Midwifery philosophy is failing

Fail Exam Grade

Midwives are so busy 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.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwifery philosophy has had essentially no impact on childbirth metrics.[/pullquote]

“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.