Homebirth Obstetriciians?

An interesting discussion emerged from the AMAYAL Humanized Birth Conference carried out conference in October 2009 in Monterrey, Mexico. It is important to note that Monterrey Mexico holds one of the highest cesarean rates in the world. In this context, Nacer Renacer, as the perinatal education branch of Amayal works through prenatal education and support to inform and educate women on natural birth. They are working with a male obstetrician who attends homebirths and natural births at the hospital working alongside a Doula.

The issue I am pondering is the emergence of “humanized” obstetricians attending home and water births. In this situation, male (mostly) obstetricians work alongside female doulas to increase access to normal birth. Midwifery is declining across the country and many countries lack midwifery training systems and recognition, for example Mexico only has one officially recognized midwifery school. In the north of Mexico there are very few traditional or formally educated midwives. The positive aspect of this diad is obviously increased access to care. However as a midwife many questions emerge, such as where do midwifery skills go within this practice? What are the outcomes? How is fetal positioning addressed? Are natural remedies used? My sense, from conversation with “humanized” obstetricians and doulas is that practice, like with any midwife is particular to each obstetrician. Some are much more open to learning from midwives and others feel that as obstetricians they have the knowledge they need. The general sense (not confirmed by data) is that cesarean rates are much higher. Barbara Katz Rothman suggested to a Venzuelan obstetrician that he should leave the births to the midwives and focus on providing humanized obstetric services. However, how many practicing midwives are there in urban Venezuela? Not many.

Although on one had I do believe that this diad is necessary and I am strongly in favor of increased access to normal birth. However, this diad emerges in the absence of midwifery. Where are the midwives? Some of these doctors have explained to me that they attend over 15 births a month. Can this replace midwifery care? 15 births a month?? When are home visits done?! Again, this clearly demonstrates the need to have more midwives. My concern about this diad is that it may imply that midwives are not necessary, that its sufficient for an obstetrician to attend homebirth in order to protect the space of normal birth. As midwives we know that our skills extend further than protecting normal birth and our outcomes are so good because of our skills in counseling, nutrition, herbs and homeopathy, fetal positioning and many more.

From informal conversations with the obstetricians I often get the sense that they don't feel that midwifery has much to teach them. They sometimes (please do not get the sense that I am generalizing) give me the sense that they insist upon the hierarchy within which they were trained and that their skills are sufficient. They state proudly that one of the benefits of their care is that is they transport, care is continued. Where I can see the benefits of this, it also makes me wonder, well how often do you transport?

Another issue that I see in this diad is almost a mind/body split. Seeing it physically I imagine that midwives have clinical and decision making skills that work within our intuition, nurturing and continuity of care. Within the obstetrician/doula homebirth model, it seems as through the midwives right and left brains are split into two people: an obstetrician who can diagnose, run an IV and make a difficult decision and a Doula who provides continuity of loving care. I have observed my reaction to this and I'm not sure if my skills and intuition could be split. So many times in prenatal or postpartum care the attention given is based on a sage combination of these skills.

I am curious to have more conversations with women who are attended by the obstetrician/doula, curious to see their results and outcomes and curious to ask them many, many questions. I also curious about whether or not midwives see this as an opportunity to stand in our ground as the experts in normal birth, as that is what we are trained for, and to train more midwives.