What About Midwifery?



It is not infrequent that I am asked this question. As as the father of a daughter who is just starting out in the field, and as a doctor who has always striven to work with, learn from, and teach local midwives wherever we have lived, I can say that I have a very positive outlook.
Whether it is obvious or not, the question is usually asked with great passion. People love their midwives, and they want to protect them. (Good!!) Being a Christian physician, I understand the trials and consequences of swimming against the strong currents of the medical “establishment.” But in church circles, being both a doctor and a conservative Anabaptist makes me somewhat of an enigma - an oddity. This helps me to understand the question behind the question: “Whose camp are you in - them or us?” My simple answer is YES!! If you want the explanation, keep reading . . .


RISKS AND BENEFITS

It’s not one of those things we think about, but with just about everything we do, we subconsciously analyze the risks and benefits of doing so. Have you ever contemplated eating a big pizza just before bed or going to Walmart on a Saturday? Of course you have! Well, then you have looked at risks and benefits. Childbirth is a natural, yet important milestone in the the lives of our families, so it deserves some close attention. As it turns out, some of the risks of a medical/hospital approach to childbirth end up being the benefits of a midwife managed delivery. But - it also goes the other way around. The risks of a midwifery approach are the benefit of a medical/hospital approach.

The Spiritual Risks and Benefits

Childbirth is not just another medical procedure. People don’t clamor to have home dental extractions. Neither do our churches work together to train lay surgeons and construct appendectomy or hernia treatment centers. As Christians, birth has special meaning to us, and the Bible has a lot to say about it:

The pain of birth is a consequence of man’s fall: “...in pain you shall bring forth children...” (Gen 3:16)
Yet the result (a child) is a gift: “Lo, children are an heritage of the LORD: and the fruit of the womb is his reward.” (Ps 127:3)
So too, by new birth, we will be reunited with the Lord in Heaven: “Jesus answered and said unto him, Verily, verily, I say unto thee, Except a man be born again, he cannot see the kingdom of God.” (Jn 3:3)


So it is no wonder that many Christians desire a more personal birthing experience. But this often conflicts with the states desire to efficiently manage childbirth, which it sees as just another medical procedure.

Conflict

If we give the state the benefit of the doubt - that it truly sees home deliveries as a risk (we’ll talk about that later), many Christians are still put into the uncomfortable position of asking themselves, “is this God’s turf, or is this Caesar’s turf?” (think Mat 22:21) How much authority does the state have, when it comes into conflict with the abilities of Christian to all exercise birthing options in a free conscience?

But the medical community doesn’t improve the appearances of its intentions by the positions some members have taken. I remember in medical school, a serious effort to force all medical students to assist in abortions. That was almost 25 years ago! The American Congress of Obstetrics and Gynecologists has pushed for “efforts to destigmatize and integrate [italics added] abortion training” for physicians, physician assistants, nurse practitioners, and midwives.1 So while ACOG is trying to eliminate barriers to the taking of life, in some ways, they are working to put up barriers against those midwives who strive to assist in the giving and respect of life. In essence, this could be seen as a drive to “weed out” Christians.

Why is there this drive? It is the age old story of the epic battle of world views. There is little difference between a child being offered up to Moloch and an unborn child being offered up to the twin gods of materialism and convenience.

Where is this all going? Recently, a Christian Swedish midwife was fired from her job for refusing to participate in abortions. The courts found that she must participate if she wants to practice.2 Sweden is not known for its overpopulation or lack of health care access, so it does not seem that there is even a legitimate worldly reason to not allow her a free conscience.

Two of my own daughters were adopted from China, where forced abortions are common. It is because of the One-Child policy that we had the opportunity to adopt them. (Just another example of the Lord turning man’s frowardness into a blessing!) Could that happen here? It might be hard to see this with the recent change in the tone and direction of the country. Yet, it does’t take much of an effort to see powerful secular people in this country (all pro-abortion) who would like to see, for example, the population of the planet decreased by 95% (Ted Turner - Founder of CNN), 50% (Henry Kissinger - Statesman, Nobel Peace Prize Recipient), or 10-15% (Bill Gates - Billionaire).3 This would mean a “reduction” of 1-6 billion people! Does any of this sound familiar?

“And the children of Israel were fruitful, and increased abundantly, and multiplied, and waxed exceeding mighty; and the land was filled with them . . . And he [Pharaoh] said,
When ye do the office of a midwife to the Hebrew women, and see them upon the stools; if it be a son, then ye shall kill him: but if it be a daughter, then she shall live. But the midwives feared God, and did not as the king of Egypt commanded them, but saved the men children alive.” (Ex 1:7,16-17)

To me, it seems like there certainly was, is, and will be a need for God fearing women who feel called to the profession of midwifery to practice in good conscience in their profession.

Summary

So in summary, here is the spiritual risk: there are worldly providers (many physicians, even some midwives) who do not share a Christian world view. Their counsel may not be compatible with a Christian walk (abortion mentality, screening for the purposes of termination, birth control (especially the abortifacients) vs God control, etc.)

The spiritual benefits of Christian providers (some doctors, many midwives): the confidence that the advice and counsel you are receiving recognizes the authority and sovereignty of the Lord, and that the human hands ushering in your child’s new life on Earth are those of a practitioner who share a love for the one true God. The one important caveat to bear in mind is that not all midwives are Christian and not all doctors are worldly.

The Economic Risks and Benefits

According to one study, the average uncomplicated normal birth costs 68% less in a home than in a hospital.4 Anecdotally, I think most of us realize that the savings can be quite a bit more than that.

It makes sense. Below is a chart illustrating the concept of The Law of Diminishing Returns, which says that more is not always better.



As you can see, with only a small increase of cost, the quality of care (and lives saved) increases dramatically. Think about how little cleanliness costs, yet it is probably the greatest life-saving factor. For example, in the 1840s, at the Vienna General Hospital, maternal death rates from infection alone fell from horrific highs of over 30% to generally less that 2% after strict hand washing was enforced!5

The more that is spent, however, may only result in a smaller number of lives saved. Think of Neonatal Intensive Care Units and what they cost to run. Good to have when needed, but expensive nonetheless.

Finally, look at the last part of the curve, where even more cost and intervention can actually result in a decrease in the lives saved. Think about amniocentesis and other usually unnecessary invasive tests that can result in miscarriage, for example.

So it sounds like there is no economic reason to forego a hospital delivery, right? It is true that there are numerous positive studies, and it seems that they universally show a lower cost. Still, it is important to realize that there are a number of presumptions: first, that the out of hospital deliveries are low risk pregnancies, and second, that there is ready access to a receiving hospital if necessary. This is an important presumption, because these studies assume that there is a negligible difference in complications between hospital and home deliveries. If there is actually a higher complication rate, the cost of dealing with those complications, which could extend well into the future (even for the life of an individual), are not taken into account. This leads us to the last section: Medical risks and benefits. What are the complication rates for mother and child in comparing home versus hospital deliveries?

The Medical Risks and Benefits

The Risks

So what is the actual possibility of a bad outcome to the mother and the child when comparing a hospital to an out of hospital delivery? But before I try to answer that, I’d like to talk a little more about the concept of “risk.” Yes, God is sovereign, omniscient, and loving:

“But even the very hairs of your head are all numbered. Fear not therefore: ye are of more value than many sparrows.” (Luke 12:7)

At the same time, he has allowed us to learn from patterns in the past - patterns we can call risk. More specifically, I’d like to introduce the concept of absolute risk andrelative risk, to put things into the proper perspective.

A good illustration of this is the chance of being killed by lightning in any given year. According to the National Weather Service, there have been an average of 51 lightning deaths per year in the U.S. So in a population of 325 million people, your yearly chance of being killed by lightning is about 1 in 6 million. The data also shows that men are about 4 times (400%) more likely to be killed (roofers and climbers). Likewise, since there are 50 states and about 50 deaths, statistically, one would expect about 1 death per state (not accounting for population size). Florida (flat, with a lot of lightning), however sees about 5 deadly strikes per year (a 500% increased likelihood).6

In other words, the Relative Risk of a man (as opposed to a woman) getting hit is high (400% increase), so is the chance if you live in Florida (500%). Does that mean if men see dark clouds, they should dive for cover? (Preferably not under a tree!) What if
you’re from Florida? Should you move to North Dakota (which hasn’t seen a deadly strike in 10 years)? The answer is probably not, because the Absolute Risk for Floridians is still less than 1 in a million, as is the risk for men. However, it would be wise (especially if you’re a roofer that lives and works in Florida) to take proper precautions, such as not playing ball outside or working in high places when you can hear lightning.

Now, back to deliveries.

First, mothers: Historically, even as late as the early 1900s, becoming a mother was associated with a mortality of 6-9 deaths per 1000 live births - nearly 1% for eachdelivery!7 Today, becoming a mother is 99% safer. In modern times, due to sanitation, good surgical techniques, and antibiotics (the risk decreased the greatest (89%) from about 1930 to 1950, when antibiotics came into use), rates are in the area of 10-15 per100,000 live births.8 For comparison, consider that the chance of being taken in an auto accident is about the same in an any given year - 10.6/100,000 population (2013 data)9 Where do midwife assisted deliveries stand in regard to the mother’s risk? Since home and birthing center deliveries amount to only about 1% of the total in the U.S., the data is very limited. One Midwife-led study of almost 17,000 deliveries revealed 1 death (due to a blood clot), so this is in the same range of the national average.10

What about baby? Most women know that pregnancy and delivery can be difficult and complex. From the moment of conception, about 1 in 5 (20%) of pregnancies end in miscarriage, which means that most women will go through one or more in their lives. An another, much larger study looked at 14 million deliveries (which included 130,000 non-hospital births). In it, comparisons were made between hospital midwife deliveries and non-hospital midwife deliveries. They found that the risk to a home or birthing center baby was roughly 4 times that of a hospital delivered baby. (1.26 in 1000 live births vs 0.32 in 1000 hospital births). This seems to make for a high relative risk, but the absolute risk for both is close to 1 in 1000 deliveries. That means for home, birthing center, and hospital deliveries, God, in his mercy, allows about 999 out of 1000 babies to return home to their families.11
Here are some other thoughts:
  • Out of hospital breech deliveries (risk of 22.5 per 1000) have 45 times the risk of
    cesarean deliveries (0.5 per 1000).12 This is high risk, as are moms with diabetes and blood pressure issues. There is not enough data to know how much risk for sure.
  • Twin births have an infant mortality rate of 22 per 1000.13 These children are often premature, and have a significantly higher risk of other medical problems, so should be managed as high risk.
  • First births - relative risk is statistically significant (2.19 per 1000 vs 0.33 per 1000 in the hospital), but is the absolute risk significant (998 vs over 999 babies make it home)? The same can be said for VBACs.
The Benefits
  • Cesarean rates approach 30% in some hospitals.
    • In non-hospital deliveries, 95% of women avoided a cesarean section. Of those, 89% of women completed a non-hospital delivery, but 6% were assisted in the hospital with pitocin, vacuum, or forceps. Only 5% needed a cesarean section. 
  • About 30-35% of hospital deliveries involve an episiotomy.
    • The percentage of women who have no tears in a non-hospital delivery was found to be 49% in the midwife study study, whereas for hospital deliveries only 24-34% of women avoided a tear or episiotomy.14

CONCLUSIONS

Quality Counts

Remember in the last issue, that I mentioned that a physician can do 5,000 deliveries, but the question is does he or she do them well? Well, the same applies to midwives. Does she know her limitations - when to refer out? Does she strive to continue educating herself?
As an ER physician (who, as a family physician, has not done routine deliveries in over 15 years), the learning and testing process never stops: Advanced Cardiac Life Support, Advanced Trauma Support, Pediatric Advanced Life Support, emergency medicine board recertification, Continuing Medical Education state requirements, etc. A good midwife also never stops learning and teaching.

Building Bridges

It is not infrequent that I hear from midwives that they do not get enough support from physicians. This is a valid complaint. No doubt much of this, either directly or indirectly, relates to “turf battles.” However, I believe that for most physicians, if it is apparent that a midwife does all she can to be excellent in what she does, that will go a long way toward building a working relationship.

Here are some suggestions: Most bigger hospitals offer a course called the Neonatal Resuscitation Program (NRP). It is usually taught by Neonatal Intensive Care Unit nurses and pediatricians. Lay midwives could ask about taking the program. If the particular course director will not offer “certification,” it is likely that they will allow an “audit,” which means listening to the lecture, possibly going through the exercises, but not becoming “officially” certified. The same goes for the Advanced Life Support in Obstetrics, which is a course designed to maintain the quality of deliveries for family doctors. I would be happy to help any midwife get started.

Another suggestion: midwives could become a volunteer EMTs or paramedics. If servicing a small hospital, a working relationship physician and midwife will naturally
and necessarily develop. This would allow midwives to, in some ways, be a part of the “establishment” without compromising independence. Additionally, potentially life saving skills can be acquired, such as starting and managing an IV in an emergency.

Unity of Purpose

No doubt I may have stepped on some toes, and pushed many a comfort zone. But when all is said and done, it’s good to remember that our purpose on Earth is to glorify God in all we do:

“And whatsoever ye do, do it heartily, as to the Lord, and not unto men; Knowing that of the Lord ye shall receive the reward of the inheritance: for ye serve the Lord

Christ.” (Col 3:23-24)

Both physicians and midwives have unique and special roles in what they do, so it is important that we learn from each other, and learn to work with each other, in order to better serve God and our patients.

Bottom line: it seems short sighted to get into an “either-or” or a “we-they” mentality, when an “all of the above” view seems to be more scriptural. The Apostle Paul puts it best, for us all to consider:

“Live in harmony with each other. Don’t be too proud to enjoy the company of ordinary people. And don’t think you know it all!”
 (Rom 12:16 (NLT))








ACOG Committee Opinion Number 612, November 2014
http://www.lifenews.com/2015/11/12/court-rules-nurse-fired-for-refusing-to-assist-abortions- must-do-abortions-to-keep-her-job/
Watts, David, “Journey to a Brave New World,” www.iuniverse.com, p.47
Anderson RE, Anderson DA. “The cost-effectiveness of home birth,” J Nurse Midwifery. 1999 Jan-Feb;44(1):30-5.
Semmelweis, Ignaz (September 15, 1983) [1861]. Etiology, Concept and Prophylaxis of Childbed Fever. Translated by Carter, K. Codell. University of Wisconsin Press.
http://www.lightningsafety.noaa.gov/fatalities/fatalities14.shtml
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm#fig1
http://data.worldbank.org/indicator/SH.STA.MMRT
http://data.worldbank.org/indicator/SH.STA.TRAF.P5
10 Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. and Vedam, S. (2014), Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women's Health, 59: 17–27.
11 Gr√ľnebaum A, McCullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol 2014;211:390.e1-7.
12 Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG 2016;123:49–57.
13 https://www.uptodate.com/contents/neonatal-complications-outcome-and-management-of-multiple-births
14 J Sleep, A Grant, J Garcia, D Elbourne, J Spencer, I Chalmers, West Berkshire perineal management trial. Br Med J (Clin Res Ed) 1984 Sep 8; 289(6445): 587–590.



Note:  Comments are open, but in the interest of civility and transparency, your full name and home town will also be needed in the post.  If that is not possible, please PM me.  Please use language and tone that is becoming of charitable Christian debate and discussion.


page8image3683120page8image3673552page8image3683328page8image3683744page8image3683952page8image3684160page8image3684368page8image3684576

Comments