Are midwives with all women or just some women?

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Apparently my book PUSH BACK: Guilt in the Age of Natural Parenting made Professor Laura Freidenfelds feel stung. Unfortunately it did not make her feel curious enough to reexamine her assumptions about midwifery and childbirth.

In Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth, Freidenfelds writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Freidenfelds piece is profoundly disappointing because when challenged on her personal beliefs she responded as a partisan, not as a person interested in the truth.[/pullquote]

Recently, obstetrician and blogger Amy Tuteur published Push Back: Guilt in the Age of Natural Parenting, in which she made fun of women stupid enough to believe that they might have a better birth experience without an epidural, and excoriated anyone who would refuse any of the bells and whistles of modern obstetrics.

Her title was a response to journalist Jennifer Block’s, Pushed: The Painful Truth about Childbirth and Modern Maternity Care, an exposé of callous obstetricians who damaged women and their babies with the thoughtless overuse of standard obstetric interventions such as the induction agent cytotec and the drastic overuse of major abdominal surgery (cesarean section).

Made fun of women?
Stupid enough to believe they might have a better birth experience without an epidural?
Bells and whistles?
Callous obstetricians?
Thoughtless overuse?

In other words, instead of giving some thought to the idea that privileged, white women swallowed wholesale the fake news and propaganda of the natural childbirth industry, Freidenfelds decides to double down by repeating it all and insisting it’s true.

Curiously, Freidenfelds doesn’t deign to provide any scientific evidence to rebut my scientific claims. She seems to find truthiness of natural childbirth propaganda more persuasive than the truth of historical and scientific evidence.

Instead she offers an intellectually lazy compromise: a highly romanticized view of nurse midwives as a middle way:

In fact, there is someone ready and willing to escort birthing women along that middle path: the nurse-midwife. Calm and sensible, evidence-based and gentle, she is too easily effaced by the competing romantic dreams of natural bliss and technological perfection. We need to notice that she’s there, and we need to figure out how to connect her services to more women.

Seriously, Professor Freidenfelds? Calm? Gentle?

Freidenfeld then proceeds to regurgitate the fake history of midwifery as turf war in which evil obstetricians sought to steal the livelihood of “calm, gentle” midwives.

Sadly, Freidenfelds doesn’t bother to address the questions I raise in PUSH BACK regarding the racist, sexist origins of the philosophy of natural childbirth, the implicit biological essentialism and the remarkable elitism of the movement.

Specifically:

What distinguishes midwifery from obstetrics? Is it truly a difference in outlook or merely midwives clawing for market share

In the paper What is gender? Feminist theory and the sociology of human reproduction sociologists Annandale and Clark criticize contemporary midwifery:

…[T]he lived experience of midwifery … is revealed only as the largely unresearched antithesis of obstetrics. An alternative is called into existence in powerful and convincing terms, while at the same time its central precepts (such as ‘women controlled’, ‘natural birth’) are vaguely drawn and in practical terms carry little meaning.

Should women be reduced to their reproductive organs and does reproduction mean the same thing to every woman?

Annandale and Clark explain that much of contemporary midwifery imagines that:

… reproduction is still centred for women and put on the agenda as if it were central to all women’s lives. This may serve to lock women into reproductive roles which may be politically problematic since the centrality of reproduction, contraception and childbirth to biomedicine is transferred to women’s experiences. This may be the reality of their experience, but equally importantly, it may not…

Are midwives with all women or just privileged white women?

Apparently the only women who count in Freidenfeld’s world view are privileged white women. Natural childbirth advocates are overwhelmingly Western, white, and well off. Certified nurse midwives are overwhelmingly Western, white and well off. I find it quite shocking that in a country that struggles with high black perinatal mortality and high black maternal mortality, Freidenfelds doesn’t even bother to give lip service to the many women of color, women of other nationalities, and women with pre-existing medical conditions and pregnancy complications whose have no interest in and cannot be helped in any way by the philosophy of natural childbirth.

Instead of addressing these fundamental issues of gender, race and class Freidenfelds expresses her surprise that despite my support for nurse midwives (the most highly trained, best midwives in the world), I don’t see them as the solution to all obstetric problems:

If Amy Tuteur and I can agree on the value of nurse-midwives’ practice, why aren’t we both looking to nurse-midwives as model practitioners? In her book and in our conversation, Tuteur insisted that the high false positive rate from obstetricians’ use of continuous fetal monitoring, which leads to a high c-section rate, is unavoidable if we want to save babies. I suggested that it is, in fact, avoidable: all she and her obstetrician colleagues have to do is walk down the hall and ask the nurse-midwives to teach them how to use intermittent monitoring effectively. Tuteur chose to ignore me, and simply insisted that obstetricians know best. She was not about to give ground in public to anyone called a “midwife,” even someone she privately recognizes is fully competent.

Why aren’t nurse midwives model practitioners?

Because not everyone who needs care is a healthy, privileged white woman. Indeed nurse midwives can’t “be with” and can’t care for the many women who are most in need — women with serious medical issues.

Because most women consider a healthy baby more important than avoiding a C-section or treating birth as a piece of performance art.

Because while Freidenfelds may blithely ignore the risks of childbirth, childbirth is inherently dangerous.

Because it is laughably easy to tell obstetricians what they should and should not do when you bear no responsibility for dead babies and dead mothers.

It seems obvious to me that not every woman is a member of the white elite. It seems obvious to me that the white elite should not assume that their needs and desires are the model that all other women seek to emulate. It seems obvious to me that a movement based on biological essentialism is deeply anti-feminist. And as a physician it seems obvious to me that the steep declines in perinatal and maternal mortality is due to the liberal use of obstetric interventions not midwifery, which had existed for millennia before the advent of obstetrics and presided over astronomical rates of perinatal and maternal mortality.

Freidenfelds piece is profoundly disappointing because when challenged on her personal beliefs she responded as a partisan, not as a person interested in the truth.

  • AA

    http://mediasitesvr01.rcog.org.uk/Mediasite/Play/9f0d45f5bf1b492b9f70b9ce1c4bd3ce1d

    Lecture on Morecambe Bay maternity services from an RCOG member.

  • Empress of the Iguana People

    OT: one thing that drives me nuts is how am I supposed to know how much tylenol to give the hatchling? She’s a 20 pound 6 month old. Not covered by the label at all. They have weight and age minimums, she’s only 4 pounds lighter, but 18 months younger. Poor kid probably has the sore throat I have, too.

    • Who?

      Miserable for both of you. Hope you both feel better soon.

      Could you seek some advice from a local pharmacist?

      I used to ask my pharmacist sister-in-law about dosages, particularly for the boy who used to get temperatures a lot. She was really good at sorting out interleaving drugs, and ‘one-off’ doses, and taking into account the different strengths of products.

      • Empress of the Iguana People

        Possibly, though not when I typed that.

        • maidmarian555

          Do you not have Calpol over there? Is Tylenol the same as Paracetamol? We can give Calpol from when babies are pretty tiny here, it’s amazing for teething……it gives the dose from 2mnths old….

          • Nick Sanders

            Never heard of Calpol, but Tylenol is a brand name for acetaminophen, which is the same thing as paracetemol.

          • maidmarian555

            Calpol is the infant version of Paracetamol in the UK. It comes in infant doses and is widely available here.

  • Nick Sanders

    I just want to wish everyone here a Happy Holidays. Whether you celebrate Christmas, Hanukkah, Kwanza, Solstice, Yule, Dongzhi, something I haven’t listed, or even if nothing else, just a Happy New Year!

    • FallsAngel

      Same to you, Nick!

    • Sue

      Thank you – and to you, and all my SOB friends!

    • Who?

      Happy Christmas Nick, and the SkOb community.

    • momofone

      Same to you, Nick!

  • Heidi_storage

    Hey, know what’s awesome? Apparently, my hospital stopped trying for BFHI certification after receiving pushback from parents! The babies are still kept with the parents unless the parents request otherwise, but our well-baby nursery remains open, and nobody made me sign an I’m-a-Bad-Mother paper when I asked to supplement with formula! In fact, the nurses and lactation consultant were all just as supportive of my breastfeeding efforts as they had been last time, but all added that they were also supportive of my decision to supplement.

    As a result, Baby lost only about 4% of his birth weight, compared to my previous son (10%), and we DIDN’T have lots of screaming for his first 24 hours of life! Breastfeeding is challenging because the baby has a high palate and is a really inefficient nurser, but it’s going so, so much better than my experiences with my daughter and oldest son. No pain, no cracked, bleeding nipples, no howling, frustrated baby who won’t sleep.

    Suck it, BFHI.

  • SporkParade

    How interesting that I’m reading this today, shortly after arriving home from the hospital with the newest pipsqueak. I was thinking earlier about the differences between birth 1 and birth 2, both of which started out as low risk labors at the end of textbook healthy pregnancies. Birth 2 was attended solely by a nurse midwife, with another one dropping in to assist during the crowning. Birth 1, in contrast, was attended by a nurse midwife, 2 OBs, and the neonatal resuscitation team. I can accept that having an OB at most births is overkill, just like having a GP do well visits that can easily be handled by nurses and PAs is overkill. But sometimes you need a dang MD or three to take care of you.

    • Heidi_storage

      Congratulations! What a nice Christmas (or Hannukah) present for you.

    • Mazal tov! But remember, too, that second labors and births are inherently usually easier than first ones for a number of reasons.

      • fiftyfifty1

        “second labors and births are inherently usually easier”

        I think she knows that. It’s the NCB crowd that doesn’t. To them, the idea that a first time mom might be at higher risk of needing OB intervention is considered to be nothing more than scaremongering.

      • SporkParade

        I don’t suppose you know what the protocol is here when a pregnant woman has had a previous precipitous labor? It’s not clear I would have made it to the hospital in time had I not already been hooked up to an EFM for my first post-dates appointment when active labor started, so I’m scared what happens if we have another one.

    • Who?

      Congratulations, glad it went well.

      May you both, and the rest of your little family, thrive.

    • fiftyfifty1

      Congrats! So glad it went smoothly.

    • Nick Sanders

      Greetings to the little spork!

    • momofone

      Congratulations, and welcome to baby spork!

  • Steph858

    Reading this article made me doubly angry because I’d just read this news story: http://www.bbc.co.uk/news/world-middle-east-38380553

    The ‘highlights’: “C-sections were being performed [in a ‘clinic’, … the only medical facility in Madaya. It was, in fact, just a room in the basement of a house, run by a dentistry student and a veterinarian]. … Lacking alcohol to sanitise equipment, tools were being sterilised using flames. With no medical gel for ultrasounds, hair gel was being used instead.”

    But of course, according to Freidenfelds, we needn’t worry as none of the C-Sections being performed in a basement by a dentistry student and/or a vet are actually necessary. Instead of getting advice from specialists outside Aleppo via Skype and Whatsapp (http://www.bbc.co.uk/news/world-middle-east-37349239), they should be talking to a duola who can advise them on how to create the ambience required to allow the exhausted and malnourished women to give birth naturally. Who needs basic medical equipment when you’ve got whale songs on a CD?

    • fiftyfifty1

      Terrible. So sad.

  • Sue

    The hospital-based nurse-midwife isn’t an alternative to obstetric care, but part of the obstetric team.

    Good hospital care is team-based, with everyone making use of best-practice guidelines, appropriate technology and clinical skills, including judgement and decision-making, and communication.

    Standard care for public hospital patients in Australian labour wards is midwife-care, using pharmaceuticals, technology and technical procedures, with medical consultation/collaboration as required – for epidural insertion or complications requiring medical input.

    Rogue HBMWs have no idea about team work or collaboration.

    • AnnaPDE

      Still, honestly, the utter NS Unheard from those nurse midwives in 5 days of Aussie hospital males me doubt whatever their training consists of. I especially loved the theories about why newborn babies are awake at night: so they could warn their mum against wolves. And the placenta was supposed to lire them away, or something.

      • Heidi_storage

        The wolf theory is really amusing, but I think if any of my nurses had tried it on me there would have been An Unpleasant Incident.

  • Yayvaccines!

    I am the product of a high-risk pregnancy, and am alive because my mom had appropriate, timely care in a hospital with a NICU. As a result, I had absolutely no desire to use midwifery care. I needed an OBGYN, a hospital, a NICU, and every machine that beeped in order to feel comfortable, relaxed, and safe. What is it about these women who, because they enjoyed midwife-led care, assume all women want it too? True, in hindsight I could have given birth in a forest accompanied only by squirrels, but who cares? Gimmie all the technology you can throw at me!

  • J.B.

    I think there’s a lot of value to cnm’s and nurse practitioners in conjunction with MD’s. For straightforward illnesses and for “low risk” deliveries, with the backup quickly available. There needs to be a lot of trust among the group, and clear understanding of when to call in that backup, and I’m sure it is not a minor decision for the MD to join such a practice out decide who to hire.

    • Spamamander, pro fun ruiner

      My first pregnancy was followed by a very competent CNM. I gave birth at the hospital, in a birthing room, and knew there was OB backup instantly available. When I asked for an epidural after 14 hours she waved the anesthesiologist down in the hallway (“The other woman laboring has a history of small babies and hasn’t been in labor as long”) and encouraged me in my decision. This experience is NOT universal.

      My other two children were followed by an OB. The third one I transferred care to a high-risk provider. Each time I got the appropriate care for my situation.

  • maidmarian555

    And what about us women who had terrible experiences with midwives (and I’m in the UK so all the ones I saw were fully qualified)? My community midwife managed to repeatedly mis-lable all my blood tests so nobody knew my blood type until I was 36wks (good job I wasn’t rhesus negative!). She mistakenly thought my baby was transverse, which lead to a period of EIGHT horrible, stressful weeks before I finally got referred for a scan to confirm he wasn’t, she completely forgot to mention I needed a pertussis booster (I only found out after looking on the NHS website for information on transverse babies- and I had TOLD her that because of previous problems with severe anxiety I had made a conscious effort not to research anything online as I was finding it all too terrifying. If I hadn’t seen a mention of the vaccine on the sidebar in ‘related searches’ I would not have known I needed a pertussis booster- which I didn’t get until 36wks after a hysterical call with my GP surgery). I went into hospital on a Thursday lunchtime, and after several days of midwife-lead care, I finally got to see an OB briefly at 1am on Saturday morning and again at 3am on the Sunday morning. That OB was the only medical person (other than the midwife I had for the final 12hrs) I saw in my ENTIRE PREGNANCY who made me feel like she knew what she was talking about, who was honest, who didn’t lie and who eventually got my son out safely. I know plenty of other women who have had equally awful experiences with midwife-lead care.

    I was really open-minded and completely ok with taking advice and not questioning my community midwife. By the time my son was here I felt like an utter fool for doing so. She (on more than one occasion) screwed up so badly that she could have risked both our lives, it wasn’t until afterwards that this really became apparent. Seems to me that too many women DO NOT question their midwives. Here, you don’t get to see a doctor unless there’s a real problem. I don’t think that’s necessarily a good thing (although no doubt it saves a tonne of money). And I’m not even going to cover the crappy ‘support’ I got in the hospital, both before and after birth. I was treated as a nuisance because my body wasn’t doing what everyone seemed to think it should be doing and was made to feel like it was my fault. BY MIDWIVES.

    I found your book very helpful. I’m sorry that other people who have clearly not experienced what I have are so dismissive. I wish I had read it (and found this blog) before I had given birth, it would have been really, really helpful.

    • Christy

      I’m so sorry you had to go through all that.

    • sdsures

      Hugs! UK midwife-led care scares me. I’m sorry you hd to go through that.

      • maidmarian555

        It’s not all terrible. It’s just a lottery as to which midwife you get and how big her caseload is. I’ve had friends who were lucky and had good care. I was unlucky. The only good thing is that I didn’t really realise how unlucky I’d been until afterwards!

        • Sarah

          Agree. It’s very, very mixed. I have had some utterly fantastic and some appalling midwife care in the UK.

        • sdsures

          Fair enough. 🙂

          • maidmarian555

            I think the problem stems from a lack of checks and balances. Nobody checks that your community midwife is doing a good job or on the standard of care that you’re getting. I stuck with mine, even when it started becoming a bit obvious that things weren’t really working out (despite my slight deliberate obliviousness, my OH was doing his nut) because she was the only midwife attached to my GP surgery and I was worried that if I complained I’d get left with no care at all. That may not have ended up being the case, but I was far too afraid to test the system when it was really unclear what would happen if I did make a fuss. I think, with hindsight, I would have really benefitted from an allocated OB as part of my care. I get frustrated when people (such as those referred to in the OP) suggest that midwife-lead care is some sort of perfect model that everyone should aspire to emulate as our version of it is completely dependant on the competence of the midwife you get given. It’s no better when it doesn’t go well than the old-school version of entirely medicalised maternity care that a number of women also seem to be so adverse to.

          • sdsures

            “I think the problem stems from a lack of checks and balances. Nobody checks that your community midwife is doing a good job or on the standard of care that you’re getting.”

            This! ^^

            In the UK, we have health visitors who come to your home to make sure the new parents and Spawn are doing OK in whatever way is best for them to feed the spawn, etc. I think it’s a fantastic resource. <3

            I'm comforted by the fact that I'll get OB care from the start because I'm high risk. I'll still get midwife-led checkups of course, but the added security net of OB is reassuring.

          • maidmarian555

            My Health Visitor gave me an enormous lecture on how I needed to breastfeed my son and that was about it. She also told me that Jumperoos were basically Satan (they totally aren’t, and my lil man loves 10-15mins in his every day) as are any useful things you can use to keep your baby occupied for more than 5mins a day. She also made me attend a weird ‘Parent and Child’ group that my partner and I were ostracised from because he attended (apparently men were actually non-gratis) where they gave me a bunch of completely not useful info and nobody would speak to us because they thought we were unemployed bums (we aren’t. I got made redundant during pregnancy and my OH is an ATC that works shifts). She was a nice lady but kinda useless…..

          • sdsures

            At that point I would have complained to my GP’s practice for providing less than minimally-required care.

          • maidmarian555

            I wrote a very, very long complaint (which garnered a sympathetic response with precisely zero action attached to it).. Sadly, where I live, funding for the Health Visiting Team has been slashed to the bone. I currently have to pre-book (three weeks in advance) to take my son for a weigh-in. They have two local sessions a week that last an hour and a half each, one in a church hall and one in a community centre. The last time I took wee man in, they told me that they were moving the venue for the sessions this year as they no longer have enough funding to run them as they currently are. In a church hall and a council-run community centre. I am half-expecting my next weigh-in to be in a skip behind the local pub. Once again, it’s a service that depends on both the individual you get allocated, but also on the funding available in your local area. It’s not entirely their fault and you can call if you need them (I *did* find them helpful when I needed support in putting together an initial bedtime routine for wee man) but in many ways, the service is not as effective or useful as it could be.

          • sdsures

            :'(

  • Empress of the Iguana People

    My mom probably would have done fine with a nurse-midwife for my brother’s birth. All 3 of her grandbabies were better served by their moms seeing the doctors.

  • Mel

    The words I use to describe my OB are sensible, calm, gentle, evidence-based and extremely capable of using modern medicine to save my life and my son’s life.

    At my last scheduled OB appointment, I brought up my concerns about an eczema outbreak that was just starting on my hands. I get dihydroitic eczema on my hands every few years and a prescription steroid cream works well to contain it – but I wasn’t sure if it was safe for pregnancy. My OB looked it up, said n number of studies had found that it was barely absorbed into the bloodstream in skin usage and said that she’d strongly recommend using it – especially if it prevented needing oral steroids or a course of antibiotics if the area became infected. I’ve had both happened before and have been using the cream happily ever since.

    When I was diagnosed with HELLP, she stopped in at the beginning of her daily rounds. Honestly, she did look surprised and frightened in the first few minutes she was talking to me – but that’s a very human response to having a previously robustly healthy patient show up at a hospital in critical condition. She was also calm the entire time and started planning out what she would do to give Spawn and I the best possible outcomes possible.

    I have to give her props; she was so calm that she managed to explain that I would most likely wake up in the ICU after my CS because I would need some extra monitoring due to the blood transfusions in such a way that this didn’t worry me at all. (I’d like to point out she never played the “dead baby card” or the “dead mom card” either; she knew me well enough to realize I knew that failure to treat HELLP would kill both of us and that bringing that up would likely scare the crap out of me pointlessly.)

    I forgot “kind”. By the time the CS rolled around, I was exhausted, scared of being awake during the procedure, terrified my son was going to be in pain or die and feeling sick and lightheaded from missing a dose of my anti-depressant. By the time I was rolled into the OR, I was near panic – and then my OB gently called my name and held my hand. I started shaking when she read out my name and the procedure and she said “It’s the right thing to do, Mel, for you and for Spawn”. (Did I mention she always called my son by the nickname we called him by?) The epidural felt so much like the multiple failed blood draws I had had over the last day that I started crying hard in the middle of the procedure and she gently wrapped her arms around me until it was placed and I will always be grateful for that act of compassion.

    And once I was ready to go, she ran a spot-less CS that got my wiggly, trying to escape, tiny son out quickly, transferred him to the NICU team, and managed finishing the CS so neatly that I didn’t need any transfusions. (She told me later that my uterus helped out a lot; it stayed relaxed when the baby and placenta were removed and then clamped down hard on its own. That entire anecdote made me laugh a few days later when I needed a laugh badly.) She even took a second before I was transferred back to L&D to let me know roughly when she’d be up to see me.

    She and the nurses also made sure a dose of my anti-depressant medication was waiting in recovery which made my queasy stomach and mild headache disappear within an hour.

    So as for a “sane middle path”, no thanks. I’ve got a much better and safer provider lined up, thank you.

    • sdsures

      “”It’s the right thing to do, Mel, for you and for Spawn”. (Did I mention she always called my son by the nickname we called him by?) ”

      That is so sweet!

    • Jen

      I love your story. The most compassionate care I received was from my OB as well. I had a planned CS which my OB fully supported. The midwives I saw were dismissive and judgmental. One even pushed me to attend the birthing classes in case I decided to change my mind and go all natural. Not supportive at all of my birth plan that my doctor and I came up with.

  • fiftyfifty1

    “…[…]…all she and her obstetrician colleagues have to do is walk down the hall and ask the nurse-midwives to teach them how to use intermittent monitoring effectively.”

    Give me a break. That would be like me, a family physician with a patient population that skews young and healthy, “schooling” cardiologists on how to achieve better outcomes for their patients while at the same time doing fewer angiograms:

    Sheesh dumb cardiologist, dontcha know that chest pain is almost never cardiac in nature?! It’s almost always something little like a pulled muscle or a chest cold. You have a lot to learn from my technique of “Being With” my patients. Listen to their chests a bit with your stethoscope and then reassure them in a Calm and Gentle manner. And it works! After all my patients have an extremely low rate of dying from heart disease while your rate is much higher!

    • fiftyfifty1

      ETA:
      P.S. Ignorant Cardiologist, don’t take what I said to mean that our arrangement will change–I do still expect you to be available 24/7 to save the day and fix my screw-ups.

      • Amazed

        Lay person here: is Ignorant Cardiologist expected to pay the child support for the 3 kids of the man your greatness won’t quite save but the Fortunate Cardiologist happens to tend to him in his final hours? Cause you know, you, OF COURSE, don’t have a malpractice insurance. Your relationship with your patients IS your insurance while the Fortunate Guy only has bucks to show.

    • RudyTooty

      The other stupid part of this comment is that an overwhelming majority of women want epidurals for labor. We don’t perform intermittent auscultation or monitoring on women with an epidural.

      Oh, and one more stupid: nurses monitor fetal well-being during labor. When appropriate, nursing staff in labor and delivery will not use continuous monitoring. The physician is not usually involved directly in this decision-making. Of course, as soon as there is a need for continuous monitoring – due to patient condition or intervention (epidural), continuous monitoring is implemented.

      As a nurse, I’m happy to perform intermittent monitoring when it is appropriate – and I have done this. The reality of modern obstetrical practice is that there are few women who meet the criteria for intermittent FHR monitoring throughout their labors.

      Her comment is ignorant on many levels. There is no context.