Scientific American is DEAD wrong about midwives

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We can thank the Editors at Scientific American for illustrating the famous H.L Mencken quote:

…[T]here is always a well-known solution to every human problem — neat, plausible, and wrong.

The U.S. Needs More Midwives for Better Maternity Care is a truly execrable piece lacking common sense, scientific support and historical accuracy. It’s neat, plausible and dead wrong.

If mortality and C-section rates ROSE as the proportion of midwife attended births rose, how will increasing the number midwives make them fall?

The ignorance is on display with the very first sentence:

Despite the astronomical sums that the U.S. spends on maternity care, mortality rates for women and infants are significantly higher in America than in other wealthy countries.

The fact is regardless of what ANY country pays on maternity care, mortality rates for black women and infant are significantly higher than other ethnic groups. The difference in mortality rates of industrialized countries largely reflects the proportion of black women in the population. “Whiter” countries have lower mortality rates.

For example, the US maternal mortality rate is 3-4X higher for black women than white women. In the UK, the difference is actually larger; black maternal mortality rate is 4-5X higher that of white women. So why does the UK have a lower maternal mortality rate than the US? Because black women represent 12% of the US population and less than 4% of the UK population.

…[T]he rate of cesarean sections is exceedingly high at 32 percent—the World Health Organization considers the ideal rate to be around 10 percent—and 13 percent of women report feeling pressured by their providers to have the procedure.

The World Health Organization FABRICATED their “ideal” C-section rate and as they themeselves have publicly acknowledged, there is no evidence and there has never been any evidence to support it. The best existing research on the topic shows that a MINIMUM C-section rate of 19% is necessary for low maternal and neonatal mortality and that rates above 40% are also compatible with excellent outcomes.

Having utterly mischaracterized the problem, the Editors offer their “solution:

Widespread adoption of midwife-directed care could alleviate all these problems. In many other developed countries, such as the U.K., France and Australia, midwifery is at least as common as care by obstetricians.

There is precisely ZERO evidence to support that claim. What are the C-section rates in these countries? It’s 33% in Australia, 26.2% in the UK and 20.8%. That’s hardly a ringing endorsement for the role of midwives in lowering the C-section rate.

What about maternal mortality? Women in the US die for LACK of access to high tech maternity care, the very care that midwives don’t provide.

A recent paper in New England Journal of Medicine What We Can Do about Maternal Mortality — And How to Do It Quickly offers four separate recommendations for reducing maternal mortality and all of them involve MORE high tech care, not less.

And if that weren’t enough to convince you that the Editors at Scientific American have no idea what they are talking about, consider this: the US C-section rate and maternal mortality rates have risen steadily as the proportion of midwife attended deliveries increased. How will increasing the number of midwives further lower these rates in the future when they couldn’t do so in the past?

In the U.S., certified midwives and nurse-midwives must hold a graduate degree from an institution accredited by the American College of Nurse-Midwives, and certified professional midwives must undergo at least two years of intensive training. This is designed to make midwives experts in normal physiological pregnancy and birth.

But whereas certified nurse midwives get similar education and training to European, Australian and Canadian midwives and meet the ICM [International Confederation of Midwives] international standards, “certified professional midwives” do not. Indeed, CPMs aren’t really midwives; they are lay people who are not allowed to practice in any other country in the industrialized world.

Most practicing CPMs have no education beyond a correspondence course and an apprenticeship with another substandard CPM. To understand just how poorly educated and trained these women are: the requirements for the CPM were “strengthened” in 2012 to mandate a high school degree. Almost all CPMs work outside hospitals at home or in unaccredited birth centers. Their neonatal mortality rates are 3-9X higher than those of nurse midwives. The Editors at Scientific American appear to have no understanding of this.

Nor do they understand that a midwifery who is an “expert in normal birth” is about as useful as meteorologist who is an expert in sunny whether. When birth is uncomplicated, you don’t need an any attendant, let alone an expert. You only need an expert when complications occur, the very situation for which CPMs lack education and training.

There’s much more wrong with the piece, including its revisionist history of the decline of midwifery care, but it’s enough to know that its central claims are flat out false. There is NO EVIDENCE that midwifery care decreases the C-section rate and NO EVIDENCE that midwives decrease the maternal mortality rate. Moreover, for the past decade the UK, where midwives are gatekeepers of maternity care has been rocked by a growing series of scandals involving the preventable deaths of dozens, perhaps hundreds of babies and mothers. Why did these babies and mothers die and why did hundreds more sustain severe injuries? In nearly every case it was because midwives refused to call for the doctors who could have saved them for fear of losing control over the patients.

Highly educated, highly trained nurse midwives are an asset in any US maternity care setting. I’ve worked with many and have high praise for the care they can provide BUT there’s precisely ZERO evidence that increasing the proportion of midwife attended births has any impact on either C-section rates or mortality rates. The Editors of Scientific American should be embarrassed that they ignored the scientific evidence — indeed appear to be utterly unaware of its existence — and printed midwifery marketing propaganda instead.

  • FortyMegabytes

    That article has vanished from Scientific American’s web site. I’m guessing someone set them straight.

  • sapphiremind

    I think they were referring to Certified Midwife, which is different than a CPM. I had not heard the title before, but it’s a bachelor’s prepared midwife (i’m not sure if we have them in the US, maybe in Canada?). It’s terribly confusing with all the different names though. From an article I recently read, CM and CNMs are similarly trained as those in Europe (meaning they have a decent education) but the CPM and lay midwives in general are the ones that should never be practicing.

  • Raymond Colison

    reminds me of an equally troubling Vox video that came out a couple months ago basically saying the same thing as Scientific American

  • Michael Ray Overby

    Indeed this particular piece seems to run counter to the high quality reporting and commentary we have cone to expect from SciAm. Expanding the numbers of the midwife contingent is not the proper way to combat the issues of maternal & infant morbidity & mortality in the United States, especially among women of color. The piece by GateHouse Media, referenced below, provides a much clearer picture of the industry that SciAm seeks to support in their article.

    • Expanding the number of inadequately educated and supervised CNMs is certainly no solution to a shortage of professionals in the obstetric field. But I worked in the UK at a time when British midwifrty was one of the best in the world, and it was very good indeed. I don’t dismiss the potential for improving care through the use of midwives out of hand; it all depends on the way it is done. First of all, IMO, is getting all non-CNMs out of midwiery, but there’s a great deal more.

  • BeeBee

    Irresponsible reporting by Scientific American. Do they not know of the recent excellent investigatory report(Nov 2018) done by Gatehouse Media on midwifery in the U.S.?

    ” GateHouse Media and the Sarasota Herald-Tribune spent nine months investigating the out-of-hospital birth industry. Reporters interviewed more than 100 mothers, midwives, physicians, attorneys, lawmakers and researchers. They read thousands of pages of disciplinary records, regulations, lawsuits and studies. They analyzed state and national birth and infant death data. They crisscrossed the country, visiting birth centers and hospitals, and even followed a mother through her home birth.”

    http://gatehousenews.com/failuretodeliver/#

    To rely on the reputation of a publication such Scientific American to the point that the reporter(s) did not bother to do the homework necessary to support their statements is just outright laziness and slovenly work. Ridiculous.

  • mabelcruet

    I used to have difficulty with the idea that a midwife would refuse to hand over care to an obstetrician should the need arise. In the UK, most midwife led units are side-by-side units, located in a hospital close to the medical led unit. It costs nothing for a woman being handed over-the midwife’s rate of pay does not depend on the number of babies they deliver, and they don’t get monetarily penalized for transferring. However, over the last few years, I’ve seen a slow trickle of cases that concerned me. I have to attend perinatal audit meetings in the hospitals I cover-these are usually rather dreary (X% of babies were singletons, X% were multiples, X% were born to women over 35, just lots of figures). One of the stats generated is the number of women who start out in low risk midwife led care with the attention of delivering in the MLU, but who subsequently get moved to Obstetric unit. I’m beginning to get a sense that the handing over of cases is frowned on-I get the impression that in some centres this is seen as a failure of care, I’ve certainly heard people commiserating with others that the patient got taken over, as though it’s an insult to the midwife that her care wasn’t good enough, and there’s definitely a sense that some labour ward managers don’t want women handed over-its a pride thing to some of them. Or a attitude that ‘birth is natural and we don’t need doctors, they just get in the way (a la Caroline Flint-sack all the obstetricians…). I worry that some people may see this as a challenge ‘I’m going to get my handover rate down, I’m not handing over anybody’, and I’ve had a case where a junior doctor was called to see a woman, the junior called a senior to review, and the midwife took it on herself to phone the senior and cancel. The vast majority of UK midwives are great, but there is a hard core, sadly mostly in the RCM, that have this pervading warped view that medical intervention is bad, doctors only want to cut you, and obstetricians are misogynists who disrespect midwives and mothers.

    • RudyTooty

      The ideology can creep in anywhere. Credentials can help – particularly if those credentials require a certain level of training and competency – but they can’t prevent anyone from adopting certain beliefs.

      Holding the belief that more obstetric intervention is a poor outcome in itself results in some twisted practices.

      Midwives (well, everyone who works in obstetrics) should be concerned not with the model of care, but the outcomes.

      Are we providing the appropriate level of care for every one of our patients? What are the obstacles that prevent patients from receiving the appropriate level of care? The idea that ‘natural labor and birth’ is somehow superior to increased technological and life-preserving interventions is surely an obstacle.

      • mabelcruet

        It doesn’t help that the RCM and its officers have it down in black and white that one of the core roles of a midwife is to protect natural birth. If someone genuinely believes that, it stands to reason that they might obstruct anything that threatens that role.

    • Michael Ray Overby

      Have you read about the Debacle of Morecambe Bay? That tends to support the impressions you describe here…

      • demodocus

        Dr. Amy has written several blog posts on it

      • andrea

        Yup. There is a search function for this page right between her YouTubes on the right sidebar. It’s not the easiest thing to see, but awesome for a quick search with keywords.

      • mabelcruet

        Yes, read the report several times. I’m also aware that the Royal College of Midwives dismissed the report, belittled it in the same way they have repeatedly ignored and dismissed loss parents (especially poor James Titcombe and his family), and that there are still midwives out there persisting in the belief that it was the midwives who were right, and that midwives were being bullied by the medical staff, despite the conclusions of the coroner and KIrkup. Unfortunately, the same issue has arisen in multiple other areas, and I’m sure there are many, many more deaths relating to the same problems still waiting to be uncovered.

    • demodocus

      It’s no more a failure than for the person needing a c-section. Of course, the nuts think that’s a failure too. Heck, they probably think my Dem could do something about his glaucoma if only he used the cure de jour. There is a limit to what a person can do to change the bodily hand they were dealt.

    • demodocus

      It’s no more a failure than for the person needing a c-section. Of course, the nuts think that’s a failure too. Heck, they probably think my Dem could do something about his glaucoma if only he used the cure de jour. There is a limit to what a person can do to change the bodily hand they were dealt.

  • Zuul

    Well, they are half-right…

    In the US, we are struggling with a lack of good and consistent prenatal care, especially for low-income families.

    This problem is solved by increasing the number of – and access to – trained medical care providers. If all American midwives were trained to provide that care, like nurse practitioners and doctors, it could be the solution to the problem. Unfortunately, they are not.

    Maybe it is better stated that midwives could be the solution to the problem, if they were trained and held to the same standards as other healthcare professions.

    I, for one, would love to see that. The more educated and skilled care providers out there helping women and babies, the better. Unfortunately, American (non-CNM) midwives are their own worst enemy, advocating against the betterment of their own profession. So I don’t think I will see that outcome any time soon.

  • MaineJen

    Ugh. This is a highly read journal. Not good!

  • rational thinker

    Wow I just read the article………………yeah that’s all I got.

  • Amy Tuteur, MD
    • mabelcruet

      I think an issue that tends to be wholly ignored by midwives is that pregnant women themselves are getting more complicated. 30 years ago, mothers were younger, slimmer, less likely to have chronic diseases-women with heart disease, cancer survivors, transplant recipients, older women with hypertension or diabetes etc were very strongly advised never to get pregnant. Nowadays, the relative percentages of mothers with pre-existing health problems has shot up, so why would you expect medical-led pregnancies and medical/surgical intervention in labour to go down? Its nonsensical to say more midwives equals better care with no other intervention because all things aren’t equal.

      • KeeperOfTheBooks

        Thanks for this perspective!
        I also wanted to add a quick thank-you to Mabel for your really interesting comments here. You bring a perspective that most of us don’t have at all, and I very much appreciate reading it.

        • mabelcruet

          Thanks! I have to keep reminding myself that I see the worst cases with the most awful outcomes, so my workload isn’t representative of maternity care as a whole, just that bit of it that needs a perinatal pathologist, so I try not to get too scary as I know parents might be reading.

          But the autopsy side of things is just one half-I also do loads of placentas every month (currently about 300 a month, I’m a one woman placenta machine!). There is a protocol that delivery suites follow to decide which placentas to send for examination-basically its any placenta where there were maternal health problems, fetal health issues or pregnancy related issues. So these are predominantly babies who are alive, but the placenta needs to be examined to explain what went wrong, or to plan for future care. Some of the clinical histories are scary-women with really complex health issues, surgically corrected heart disease, past history of various cancers, women with multiple previous miscarriages. But there are also placentas from women who were absolutely fine, perfectly healthy normal pregnancy, then all of a sudden things go wrong. These are from normal hospitals (district general hospitals) as well as the regional specialist centre, and it really hits home just how quickly it can all go to pot and the various ways in which it can go wrong.

  • Anj Fabian

    The CPM requirements always imply that it’s years of “intensive training” comparable to medical residency.

    Ha.

    I say again “Ha.”.

    It’s nothing like that.

    “I’m tired. I am currently in my 3rd week of my OB/GYN rotation. 12hrs a

    day and a 26hr on-call every 4th day (including weekends).”

    http://biancabelcherpa.blogspot.com/2012/02/my-obgyn-rotation.html

  • space_upstairs

    My OB (in Chile) works with a midwife, and both were great. While the midwife was partial to many “natural” things like preferring vaginal birth over C-section in general and barrier over hormonal methods for post-partum birth control (I plan to use spermicide-lubricated condoms plus lactation and/or stick to third base until I can get a copper IUD, since I don’t want to go back on hormones for my own reasons), she praised the epidural as one of humanity’s greatest achievements and has no problem with prudent C-sections. In my case, when my labor stalled, she initially said my baby was mischievous, but when she saw the birth weight, she said my OB made the right call because of all the complications like cord prolapse and tears that can occur attempting a vaginal birth of a macrosomic baby through modest-sized hips. So…if more midwives in affluent English-speaking countries were more like her, working as a team with OBs and understanding nature’s limits, rather than the crunchy competitors to OBs I hear about on here, they would probably help improve birth outcomes regardless of C-section rates (which, in Chile, do run over 40% without disaster).