Preventable deaths are the inevitable result of the radicalization of midwifery


Ideas have consequences.

Bad ideas about childbirth have deadly consequences.

That’s the take home message from the shuttering of the UK Campaign for Normal Birth. Midwives promoted process (normal birth) over outcome (healthy babies and mothers) and, inevitably, babies and mothers died.

It wasn’t always this way. There was a time when midwives were guardians of safety.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwives never intended for anyone to die, but deaths became acceptable collateral damage.[/pullquote]

Midwifery is often referrred to as the “second oldest profession.” Ever since our ancestors acquired the ability to walk upright, human childbirth has been fraught with extreme risk to both mother and baby. The first midwives were those who recognized that assistance in childbirth can minimize those risks.

They understood that something as simple as massaging a woman’s uterus after childbirth could prevent life threatening hemorrhage and that different fetal positions like breech posed specific problems that could be overcome with specific maneuvers. They acquired knowledge of the pharmacologic properties of certain plants and gave extracts to women with the intention of starting labor or stopping bleeding.

Outcome, whether mothers and babies live or die, was the MOST important goal in midwifery. It isn’t the only goal, of course; safe care can and should be accompanied by compassionate, comfortable care. But it was the sine qua non.

Despite profound changes in the human condition, midwifery changed very little … until the advent of midwifery theory. That’s when midwifery became radicalized and, as a result, babies and mothers died preventable deaths that midwives could have prevented but didn’t. Don’t get me wrong: midwives never intended for anyone to die, but deaths became acceptable collateral damage in a relentless campaign to promote process over outcome and midwifery autonomy over everything.

Don’t believe me? Consider this paradigmatic academic paper Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy. Yes, you read that right; it is an exhortation for midwives to apply the nonrational to the care of patients.

The authors attack rationality itself:

We expose the limitations of pure rationality in the context of childbirth and use the concept of safety to exemplify the limitations that pure rationality imposes. The paper draws on philosophical and spiritual theory to present an analysis of ideas about mind, body, soul and spirit… This revised conceptualisation provides a theoretical basis that allows for and promotes more possibilities and thus more holistic ways of knowing in midwifery.

Both premise and conclusion are stunning: Many principles of midwifery are not supported by science. Rather than modify midwifery to reflect scientific knowledge, scientific evidence should be abandoned in service to midwifery autonomy.

For the treatment of postpartum hemorrhage, the authors suggest:

…[W]hen a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking… [T]he midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage… Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.

In other words, scientific evidence mandates technological intervention to treat postpartum hemorrhage, which isn’t compatible with the privileging of process over outcome. Rather than modify midwifery practice to reflect scientific knowledge, scientific evidence should be abandoned in service to midwifery autonomy.

There is a direct line between radical midwifery theory and the deadly Campaign for Normal Birth. In a Royal College of Midwives “analysis” published about the same time, the RCM insisted:

Care based on robust evidence probably has the highest profile it has ever had within midwifery. However, if policies, protocols, guidelines and pathways of care are too rigid and are unable to be applied flexibly, then there is a risk that midwives are unable to feel empowered to practice the art of midwifery. They need to use the intuition that experience and knowledge brings, to sense when a problem may or may not be occurring.

The RCM uses an example, too. A woman whose baby was breech was encouraged by the midwife to have a vaginal birth. The lesson midwives were to take from this:

Most midwives base their antenatal care on national guidelines … and local policies. ‘Trusting your intuition’ promotes these tools to be used flexibly …The intuition that Angharad would benefit from an extra visit at home enabled her to have the space and time to make informed choices that were right for her. Angharad made a choice that did not follow the current recommendations, i.e. the ‘safest way to have a baby in the breech presentation is by elective caesarean section’.

In other words, scientific evidence indicates that technological intervention (C-section) may be safer for breech babies, but that isn’t compatible with the privileging of process over outcome. Rather than modify midwifery practice to reflect scientific knowledge, RCM encouraged midwives to ignore scientific evidence in service to midwifery autonomy.

It’s not difficult to imagine why so many babies and mothers died as a result of such “reasoning.” In nearly every case, patients died because midwives ignored scientific evidence in favor of their intuition. This is a betrayal of the fundamental ancient goal of midwifery, putting patient health at its heart, and replacing it with a radical, contemporary imperative, putting midwife control at its heart.

Why did the UK National Health Service allow this deadly, self serving ideology to flourish? NHS made a Faustian bargain with midwives in exchange for the promise of saving money; midwives are less expensive than obstetricians. But it turns out that dead and injured babies are more expensive than both.

The radicalization of midwives has turned them from life savers to purveyors of and apologists for preventable deaths. That is unethical, immoral and completely unacceptable.