Journo

Primum Non Nocere

Bay State drops the ball on women's healthcare

The Massachusetts legislature has dropped the ball on women's healthcare. A bill which would provide an ‘umbrella' for all three groups of professional midwives (Certified Nurse Midwives, Certified Midwives, and Certified Professional Midwives), with enhanced standardized regulations and oversight, will decidedly not pass today. Boston's Weekly Dig quoted Rep. Vincent Pedone (D-Worcester), who put a hold on the bill due to his concerns about safety: "I have questions regarding the level of... safety for child-bearing women in Massachusetts ... My feeling is that the level of education, training and oversight is not adequate for us to give our seal of approval. It puts both the mother and baby at risk."

The point of the bill--to regulate and oversee already educated, trained and practicing midwives who have registered with one of three nationally recognized midwifery organizations--was apparently lost on Pedone, and the others who did little to move the bill forward. The point of the bill is to enhance the level of safety and care by creating a Board of Registration in Mass for midwives; what Pedone is questioning is the effectiveness and safety of the practice of midwifery itself. The legislators are suffering not only from startling ignorance concerning women's healthcare in this country but also, apparently, from a lack of internet access or a library card. The information is out there, compiled for decades by the WHO, by the United Nations, by medical anthropologists from all specialties, by doctors and by midwives. If Pedone had questions, he need only Google to find the answers.

Most of the United States suffers from a strange fetishism: a near-worship of the Western model of biomedicine, a complete and bottomless trust in the symbol of the white lab coat. Part of this worship is understandable--when it comes to fixing problems and curing pathologies, America is hard to beat. Pregnancy, however, is neither a problem nor a pathology, and the high level of medical intervention insisted upon by most US hospitals does little to aid the natural, biological process of childbirth. In fact, in lots of cases, it hinders, even harms.

According to the United Nations, the US is ranked 163 in world-wide infant mortality rates, at 6.3 per 1,000 births, and our maternal mortality rate is not much better at 17 per 100,000 (Iceland, by comparison, is 0; Austria is 4). Our citizens believe in our status symbols (wealth, technology, science, schools) and that those symbols enhance our level of health and heath outcomes. Why, then, are we 163?

More babies die at birth in the US than in New Zealand, Cuba, and even Slovenia. We're behind Cuba and Ireland and even the Channel Islands. You have better chances of delivering a healthy baby in South Korea, Singapore, Switzerland, and the Czech Republic than you do on our own soil, and there's no place more enticing for an expectant mother than Iceland, the first place winner, with a mere 2.9 deaths per thousand. The Massachusetts rate of C-section is over twice the WHO condoned rate, at 33%, only slightly higher than the national average of 31%. We induce; we monitor; we inject; we cut. Sometimes, the data shows, we kill.

A group of Mayans in Mexico practice midwifery in the home for nearly all their births, and although their midwives are trained to refer problems to nearby hospitals, they rarely do. Their infant mortality rate is 4 per 1,000. Babies are born with dad and female relatives in attendance, with a folk-trained midwife with basic skills (disinfect the blade you cut the cord with, and that sort of thing) administering massage. There are no fetal monitors or epidurals or episiotomies, and certainly no inducement of labor when a woman doesn't deliver by her entirely arbitrary guesstimate of a due date. More babies live. The !Kung San, a hunter/gatherer tribe of the Kalahari who practice solitary birth (ideally with no midwives or attendants) have a maternal mortality rate of 4 in 1,000. While that's significantly higher than the US, it's also in astounding defiance of Western stereotypes about ‘primitive' birth practices.

Of course, women in the US, even women inclined towards natural childbirth, birthing centers, midwives, or home births, have one nagging question: What if Something Goes Wrong? It's a legitimate worry, of course, and with it comes the guilt and blame associations often attached to hippie dippie mothers who ‘irresponsibly' choose home births, even those mothers who have healthy babies to show for it. Midwives, of course, are also interested in the Something going Wrong, and data from the University of Michigan shows that Wrong is Relative: midwives generally deliver with lower instances of C-sections, neonatal death, and low birth weight than doctors do. When there are real problems and high-risk pregnancies, midwives are "effective in screening... and referring those clients to obstetricians," according to Barbara Graves at Bay State Health (from the Dig article). No one ever said that by choosing a midwife, childbearing women forfeit the opportunity for high-tech medical care. And yet that seems to be the public impression.

Women are biologically capable of giving birth without any help from white lab coats, IVs, and C-sections. It's nice to know we've got the option, of course, but Mass seems to think it's our only option. When the midwifery bill comes up for consideration next time around, physicians, midwives, and legislators alike should take a good look at the hard data and remember the Hippocratic tradition: primum non nocere.

"First, do no harm."

For more information, visit here.