Regulating Obstetrics Like We regulate Midwifery?

What would the landscape look like if we were to regulate obstetrics the way we regulate midwifery?

Regulating Obstetrics Like We regulate Midwifery?

Who is regulating obstetrics? Obstetricians are. Who is regulating midwifery? Obstetricians. In what other practice would this be seen as anything but a gross conflict of interests? Midwives know full well when the specialist skills of an obstetrician are required, and yet obstetricians deny them, and most notedly, they deny WOMEN, their rights to bodily autonomy.

Restrictions on midwifery are having an enormous impact on women from one side of the globe to the other. Midwives cannot attend homebirth, they can’t open birth centres. They can’t get practicing rights in hospitals if they work independently. In some places, the number of vaginal exams they must perform is numbered – regardless of the client’s personal preference. Whether they can attend VBAC, how many weeks pregnant the woman must be before she can be attended by a midwife, or when her care must be transferred to an obstetric setting. The list of restrictions is never ending, yet the people who make the rules and restrictions (the obstetricians) have very few restrictions on their practice. They have guidelines, but the guidelines aren’t binding.  

Safety in birth is defined by obstetricians not by midwives, despite midwifery being a stand-alone profession within the maternity care industry. In the US only around 8% of women see a midwife during pregnancy or for birth. In other countries around the world women routinely see midwives, but the care they receive is based on the obstetric model of care rather than the midwifery model.

We see vastly different outcomes between women who receive genuine midwifery care and obstetric led care. The rates of intervention, including everything from induction to episiotomy, epidurals, forceps, and caesarean surgery, are all higher in the obstetric model. Interestingly the rate of premature birth is also lower with midwifery care, possibly due to the fact that midwifery does not routinely induce or perform booked caesareans. We also see that fewer women lose their pregnancies before twenty-four weeks with midwifery led care.

Here’s what we need to pay particular attention though: When we compare the high rates of intervention from obstetrics, to the low intervention rates with midwifery, we see virtually no difference in outcomes for women or babies. Surely all those interventions should be making birth safer for women and babies! Most notably, it’s rather confusing that we perceive things the way we do, particularly given higher rates of premature birth and foetal loss found within the obstetric model.

Why, in the face of this, are we allowing obstetricians to define safety when, at the very least, their figures are in need of urgent investigation?

Despite obstetricians using all kinds of machinery and equipment, testing, and despite all the protocols for women in their care, midwives still provide perfectly safe maternity care. What we see from midwifery care however, are compellingly higher rates of satisfaction in new mothers.

It’s important to note that when we say there is no significant difference between outcomes for women and babies, we are talking about death. Death is the yardstick for successful maternity care in 2016 – according to obstetricians. We’re not talking about things like intact perineums, or damaged pelvic floors, or injuries sustained by newborns during highly medicalised births. We’re certainly not talking about how women feel about the care and support they received, because having a pulse is the yardstick.

Let’s take a look at some regulations that might improve outcomes for women, and see how well the shoe fits when you put it on the other foot. Regulating obstetrics might do wonders!

  • Practice guidelines for hospital maternity care will be determined by midwives and women instead of surgeons: As midwives have far more simple, cost effective ways to manage healthy pregnancy, greater knowledge about maintaining health in pregnancy, and a greater skill set than surgeons (for example surgeons are taught to perform caesareans for a breech baby or twins, midwives know how to attend unusual births) midwives will be called upon to create new guidelines for hospital maternity units.
  • Surgeons will not be permitted to attend vaginal births after caesareans unless a woman is referred to obstetric care by a midwife: As we know, the less intervention that occurs during a normal birth, the greater the odds of the woman achieving a vaginal birth. This is no different for VBAC. Under obstetric regulations the VBAC rate is embarrassingly low, yet with genuine independent midwifery it’s surprisingly high. Given that caesareans are major surgery and they carry tremendous risks the more you have, it’s vital that we increase our VBAC rate immediately. Regulating obstetrics could be life saving!
  • Surgeons will not be permitted to open a private practice unless they have a collaborative arrangement with midwives: Midwives would need to oversee every aspect of practice that is provided by independent surgeons, and no medications, testing, or procedures would be permitted until a midwife had ordered it.
  • No venue will be able to host births unless there are twenty-four hour midwifery staff: Obstetricians have closed down many successful and popular birth centres on the grounds that there was no surgical team present. This has done nothing but force midwives to practice without obstetric back up, and force women to give birth unassisted, when they would prefer a midwife.

As you can probably see, these restrictive practices are absurd. They would make the practice of obstetrics all but impossible. Which is, incidentally, exactly what is happening to midwifery. Midwifery however, has not been the practice which has given us a one in three caesarean rate in many places, higher in many more.

The truth is that obstetricians and midwives need to work both independently and they need to be able to work together, seamlessly. Neither fully understands how the other practice works, because they are only trained in their own field, Allowing obstetricians the power to regulate midwifery is as ridiculous as allowing midwifery to regulate obstetrics! Midwifery has so many guidelines and regulations that it is all but impossible for a woman to find true midwifery care. 

So how are we currently regulating obstetrics? Obstetricians have guidelines, not to be confused with rules or regulations. For example governing bodies such as RANZCOG and ACOG suggest vaginal birth after two caesareans is a reasonable option for women, but finding a private surgeon to attend a VBA2C is extremely difficult. Finding a hospital who will permit it on the woman’s terms is also extremely difficult. Finding a midwife to attend a VBA2C is almost impossible because the regulations for midwifery are set by the surgeons. Surgeons who don’t even follow their own guidelines, making regulations for midwives whose practices they don’t understand.

How many forced caesareans are happening because of the obstetric regulations placed on midwifery? Sure this issue impacts on the economic freedom of women who are midwives, but its impacts are far greater to birthing women. 

We should view our current maternity system through a new lens. It’s something akin to asking plumbers to provide the regulations to govern electricians. But it’s worse than that, because plumbers have no vested interests in the business of electricians, whereas obstetricians who control the provision of midwifery keep all the business for themselves.

In many third world countries, the maternal and foetal mortality rate is being reduced by the low cost provision of skilled midwives. Highly skilled midwives who recognise normal birth, and the need for obstetric intervention. In most births they simply assist the woman in her own setting, but in some instances they recognise complications and assist the woman in finding more specialised obstetric care. Midwives are reducing the death rate, and funnelling women in need through to obstetricians. This highlights how effectively midwives and obstetricians can work together for the wellbeing of women and babies. This model of care requires no regulating obstetrics or midwifery, the two work together in comfortable recognition of their respective expertise.

In order for women and babies to have the highest quality, best standard of maternity care, they require a good fluid balance between midwifery and obstetrics. Regulating obstetrics will do no more to assist women and babies than regulating midwifery is currently doing. In fact it may have awful consequences. 

Some women may prefer an obstetrician, but if the skills set of an obstetrician are not required, then a referral to a midwife may be an option – it should not be compulsory. Maternity care should be a two-way street. Midwifery must be the front line for pregnancy care for a multitude of reasons, safety, satisfaction, and the cost of healthcare being just a few. Regulating obstetrics is not the solution here, any more than regulating midwifery has been.

Some women need to see an obstetric surgeon because they have complicated pregnancies, but the majority of women have normal, healthy pregnancies and fare better under the guidance of a known midwife. 

Regulating obstetrics to the degree that we currently regulate midwifery would serve to benefit no one. In practice it would do nothing but totally paralyse essential services. Loosening the reigns on midwifery would improve the safety, choice, and the satisfaction that women express when they are entering that most monumental of times in their lives. Motherhood! It’s time to let midwifery be the independent practice that it is, the practice that relies on obstetrics for back up, not regulation.

FOR FURTHER READING 

regulating obstetrics - woman being shown baby after caesarean
How would it look if we regulated obstetrics in the same way we regulate midwifery?
License: Creative Commons CC0.

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