Midwifery philosophy is failing

Fail Exam Grade

Midwives are so buy congratulating themselves and each other that they’ve failed to notice that their philosophy of birth is being rejected.

The latest example comes from a Stanford study. Despite decades of midwifery demonization of pain relief in labor, the US epidural rate has … risen.

Midwifery philosophy has had essentially no impact on childbirth metrics.

“We were blown away,” said Alexander Butwick, MD, an associate professor of anesthesiology. “We were really surprised the rates were so high.”

Seventy-one percent of pregnant women get epidurals or other spinal anesthesia, according to the study, which appears online in Anesthesiology. That’s an increase of 10 percent from 2008, according to the researchers…

“There’s a lot of misinformation available online that is more likely to suggest epidurals may not be great,” Butwick told me. “And yet, here we are. The rates have gone up, for whatever reason.”

The sine qua non of contemporary midwifery philosophy is cult like obsession with unmedicated vaginal childbirth. There are two main reasons for this: the naturalistic fallacy and the promotion of midwifery itself.

The naturalistic fallacy is based on the erroneous belief that if something was a certain way in nature, that’s the way it ought to be. Couple that with basic ignorance of the inherent dangers of childbirth — astronomical rates of perinatal and maternal mortality — and you end up with the bizarre injunction to “trust” birth.

The promotion of midwifery has led to the demonization of anything that takes childbirth out of control of a midwife.

There is nothing natural about checking blood pressure, listening to the fetal heart with a Doppler or recommending chiropractic. Some midwives recommend herbs or over the counter medications like castor oil to stimulate labor and prevent a term pregnancy from extending into a higher risk postdates pregnancy. But as anthropologist Margaret MacDonald explained The cultural evolution of natural birth:

[If an intervention] can bring back the clinical normalcy of the labour pattern and keep it within the midwifery scope of practice, it is generally regarded as a good thing by midwives …

Toward these dual ends — glorifying nature and discouraging anything midwives cannot do — midwives have routinely demonized childbirth “interventions,” reserving particular opprobrium for epidurals and C-sections.

How’s that working out?

In addition to the epidural rate rising by 10% since 2008, there has been no change in the C-section rate, the induction rate reached an all time high in 2010 (23.8%) and has declined only slightly since then. Furthermore, mounting data indicates that labor induction at 39 weeks offers the best outcomes for babies and mothers and actually reduces the C-section rate.

Childbirth care in the US is a doctor led system, but the trend is similar in countries with midwife led care.

The Canadian C-section rate rose from 26.7% in 2007-2008 to 28.2% in 2016-2017.

In the United Kingdom induction rates increased from 20.3 per cent in 2006-07 to 29.4 per cent in 2016-17 and the cesarean rate rose to 27.8%. In addition, the Royal College of Midwives was forced to shutter its Campaign for Normal Birth as a result of multiple midwifery scandals involving high rates of death among babies and mothers and massive increases in maternity liability payments.

The Australian C-section rate at 33% is higher even than the US rate and has increased from 30.9% in 2007.

The one exception is the Netherlands. The low Dutch C-section rate decreased from 16.7% in 2010 to 15.9% in 2015.

Arguably the issue nearest and dearest to the hearts of midwives is homebirth since that is the setting that affords them the greatest autonomy. But despite efforts to promote homebirth, sometimes backed by the government, the results have been dismal.

In the US, the rate of planned homebirth has been rising but still represents less than 1% of planned births.

In the UK the homebirth rate dropped from 2.3% in 2012- 2015 to 2.1 in 2016.

Australia’s rate of planned homebirth is only 0.4%.

The homebirth rate in the Netherlands has continued to plummet falling from nearly 30% in 2006 to only 13% in 2015. The dramatic decline was attributed to more women wanting access to pain relief and to greater publicity of the relatively high Dutch perinatal death rates.

There appears to be only one area in which midwifery philosophy has been relatively successful and that’s its penetration into mainstream media and social media. There is a plethora of mainstream media articles bemoaning high C-section and intervention rates; there are countless books extolling midwifery philosophy, and the Twitterverse in particular is filled with midwifery advocates routinely exchanging tweets involving dozens of midwives congratulating themselves.

Midwifery conferences reinforce this sense of professional success. Midwifery has become an echo chamber; midwives rarely venture outside of it to engage with their colleagues in obstetrics or any childbearing women who don’t already share their high opinion of themselves.

But the numbers don’t lie. Midwifery philosophy has had essentially no impact on anything beyond paying lip service to it. Intervention rates continue to rise; scientific data and rising liability payments continue to demonstrate the deadly outcomes of trusting birth; and women ignore the injunctions closest to midwives’ hearts — continuing to choose epidurals in rising numbers and rejecting planned homebirth.

While it can be infuriating to watch midwives on social media congratulating each other for propounding a philosophy that harms mothers and babies the reality is that they are so busy patting themselves on the back that they’ve failed to notice that most people have stopped paying attention to them.

  • mabelcruet

    I would just like to say Milli Hill is a malignant pustule on Satan’s left bollock. Thank you.

    • namaste

      I am SO stealing that phrase!

      • mabelcruet

        You’re very welcome!

        What do you call Milli Hill and Sheena Byrom holding hands?

        A synapse…

  • aurora

    No offense Mr. Butwick, but how are you blown away? Let’s see you sign up to pass a kidney stone the size of a grapefruit through your urethra without any pain meds…

    • EmbraceYourInnerCrone

      I always liked what Carol Burnett had to say about how labor pains felt: Ok , now take your lower lip, and pull it up over your head.

    • Russell Jones

      For real. Would he also be “blown away” to hear that most people would prefer to avoid sliding bare-assed down 100 feet of coarse-grained sandpaper into a barrel of salt?

      In any event, seeing that the midwifery propaganda is having such a severely limited effect is much needed good news in a week filed with horrible news.

    • Sue

      I thought the same. How could anyone be surprised that women want access to safe and effective pain relief?

  • MaineJen

    “We were blown away,” said Alexander Butwick, MD, an associate professor of anesthesiology. “We were really surprised the rates were so high…The rates have gone up, for whatever reason.”

    Is…is he joking? He DOESN’T KNOW why many women get epidurals?

    How about: because it’s a very effective form of pain relief, and it allows you to remain completely awake and alert during the birth of your child? Did this not occur to him? Has he witnessed an actual birth before?

    Pain sucks. Pain relief is good. Why do we need more of an explanation than that?

    • AnnaPDE

      You’d think that as a professor of friggin’ anaesthesiology he’d be across this whole “let’s avoid pain” thing, but clearly he missed this tiny irrelevant detail completely unrelated to his area of expertise.

      • EmbraceYourInnerCrone

        But, it’s a Natural pain and so you don’t need medication for it, and women are “designed” to go through childbirth so how could it be painful enough to warrant anesthesia? /snark

        Unfortunately there are also people who think painful periods are also “natural” and nothing that one should need pain killers or The Pill to control. Yeah try being 14 and having periods that last a week and are so painful you can’t straighten up but you have to go to school. Good times…

      • PeggySue

        Or, he doesn’t look at the services he’s billing for.

    • Russell Jones

      Dudebro’s either willfully ignorant or he’s lying through his teeth.

    • mabelcruet

      I reckon he didn’t bother speaking to pregnant women while he was in the planning stages of designing his project, and only spoke to midwives. And the midwives told him ‘women don’t want epidurals, women feel surges, not pain, women don’t want medicalised birth,’ and he swallowed those lies wholesale. It’s either that, or he’s an idiot.

  • mabelcruet

    Fairly typical of midwife propaganda.

    https://www.midwifery.org.uk/news/agnes-gereb-sentenced-to-two-years-in-prison-for-attending-home-births/

    Agnes Gereb started out as an obstetrician-her license was revoked because of the death of a newborn, and then she was charged with manslaughter after a homebirth death that she presided over. She now works as a midwife, but was charged with malpractice and sentenced in a criminal court, but the Midwives like Byrom are now crowing over the fact that she has been granted clemency by the Hungarian president. The way the midwives are spinning it, she was sentenced merely for attending home deliveries, with no mention of the babies who died or were damaged under her care.

    • Anna

      The babies and their families are not even a consideration. Sometimes the parents are so brainwashed they absolve their caregivers of negligence.

  • I think it’s very important to differentiate between the midwife who is also a nurse, in effect an advanced practitioner, working as part of a team of specialists, and the midwife who is essentially a minimally trained or untrained maverick who is accountable to no one and works alone. It’s unfortunate we share the same name, which is one reason why I don’t mind being called a “medwife” at all.

    • LaMont

      That is definitely true, but when you see the stuff with proper CNM organizations slamming doctors and talking about how it’s their job to prevent doctors or epidurals from getting close to patients, as a layperson it makes me absolutely terrified and baffled. Having any non-OB involved seems like a good chance of setting an obstacle between yourself and lifesaving care/pain relief. (I mean, as an American woman, getting pregnant in our looming post-Roe landscape will be like playing Russian roulette anyway, so small potatoes I guess…)

      • EllenL

        Very well put! Even when midwives have the best education available, a philosophy of non-intervention often trumps good practice. That puts women and babies at risk.

        • I never felt threatened or discriminated against when it became obvious that the state of the laboring woman required [according to the legal parameters of practice for midwives] to hand over the case to an OB. We then worked together for the woman’s best interests.

          Today, it seems as if [at least] some midwives feel their autonomy is threatened unless they are in total control, and their relationships with doctors are confrontational, not collaborative. That’s sad.

          • Amy Tuteur, MD

            And dangerous!

      • It boils down to creation of universal [that is, Federal] licensing and education curricula, legal standards of practice, oversight, and supervision.

        In the 70s, when I was in the UK, that’s what we had. The Central Midwives’ Board published a little book we had to memorize, which clearly stated our parameters of practice. Licensing was dependent on both written and oral examination, the presentation of our birth registers [keeping one was a legal requirement], and completion of an accredited midwifery course. Only registered nurses could apply to do the course. The result was a highly professional and well-educated midwife who worked [i]in conjunction with [/i] doctors and other health professionals, both in and out of hospital.

        Alas, the NHS midwifery reputation has been sadly tarnished in recent years. But I saw the system at its best, and that was very good indeed.

        • maidmarian555

          My Community Midwife for #2 had returned part-time after previously retiring and she was definitely of that old-school. She was also by a country mile the best midwife I came into contact with through two pregnancies and births. Super supportive, honest and kind. I really, really liked her. She also made me feel safe because she was clearly competent and knew her stuff. I can’t tell you what a relief it was to have someone responsible for my care after all the crap I had with my first child. It made a huge difference.

    • Anna

      I think its time for “medwife” to be a label worn with pride. No matter how much midwives want it we are never going back to the 50s and high rates of perinatal mortality. Embrace the futre or step aside I say!

  • Glia

    We were blown away,” said Alexander Butwick, MD, an associate professor of anesthesiology. “We were really surprised the rates were so high.

    Sorry, but that is hilarious.

    “After surgery, most people want drugs to decrease their pain, so weird!”

    “Oh my goodness, when people have broken bones, they almost always want pain relief!”

    “We are seeing evidence that people prefer not being in pain to being in pain–how can we explain this incredible phenomenon???”

    • MaineJen

      This was my reaction as well. “Oh my goodness, women do NOT want to suffer in incredible pain when there is effective relief available! I am shocked!” Forgive me, but this strikes me as a hilariously *male* response.

      • Steph858

        I don’t see why men should be surprised at this either. I mean, it’s not like there are women out there who express shock when men want anaesthesia for their vasectomies. You don’t need to experience childbirth yourself to be able to understand that it’s a very painful experience, any more than you need to break a bone to know that broken bones *hurt*. Almost everyone winces when they view pictures of visible injuries because, even if they’ve never suffered such injuries themselves, they know that those injuries must hurt and the wincing reaction is a result of experiencing a kind of ’empathetic pain’.

  • mabelcruet

    Another horrible case coming through the courts.

    https://www.telegraph.co.uk/news/2018/06/28/parents-suing-nhs-newborn-suffocated-breast-feed-due-negligent/

    Reading the media reports, I think you’d be hard pressed to say for certain if the hypoxic episode occurred during breast feeding or if it occurred a little earlier during the water birth (for which the baby needed resuscitation after)

    • Amazed

      One of our regular commenters here, Keeper of the Books, had her first turn blue on her breast. Fortunately, she saw it immediately and yanked the baby off the boob.

      Like homebirth disasters, I wonder how many other misses or near misses there are.

      I recently described how my friend’s preemie who has never as much as smelled milk in a breast pushed her head in the front of my shirt as her mom was making her a bottle. KotB’s story had me immediately alert. Even so, in the brief time it took me to rise so I could take her out more securely, she had already pushed a hand in as well to do away with this annoying bra. I can totally see how a baby’s feeding instinct can lead to a tragedy in mere seconds… and I refuse to believe that midwives cannot see it. What, are midwives and LCs’ mouths somehow more special than ours? My jaw certainly won’t dislocate if I say, Hey, make sure she’s breathing, OK?

      • Merrie

        I remember when we did my son’s newborn photos, he started nuzzling the photographer, who was herself a nursing mom of an older baby (though obviously her baby was not nursing at that precise moment). She was like “I do have some of what you want, but it’s not for you.”

        • mabelcruet

          It’s the rooting reflex, babies come pre-programmed to latch onto the nearest breast, no matter who it belongs to!

          • AnnaPDE

            My husband’s mum was a teacher at a Catholic school. When he was a newborn, she handed him to one of her colleagues — a nun. Baby hubby was latched on to that nun, through clothes and everything, in an instant.

          • MaineJen

            Isn’t there a picture floating around the internet of a baby latching onto a statue’s breast?

          • mabelcruet

            I’ve always liked this one:

            https://goo.gl/images/7je3Ad

          • aurora

            I thought according to lactavists that your boob is the only magical boob for bonding and love?

          • mabelcruet

            When I was a medical student, I used to feel really bad at doing newborn baby checks-one of the things we did was to check the various primitive reflexes, and to check the rooting reflex you stroke the baby’s cheek and it should turn its head towards the side being stroked. The poor wee things would turn and start snuffling and rooting and pursing their lips looking to latch on-it felt really cruel to me, like teasing them with the promise of food and taking it away again!

    • Angharad

      How frightening! When my first was born, I remember her nose was smooshed up against my breast trying to eat, and I asked my LC how to position her so she could breathe. The LC told me I didn’t need to worry about it because there was no way my breast could possibly interfere with her breathing due to the way babies’ noses are shaped.
      That sounded really suspect to me, but I didn’t want to argue with a medical professional, so I just waited until she left and then started using bottles because I was worried my baby would suffocate.

    • PeggySue

      Poor little baby, poor parents.

    • Anna

      Why the heck wasnt a baby that required resus in special care!? Not left alone with a new Mother, poor bloody parents ffs.

  • The Bofa on the Sofa

    The rates have gone up, for whatever reason.”

    I’m guessing the #1 reason is because of availability. When epidurals are available, women get them.

    Why do so many women get epidurals? Because they can.

    It’s no deeper than that.

  • LaMont

    Non-spoilery:
    The latest episode of The Handmaid’s Tale of all things implied that giving birth “in a stream” was safer and less likely to give you an infection than giving birth in a sterile hospital environment. They also implied that you need to feel all the pain if you want to be a real woman. They put these words in a proper, feminist DOCTOR’S mouth. I am still furious about it.

    • MaineJen

      Oh jesus. I am always afraid it’s going to go this way, when they do birth in popular media. I had to stop listening to a favorite ‘science’ podcast when they had a guest on who was going on and on about her ‘healthy’ home water birth, and the hosts were credulously lapping it up.

    • Steph858

      I interpreted that as a nod to the book. The book alludes to an unholy pre-coup alliance between Feminists and Conservative Christians; they united against the common enemies of pornography and prostitution, right up until after they’d overthrown the government, at which point the Conservatives threw the Feminists under the bus. The Handmaid’s Tale was written not long after the Iranian Revolution, which saw a similar alliance based on “Enemy of my Enemy” (the enemy being the Shah) principles between Leftists and Islamists; we all know how that turned out. Atwood was trying to warn Feminists to avoid such dangerous bedfellows.

      Anyway, these days there are plenty of self-professed Feminists who spout ‘natural childbirth’ ideology couched in pseudo-feminist rhetoric about “Taking back control from those evil obstetricians”. Despite holding ostensibly incompatible worldviews, such Feminists share this ‘naturial childbirth’ ideology with the Conservative Christians – as we see when talk of inducing Offred causes Aunt Lydia to clutch her pearls. I saw this scene as an update (sex-negative Feminists are in a minority now, so having them unite with Conservatives on porn/prostitution etc would be out-of-date) on the alliance spoken of in the book.

  • fiftyfifty1

    I wonder how the Dutch have such low CS rates. I wonder what they do different, or perhaps what is different about their population.

    • mostlyclueless

      From what I understand, ~15% is about the going c-section rate for low-risk pregnancies in the US (not based on published stats, just talking to OBs I know). So that suggests to me that the Dutch probably have a mostly healthy, low-risk population — unlike the US, where underlying complications are rampant. They have one of the lowest obesity rates in the world at 12.8%, vs. the US at 38.2%.

    • The Bofa on the Sofa

      I’m also wondering about the correlation between home birth and c-sections in the Netherlands. As home births go down, so do c-sections?

      It’s almost like more home births caused more c-sections!

      • Figures quoted for the Netherlands are usually badly out of date. Hospital births and C/S are up, in part because of better data dictating policy, and because Holland now has a large Asiatic and black minority, with all the attendant problems.

    • Sarah

      They’re one of Europe’s healthier populations, which I expect explains part of it. Low obesity rates for a rich country, plus socialised healthcare means there won’t be the same population of women with untreated chronic conditions that are worsened by pregnancy as in the US.

    • Amy Tuteur, MD

      They also have relatively high perinatal mortality.

      • EllenL

        Exactly. The logical conclusion is, they have lower C section rates because providers don’t perform them – in situations that would dictate a C section elsewhere, and result in better outcomes.

    • Pcogale

      The thing that annoys me sometimes (well often) is women that want a VBAC because they had an unnecessarian. Wanting a VBAC is fine, but it’s the, ‘I didn’t need to have a C/S because my baby came out screaming and had APGAR’s of 9 and 9’. Ummm that’s probably because the baby came out before it was too compromised. If the OB’s had’ve waited longer and your kid then had issues – well I know who you will be blaming.

  • Ha, ha, that’s awesome! I’m happy to hear that the amount of noise the NCB crowd makes far outweighs its influence in the real world of women having babies. It isn’t great to hear that the homebirth rate is rising in the US, though.