Midwives: No room for gifted amateurs

Sunday, July 22, 2007

By John V. Mackel

I am writing in regard to the article about lay midwifery.

I practiced low-risk obstetrics for more than 20 years as a family physician in a major center in Canada and have personally delivered about 1,500 babies. As a United Kingdom graduate, where most of low risk OB care is provided by nurse midwives, I received my undergraduate training in OB from them and still appreciate their skills. I worked with them in our hospital unit for most of my career in OB care.

I no longer practice OB, so I have no vested interest. Also, I now have two wonderful baby granddaughters, both of whom were delivered by nurse midwives in a hospital birthing center. I fully approved of this, so I am certainly not anti-midwife.

Mothers may become high risk during their pregnancy or delivery or immediately afterwards. This can be obvious (such as bleeding) but can also be hidden (such as high-blood-pressure problems). It requires considerable training and experience to practice good OB care. It also needs expert help, immediately available, and the right environment of care.

Mothers can become very high-risk during their delivery process and. this can happen with little or no warning. This requires immediate intervention. I have experienced these situations both personally and also as part of our four-physician group, all of whose practices were low-risk. So this is not some kind of theoretical problem. Since we were in a hospital environment, immediate expert help was always available.

While I agree that normal delivery is not a medical issue, it can become so with frightening speed. Low-risk is not the same as no-risk. A normal delivery is only normal in hindsight.

Lay midwives seems to be saying that they can accurately predict the level of risk in a delivery ahead of time. That is news to us practitioners. The problem with prediction is that some of the most serious problems in OB practice are not predictable at all. They may occur very late in labor, during the actual delivery itself or immediately afterwards, and with great rapidity. Some of my worst experiences were with patients who, by any measure, were low-risk. An example of the perfect storm is when the mother is bleeding heavily and the baby is not breathing. Even in a hospital, this is frightening. I cannot even conceive of what it would be like at home with a lay midwife in attendance.

Which of the two patients will have the midwife's attention?

The advocates of home delivery seem to gloss over these problems, but they are real, they are serious, and I can personally attest to them.

Most concerning is the underlying attitude that focuses on the process of delivery and ignores the outcome of delivery, although it is the outcome that is of greatest importance. It is not much use having a nice delivery experience if the baby ends up damaged, often permanently, in the end.

These are not only human tragedies for the child and the family, but also for society in general. They are also extremely expensive, and the cost is borne by society, both directly (in costs of care) and also indirectly (loss of a functional member of society).

Look at the outcomes of old-style OB care from years past when home delivery was the norm, or outcomes today in the Third World. Look at the high death rates for babies and mothers and high rates of major disability in the survivors. Let us not turn the clock back to the 1920s.

There is also an ethical dimension to this issue. I strongly believe that we have to support those who have no voice, the infants themselves. Would they choose to be exposed to any additional avoidable risk? I think not.

We should reject this ill-advised initiative. There is no place for gifted amateurs in a delivery room.

John V. Mackel of Cape Girardeau is a medical doctor and former professor of family medicine.

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