Between 1935 and 1985, the number of American women who died from complications of childbirth dropped by 99%. Our health care system achieved this success by orienting around safeguards to protect women against the worst possible outcomes — an approach that continues to this day to define the delivery of hospital-based US maternity care.
Recently, conversations among care providers, policymakers, and patients have begun to challenge this assumption. Have we created a system so focused on vigilance to protect mothers and newborns at birth that we interfere with the normal processes of childbearing? And if so, at what cost?
How Childbirth Changed
Historically, childbirth was the realm of apprentice-trained midwives who provided a supportive presence through this normal life transition. As the discipline of obstetrics formalized in the US, the medical profession entered the birthing sphere with an explicit recognition of the pathologic risks associated with labor and delivery. In an attempt to improve birth outcomes and also to facilitate more standardized education for physicians, maternity care was moved into hospitals and out of the hands of midwives.
A dramatic reduction in maternal mortality followed as a result of the rigorous imposition of measures to mitigate very real risks of adverse outcomes in childbearing through ready access to lifesaving interventions. These include medications to prevent excessive bleeding, sterile conditions, and cesarean delivery. For the average healthy American woman, however, we have seen the medicalization of childbirth lead to certain undesirable trends. For example, cesarean delivery, or c-section, is a lifesaving surgery when used judiciously. But it can also become the unintended result of a chain reaction that starts with an innocent ultrasonography, a not-quite-perfect fetal heart rhythm, or simply a patient's request. Although we will never know whether a c-section delivery was truly justified, we believe that rising c-section rates are a major cause for concern, because they increase mothers' chances of hemorrhage, infection, and the need for complex intervention in future pregnancies.
Midwives as Part of the Solution
Attention from the obstetric community to soaring cesarean delivery rates resulted in the 2012 consensus statement from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists (ACOG) calling for labor management standards that require more patience and flexibility before wielding a scalpel. We applaud the introspection demonstrated by this effort, which acknowledges our shared goal to provide the appropriate level of care required to maximize outcomes. Taking this one step further means reaching for guidance from our colleagues in midwifery. They have much to offer in this respect, hailing from a long tradition of "honoring the normalcy of women's lifecycle events."
Studies in the US suggest that midwife-led labor is associated with lower c-section delivery rates, reduced reliance on oxytocin to induce or speed up labor, less narcotic use, and fewer diagnoses of abnormal labor and fetal distress. In the United Kingdom, where midwifery is fully integrated into maternity care, researchers found that low-risk women in midwife-led units are more likely to achieve a vaginal birth and less apt to receive interventions to hasten delivery. Neonatal outcomes were statistically similar to obstetric-led units.
Nevertheless, physicians' perceptions of the role of the midwife vary widely. While some physicians see midwives as partners who bring a unique and valued set of skills to caring for women, others are reluctant to embrace this partnership because of negative perceptions either of nonphysician providers generally or midwives specifically. Furthermore, the recent lauding of midwifery is frequently interpreted by the media as an affront to the medical establishment, as depicted by headlines such as "Doctors Versus Midwives: The Birth Wars Rage On" and "Are Midwives Safer Than Doctors?" Our task ahead is not to compare the merits of obstetrics and midwifery, but rather to address patients' goals and to work together toward continuous improvement of maternity care in this country.
We advocate that explicitly establishing professional standards for collaborative physician-midwife care is critical to a needed culture change in our birthing units from one that sees laboring women as disasters waiting to happen to one that monitors for risk in the context of care that fully encourages normal processes. After all, this is not a simple zero-sum game; it requires an appreciation for the roles both professions play in the endeavor of healthy birth outcomes.
A New Way of Working Together
While combined physician-midwife practices have become more prevalent, many physician-led maternity units believe that by virtue of staffing midwives, they are reaping midwifery's many benefits. Unfortunately, this reflects a lack of understanding of the philosophical differences between these professions. Midwifery's high-touch, low-technology approach to birth is difficult to sustain in an environment implicitly designed to support the opposite.
ACOG recently took the lead in forging a path with advanced practice clinicians from various disciplines. In March 2016, ACOG outlined its commitment to team-based care as an important way to address the broadly shared triple aim of health care — improving the experience of care, improving the health of populations, and lowering per capita costs. Patients are best served by a team-based approach with collaboration between professions representing one aspect of a team's success, ACOG said. Beginning with the patient's goals at the center, team-based care also relies on a shared vision, accountability and respect for each member's unique contribution, effective communication, and dynamic leadership. The ACOG statement lays a progressive groundwork for the integration of obstetricians and midwives in team-based care.
We propose the development of new practice models that begin with a deep understanding of patients' goals and employ a team of obstetricians, midwives, and other maternity care providers to achieve them. Obstetricians would no longer be required to serve as the de facto leader, allowing other members to take the lead when appropriate to meet patients' needs. For the vast majority of healthy, low-risk women, this would potentially result in a greater role for midwives and bedside nurses in labor and delivery, similar to care in the UK and other parts of Europe that have better infant and maternal outcomes than the US.
A team-based approach would identify those gaps in obstetrics where midwifery can shine, allowing us to reduce the overall "treatment intensity" for women who do not warrant it. Although team-based models must heed state-level scope of practice regulations, it seems these models of care can thrive in a payment structure increasingly rewarding quality over quantity. Future research may evaluate the effectiveness of team-based maternity care models in achieving patient satisfaction, improving quality, reducing costs, and engendering a cultural shift toward normalcy.
Despite tremendous variation in maternity care, the literature suggests that it is who cares for a woman that is the single most powerful determinant of her childbirth experience — particularly whether or not she has a c-section. The difference isn't a matter of technical skill or access to the latest advancements. It is determined by how the provider strikes the balance — culturally, operationally, and technically — between averting poor outcomes and encouraging normalcy. Although there have been marked historical shifts in whether obstetricians or midwives "own" the endeavor of childbirth, mothers and babies in this country will be best served by making room at the table for both perspectives.
This post was adapted from an article in Obstetrics & Gynecology ("The Green Journal"), the official publication of the American College of Obstetrics and Gynecology.