Doctors vs midwives

A highly qualified, well educated woman, labouring with her first baby, presents to a birthing centre after a stuff-up with her home birth midwife. The midwife couldn't attend, but left detailed instructions with the patient. The membranes rupture and thick meconium pours out.

The pleas of the staff (birth centre midwives as well as doctors) for foetal monitoring go unheard. Hospitals are, after all, centres for 'birth rape', and this mother is determined to not allow a brutal violation of herself and her child to occur.

Several hours pass. The staff become deeply distressed. Decelerations in the foetal heart with contractions are occurring, and the risk to the foetus is increasing. Finally, a caesarean section is performed, but the baby has died by the time delivery occurs. The cause: birth asphyxia.

A noted home birth advocate gives birth at home, with no assistance, in a practice called free birthing. After 2 days of labour, the child is born terminally asphyxiated. The baby girl dies in the ambulance on her way to hospital. The free birth advocates and the coroner's court are at each other's throats. The mother claims that the stillbirth of her child was less traumatic than her first, hospital, birth.

Who is to blame for these tragedies?

I am an obstetrician, and a mother. It would therefore be expected that I would be critical of both these cases. I am expected to espouse the medical model of care, involving a birth in hospital, rapid recognition of foetal distress, timely intervention and a safe mother and child at the end of it all. It is easy, and even expected of me, as a member of the medical establishment to suggest that the patients were the cause of their own downfall, that they made foolish choices but I believe the case is not that simple.

If I walk into any bookshop and ask for the pregnancy and birth books section, I can pretty well guarantee that of the books available, a large majority will be biased towards active birth, water birth and home birth. All of the books that are biased in this way will state that women can give birth naturally, that their bodies are designed to give birth and with will power, any child can be born normally.

The actual statistics on this subject, however, are troubling.

If, for example, we look at mortality in childbirth in the late 19th century, when the first reliable records were kept, we find that maternal mortality rates were 500 per 100,000 births per pregnancy. Given that the average number of pregnancies may have been as high as eight, this gave a cumulative lifetime risk of around 1 in 25 of death related purely to pregnancy.

Today's equivalent can be seen in sub-saharan Africa, where maternal mortality is estimated at 1:16 per life time, or Afghanistan, where birth can only be attended by women, and women are not allowed any education in literacy, let alone birthing practice, and the lifetime risk is 1:6.

Interestingly, the fall in maternal mortality noticed in the late 1800s is now considered to be almost solely due to the practice of midwifery and the presence of skilled attendants at most births. At this time, patients attended to by doctors had a much higher mortality than those attended by midwives. It is possible that the divide between doctors and midwives may well have originated in these times.

A further, much greater fall in mortality, however, was recorded in the 1930s, when access to antisepsis, antibiotics and caesarean section improved very markedly. From that point, maternal mortality fell to very low levels across the developed world, and has remained low since. This fall in mortality was largely due to interventions by doctors becoming much more effective.
It is far more difficult to get statistics on infant death, but it is clear that the time surrounding birth and the first week of life is the most risky for all infants. In the 1800's, up to one third of children did not survive their first 5 years. The rate now of perinatal mortality is around 3 per 1000 births.