Thursday, January 10, 2008

Why reality wins again

In Reality wins again, I wrote about Navelgazing Midwife's post The Myth of the Vertex. In it, I drew attention to Navelgazing Midwife's change of heart about some previously deeply held beliefs. Why did she change her mind? In a word, "experience". Here are several quotes that illustrate the point:
Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief...

... I was wrong and I wonder why so many women see every care provider as a threat...

... Sometimes emergencies happen and someone has to be trusted to take care of them. Sometimes births need help and someone has to be there to give it. And take the liability for it, too.
Navelgazing Midwife has implicitly acknowledged two important points: experience is critical to becoming a safe and competent practitioner, and she did not have enough experience during her training to understand that her personal beliefs were wrong. She is not the first direct entry midwife to discover this. I have written about it before:

In Licensed Lay Midwifery and the Medical Model of Childbirth (Sociology of Health & Illness, Vol 7 Issue 1 p 36, March 1985), authors Weitz and Sullivan intensively interviewed 27 of the first 29 women who became licensed in Arizona. They investigated the role of experience in the midwives' attitude toward the "medical model" of childbirth:
The experiences of these licensed midwives, however, have created in them a greater awareness that childbirth can become a medical problem. As the total number of babies delivered by each midwife has grown over the years, they have gained greater exposure to the potential hazards of childbirth. One midwife, for example, when asked if her feelings about the responsibility of being a midwife had changed over time, responded:

'I think I've become more aware of it with every birth I do. I think that when I first started it was like a game and I wasn't really thinking that much about it and now I think it's come to be a major thing. Part of the reason for that is the fact that I'm a licensed midwife, and that I operate under a lot of regulations. If something goes wrong, it's my head that goes on the chopping block.'

Although the midwives are restricted by state rules and regulations - as well as by their own desires - to working with a 'low-risk' population, a few of the babies they have delivered were physically depressed, traumatized, deformed or stillborn. Similarly, some clients failed to progress during labor, tore, or hemorrhaged. In the first four years of the reactivated licensure system, 14 per cent of mothers were transferred to a hospital before delivery. Of those who delivered at home, 15 per cent of mothers and 3 per cent of newborns required postpartum outpatient care and 3 per cent of mothers and 2 per cent of babies required postpartum hospitalization. Thus, while the typical delivery confirms the midwives' definition of childbirth as a natural, healthy process, they increasingly see the potential for medical problems to arise...

Midwives' faith in the natural childbirth process is further strained as they learn the difficulties in predicting who among their 'low-risk' clientele will safely deliver at home. Although they express confidence that 90 to 95 per cent of all women can safely deliver unaided, the midwives still fear the risks they take when they cannot completely screen out the other 5 to 10 per cent. Because of this fear, 85 per cent of the midwives refuse to accept potential clients who meet the legally prescribed health requirements but whom they regard as poor candidates for home delivery (e.g., women who have not given birth before, do not intend to breastfeed, or do not seem psychologically prepared for home birth).

In sum, the midwives' initial views about the safety and naturalness of childbirth are being tempered by experience...
One of my primary objections to direct entry midwifery is that the midwives do not have enough clinical experience. This means that they have very limited experience in recognizing impending emergencies and virtually no experience in managing them. Their attitude toward birth and its inherent dangers are based on their personal beliefs, and therefore bears little relationship to reality.

As the above study of midwives shows, the education and training of direct entry midwives reinforces their erroneous beliefs about childbirth. As they acquire more experience, they learn to their chagrin that the chance of complications is higher than they had believed, their ability to predict those complications is not nearly as good as they had believed, and that their view of "naturalness" of childbirth needs to change to accommodate reality.


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