June 24th, 2019
Certified Nurse Midwives (CNMs) are licensed health care professionals that provide prenatal, labor, and postpartum support for women. In a culture that often ignores the preferences and health of mothers and “views women simply as vessels for childbirth,” in the words of Harvard obstetrician Neel Shah, midwives can advocate for mothers and provide continuous support, with an emphasis on empowering patients and avoiding unnecessary interventions. This leads to demonstrably better health outcomes, both for mothers and children.
A recent segment on CBS’s “Whistleblower” series titled, “Doctor vs Midwives: Dangerous Deliveries,” ignores the broader context of midwifery, painting a distorted picture of maternity care in America. The segment tells the story of Dr. Judy Robinson, former head of obstetrics and gynecology at HealthNet health center in Indiana. Robinson was disturbed by the high number of complications and preventable deaths at HealthNet that were happening because the midwife-led obstetrics team refused to involve obstetricians in high-risk cases. Robinson later found out that it was HealthNet that was keeping ob-gyns shut out of births (even though ob-gyn involvement is required for high-risk births) to avoid costs for maternity care staff while keeping the larger reimbursement from Medicaid for such births. Robinson could no longer stay silent, and blew the whistle.
This segment shows the tragedy of what can happen when health systems value profits over patients, but also reinforces some inaccurate stereotypes about midwifery, such as the idea that involving midwives will lead to dangerous complications. For high-risk pregnancies, like many of those at HealthNet, ob-gyn involvement is required to help anticipate and address potential complications. However, serious complications such as preeclampsia and pulmonary emboli are still too common, even for ob-gyn-led births. Overall, there is much more that health systems can do to listen to patients’ concerns and prepare for potential complications.
For low-risk pregnancies, research shows that involving midwives in maternity care actually leads to better outcomes and fewer unnecessary procedures. Incorporating midwife care into maternity care has been shown to increase the likelihood of spontaneous vaginal birth, and reduce the likelihood of neonatal mortality, preterm birth, low birth weight, and cesarean birth. Additionally, having continuous, one-on-one support from a midwife or doula during labor is associated with reduced negative feelings about childbirth, compared with just having physician care.
While the CBS segment made it seem as though midwives were attempting to shut out the doctors, the reality is that midwives and ob-gyns often work together to provide quality maternity care, especially for high-risk patients. While many low-risk patients have great outcomes working only with a midwife, they are trained to transfer care to ob-gyns if risk to the mother or child increases at any point.
It is true that partnerships between midwives and ob-gyns are not always seamless. There can be tension between midwives and ob-gyns around who can and should provide care for certain patients, a conflict that is often intensified by stereotypes about midwives and state policies that restrict certain aspects of midwife care. However, in states where midwives are given greater independence to practice, such as Washington State, ob-gyns and midwives have learned to collaborate closely, transfer care when health risks emerge, and jointly work toward better outcomes. Having midwives attend to low-risk cases can even reduce burnout among overworked ob-gyns. Unfortunately, tv segments with the title, “Doctor vs Midwives: Dangerous Deliveries,” only serves to further alienate health professionals who should be trusted partners.
While Robinson should be applauded for speaking out against HealthNet’s unethical practices, the story needed more context about the larger picture of maternity care in America and the positive track record of midwifery as a whole.