “autonomy” (big government interfering in your car choices), etc. People are disturbingly convincable.

  • SporkParade

    My theory is still that natural childbirth advocates are so petrified at the danger and pain of childbirth that the only way they know how to deal with it is by brainwashing themselves to believe that birth isn’t dangerous or painful at all.

    • JJ

      Yes I agree. The brainwashing technique is called “birth affirmations”.

      Ex: “My body can safely birth” or “My body knows how to grow a healthy baby”. Calling contractions things like waves and surges.

      • Liz Leyden

        If your body doesn’t grow a healthy baby, is it a personal failure?

        • SporkParade

          Yes, if all the women on my What to Expect board who talked about feeling guilty that they needed C-sections are anything to go by.

        • Medwife

          Sure, just like if your ovaries go into menopause 40 years to soon, it’s judgmental to say “primary ovarian failure”. It makes women feel judged apparently. I’m sorry but why should I take what my ovaries do as a personal judgment? They’re ovaries. I’m not the boss of them.

  • SuperGDZ
    • Amy Tuteur, MD

      I didn’t see it until after I wrote this piece, but I just edited the piece ot includ it.

      • SuperGDZ

        Whew, that’s a relief. When I came back to this page and saw that you’d linked directly to it, thought I was going mad.

    • The Computer Ate My Nym

      That piece confused me. The midwife kept talking about being the “guardian of normal birth” but her first example of why she was stressed was about being certain that something was off and not getting enough backup in investigating the impression. That’s not about not being able to have a normal birth, it’s about a birth getting complicated. I’m not sure what a strip that is “bad but not bad enough to act on” is, since I’d think that at the first sign of trouble at the very least the case would move to OB. The second example was one that would stress anyone but I don’t see what she was expecting to be done differently by that point. Frankly, it sounded like what she really wanted (know it or not) was a higher tech environment with more support, not more “normal birth”. And less paperwork, because who doesn’t want less paperwork, but that’s an unsolved problem as far as I know.

      • SuperGDZ

        She wanted it to all be nice, but it wasn’t. It turned out to be hard, and sad, and scary, and she hated the risk management structures that were put in place precisely for that reason because they wouldn’t let her forget that it wasn’t all sunshine and unicorns.

    • Ash

      The entire “Day in the Life of…” series is pretty neat if you look at the other articles.

      http://www.theguardian.com/healthcare-network/series/day-in-the-life-of

  • Allie P

    Who has read The Gift of Fear? Love that book. Fear should be respected.

    • NoLongerCrunching

      Also “Protecting the Gift,” about listening to your gut when it comes to your children.