When Sigrid Chapman gave birth last month … she turned to a midwife instead of an obstetrician to handle the delivery, a choice being made by more women.
Although nurse-midwives attend to a small portion of births in the United States, demand for their services has increased almost every year ...
Now, midwives in New York State see the potential for additional growth. They won a major battle last week to work more independently after the Legislature repealed a requirement for written agreements with doctors to deliver babies.
The change … could increase the availability of midwives to women … who opted for midwifery because of its focus on natural childbirth.
"My obstetrician wanted to do a repeat Caesarean section, and the midwife was less skeptical and more encouraging about doing what I wanted," said Chapman.
Midwives work with obstetricians … But … the professions practice with different philosophies.
Midwives specialize in assisting through low-risk pregnancies and helping women who want natural births with minimal technological intervention. Obstetricians tend more toward active management of deliveries to anticipate and prevent potential problems.
The written agreements spelled out the working arrangement between doctors and the 1,300 licensed midwives in the state.
Midwives contended the agreements were unnecessary because midwives have a professional and ethical obligation to consult with obstetricians with or without a written practice agreement, particularly when a pregnant woman encounters problems and needs the expertise of a physician.
Midwives argued that physicians … refused to sign agreements, preventing them from delivering babies. They noted that elimination of the agreements doesn't change the scope of their practice — what it is they are allowed to do professionally as midwives.
We recently had the same situation in Australia, with insurance requiring a signed collaborative agreement with an obstetrician. The only catch was that obstetricians refused to sign such agreements. We are now required to submit a care plan for every woman in our care.
"The bill makes it easier to practice, and for patients, it removes a barrier to access us," said Laura Sheparis, president of the New York State Association of Licensed Midwives.
… The American College of Obstetricians and Gynecologists made the legislation a patient safety issue, arguing that the agreements ensure an OB-GYN will be contacted immediately if a midwife is faced with a high-risk birth. After passage of the bill in the Legislature, the organization stated that patient safety will continue to exist in midwife-attended births in hospitals but not for home births.
"The agreements are a safety net in case something goes wrong at the end of labor," said Donna Montalto, executive director of the college's New York State section. "If there's no doctor supervision, midwives shouldn't be doing obstetrics."
It must be said that midwives do not practice obstetrics. Only obstetricians do that. Midwives practice midwifery which is a separate and distinct profession to obstetrics. And nursing. And physiotherapy. And dietetics. Midwifery is a profession in its own right.
Dr. Mark Weissman, a Buffalo OB-GYN, said he supports midwifery and believes most midwives will continue to collaborate with physicians, but he worries that the relationship will be unregulated with the elimination of the agreements.
"The delivery of a baby should be a shared responsibility. Without the agreement, midwives will be able to perform home births and create their own birth centers," said Weissman, chairman of the college's Buffalo-area section.
Shock horror! Midwives running birth centres! What is the world coming to?!?!
For midwives, the written agreements come across as an unneeded obstacle to providing services that they see as increasingly relevant to pregnant women, especially in efforts to help avoid Caesarean sections. "We have a pretty good track record of achieving natural births," …
… the report lends support to midwifery. She cited its conclusion that choosing a midwife will likely decrease the chance of an unnecessary Caesarean since the likelihood that one will be needed is generally less with midwives than with obstetricians.
With obstetricians more inclined to perform a Caesarean, some women worry about losing control of their delivery. Chapman, a neonatal nurse … received a Caesarean for her first birth in 2008, but she found it difficult to recover from what turned out to be a physically and emotionally wrenching process for her.
"It was very hard on my body," she said. "When I got pregnant again, I wanted the delivery on my terms. I wanted to do it on my own and feel like a real woman."
Her second baby was larger than average, like her first, and the obstetrician worried that a normal birth could cause a uterine rupture, particularly with the previous Caesarean.
"When I asked her about doing a vaginal birth, she looked at me as though I was crazy," said Chapman. She sought out a midwife anyway … and liked that her desire for a vaginal birth was treated with encouragement rather than skepticism.
The baby was born naturally … Mom was thrilled with the way it went. " ... the midwives made me believe I could do it instead of leaving me with the feeling that I would have to fight for it."
The situation can be likened to GPs referring their patients to specialists when the need arises. Do GPs have practice agreements with cardiologists, rehab specialists, endocrinologists, paediatricians, neurologists, haematologists, oncologists, gynaecologists, psychiatrists etc? Or do they simply consult and refer according to best practice, as required by their professional body?