Choosing Your Maternity Care Provider
by Marsden Wagner, MD
World Health Organization

Your choice of a care provider will be the most important factor in whether
or not you get the birth that you desire.  How do you go about being
pregnant and giving birth in circumstances where the use of technology is
appropriate and right for you, your baby and your family? The first step is
to get the right health care professional to assist you during the pregnancy
and birth. A key decision is to decide if your primary maternity care
provider is to be a midwife, a family physician or an obstetrician.
   
The United States and Canada are the only countries in the world where
highly trained surgeons, called obstetricians, attend the majority of normal
births. The American obstetrician is trying hard to be all things to all
women—primary maternity care provider for normal, healthy pregnant
and birthing women, specialist in complications of pregnancy and birth,
specialist in women's diseases and a highly skilled surgeon. No other doctor
anywhere in the realm of health care tries to maintain competency at all
these levels and in so many areas because it is totally unreasonable to
expect this from one human being.

While American obstetricians have worked hard to convince the public they
are the safest people to assist at all births, the scientific evidence does not
support them. For example, a large scientific study published in 1998
looked at all births in the United States in one year—more than four million
births. Because doctors really do need to manage the few births that
develop serious complications, the study eliminated complicated births and
looked only at low-risk births.

Compared with physician-attended low-risk births, midwife-attended low
risk births have 33 percent (one-third) fewer deaths among newborn
infants. Furthermore, midwife-attended births have 31 percent (nearly one-
third) fewer babies born too small, which means fewer retarded and brain-
damaged infants.

There is not a single report in the scientific literature that shows
obstetricians to be safer than midwives for low-risk or normal pregnancy
and birth. So if you are among the more than 75 percent of all women with a
normal pregnancy, the safest birth attendant for you is not an obstetrician,
but a midwife.

The Common Hospital Birth Scenario

For 50 years now the United States has had a system of maternity care in
which the woman goes into labor, goes to the hospital and is admitted into
labor and delivery by a labor and delivery nurse (L&D nurse).  It is the L&D
nurse who examines the woman and calls the obstetrician with a report.  
The obstetrician, who is either at home or in his or her office (usually seeing
normal, healthy pregnant women) then gives orders over the telephone to
the nurse, most of these orders will not be based on individual care of this
particular laboring woman but are instead standard protocol orders this
doctor uses with all of his or her laboring patients.  It is the nurse who will
then assist the woman during the course of her labor along with the many
other laboring women this nurse is responsible for keeping track of in order
to give reports via telephone to the doctor.

The obstetrician may or may not come by the hospital sometime during the
labor to briefly check the woman himself. But it is the job of the L&D nurse
to monitor the labor and call the obstetrician when the birth is imminent so
that the doctor can rush in, catch the baby at the last minute and get all the
credit (and money) for "delivering" the baby. If the nurse calls the
obstetrician too soon and the doctor has to hang around the hospital waiting
for the birth, the doctor may be angry with the nurse for wasting his time.
But if the nurse calls the obstetrician too late and the baby is born before
the doctor gets there, the doctor may be angry with the nurse since he or
she will not get paid for that birth.

Who Will Be With Me in Labor?

If you are considering a hospital birth with an obstetrician as your primary
birth attendant, ask him or her how much time he or she will spend with
you during your labor. One of the reasons a midwife is generally a better
choice to attend your hospital birth than an obstetrician is because the
midwife is there in the hospital with you during your labor while the
obstetrician is not. It is an incredible irony that the obstetrician insists that
the woman who is his or her client give birth only in the hospital, while the
obstetrician who should attend her birth is not in the hospital. If your
obstetrician is not with you in the hospital during labor, then where is your
obstetrician?

Why is it important to insist that your obstetrician be with you during your
labor as well as at the birth? In a study of obstetrical malpractice cases
involving permanent brain damage of the baby, the absence of the
obstetrician from the hospital during the labor played a central role in
causing the tragedy in approximately two-thirds of the cases. This research
showed that telephone conversations during a hospital birth between
nurses at the hospital and the doctor who was not in the hospital gave rise
to misunderstanding or miscommunication that caused adverse effects for
the mother or baby. If you choose an obstetrician as your primary birth
attendant and he/she cannot guarantee that they or another obstetrician
will be physically present (not just on call) during your labor as well as the
birth, you are wasting your money and putting your baby in danger, and
you need to get another birth attendant.

If you doubt this description of hospital birth, ask any of the more than
25,000 L&D nurses in the United States. These nurses are skilled
professionals who do what is really an impossible job. They must monitor
the laboring woman and assist at the birth, all the while keeping the doctor
happy and covering up for the fact that the doctor is not there most of the
time and in most cases makes a minor contribution to the birth. The fact
that defines and limits these nurses is that they have no autonomy and can
do nothing without doctors' orders.  Most L&D nurses also never receive
training in how to support a naturally laboring mom and so they are quick
to offer drugs as an answer. Some have never even seen a natural birth!

Who Are Midwives?

Midwives are autonomous professionals who provide primary maternity
care and are analogous to family physicians who provide primary health
care. If the family physician hears a heart murmur and refers the patient to
a specialist cardiologist, this does not mean the family physician is the
cardiologist's assistant and somehow less competent, but only that the
cardiologist has a different expertise—an expertise for certain
complications—than the family physician has. The cardiologist makes
suggestions for treatment of the family physician's patient, which the family
physician and patient may or may not choose to follow. The cardiologist and
the family physician are professional equals who collaborate with mutual
respect to provide the best quality care for the patient.  

By the same token, a specialist obstetrician does not give orders to a
midwife any more than a cardiologist gives orders to a family physician. The
midwife may refer a woman to an obstetrician because of a complication,
but this does not make the midwife the obstetrician's assistant. The midwife
and obstetrician then collaborate as professional equals.  Midwives
specialize in normal, natural, low-risk births.

A Midwife or an Obstetrician: What’s the Difference?

One main reason midwives have better fetal/maternal outcomes and are
safer than doctors is because midwives use far less unnecessary technology.
Because obstetricians are surgeons, they turn birth into a surgical
procedure. Proof of this is that the birthing woman is treated as if she is a
surgical patient: she is put on her back in a bed that is really a modified
surgical table, often with her legs up in surgical stirrups. For more than 25
years we have known scientifically that this is the worst of all possible
positions for a woman giving birth; in this position the baby's head
compresses the woman's main blood vessel that supplies the womb and the
baby and reduces the blood and oxygen going to the baby. If the woman is
in a vertical position (sitting, squatting or standing), more blood and oxygen
flow to the baby, the woman's bony pelvis opens more to let the baby out
and she gives birth downhill instead of uphill against gravity. One way to
find out if a hospital is practicing modern maternity care or not is simply to
see what position women are put in during birth. If the hospital staff is still
putting women on their backs during birth, they are ignoring all scientific
data and still pretending birth is a surgical procedure.  Obstetricians also
have much higher c-section rates--sometimes double that of midwives--
even when all things are considered equal.
.
Birth as a Surgical Event?

Between 50 percent and 80 percent of births in most American hospitals
involve one or more surgical procedures, further proof that obstetricians
have turned birth into a surgical event. Those procedures include drugs to
start or speed up labor, episiotomy (cutting the genitals with surgical
scissors to widen the vaginal opening), placing metal forceps or a vacuum
extractor on the baby's head to pull the baby out (you can imagine the risks
involved in this), and cesarean section to cut the baby out. In reality, and
shown through research, any of these surgical procedures is necessary in no
more than 20 percent of all births. And since all surgical procedures carry
risks, the high frequency of their unnecessary use in physician-attended
births leads to more dead and damaged babies than would ever occur in
midwife-attended births. Large numbers of research reports document that
midwives use far fewer surgical interventions than doctors. A case in point
is the use of episiotomy. From half to three-quarters of all women in
America birthing their first baby in the hospital with the assistance of a
doctor have this surgical cut done to their genitals. It is scientifically proven
that no more than 20 percent of women will need this cut; the best rate is
about 5 percent. Among midwives in independent practice in the United
States (that is, when doctors are not giving midwives orders as to what to
do), between 2 percent and 20 percent of women undergo episiotomy.

While midwives trust women's bodies, use low-tech assistance, the skilled
use of their hands, and understand the importance of preserving normalcy,
doctors, in general, do not trust women but trust drugs and machines, use
high-tech assistance, and focus on the pursuit of abnormality. So having a
highly trained surgeon obstetrician assist at your low-risk birth is about as
sensible as hiring a pediatric surgeon as a baby sitter for your healthy 2
year old when you go out in the evening. Like the obstetric surgeon who
gives the normal woman a shot of the drug Pitocin to hurry her labor, the
pediatric surgeon baby-sitting your normal child will focus on medical
management: when your robust 2 year old gets tired and fussy, the
pediatric surgeon will give him or her a sedative to hurry the child to sleep.
The result? In the one case you get the medicalization of birth (remember,
birth is not an illness), with a lot of unnecessary risky interventions and
very expensive medical care, and in the other case you get the
medicalization of childhood (being 2 years old is also not an illness), with
unnecessary risky interventions and very expensive baby-sitting.

When deciding on your primary maternity care provider, it is important to
ask midwives or doctors about their practices: find out if they prefer to put
you on your back during birth and how often they do episiotomy, forceps or
vacuum extraction, and cesarean section. If they don't know their rates of
surgical interventions or refuse to tell you what their rates are, look out!
Beware of any tendency to patronize you, to suggest that you cannot
possibly understand all this technical stuff, or that you should just " trust
me, I'm the doctor." If you can read, then you can be as educated as anyone
else about labor and birth!

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