Thursday, February 14, 2008

Midwifery licensing and rhetorical tricks

Homebirth advocates face an uphill task in seeking the legalization of direct entry midwifery. When reduced to its basic elements, the argument for direct entry midwives is not particularly compelling: states should create a second, inferior class of midwife with less education and training than any midwives anywhere else in the industrialized world because .... Well, because there is a tiny group of women who don't have the educational background to qualify for standard midwifery programs, don't wish to spend the time to become qualified, and want to make money attending childbearing women anyway. That's not going to convince many people, so the essence of advocating for the licensing of direct entry midwives is to trick the people being lobbied.

First, it is important to hide the fact that direct entry midwives are grossly undereducated and grossly undertrained. There are specific rhetorical claims designed to obfuscate the substandard training of DEMs. DEMs are portrayed as "experts" in normal birth and "specialists" in out of hospital birth. That's quite a rhetorical trick; the fact that DEMs receive minimal education and no training in managing birth complications is turned on its head to a claim that they are "experts" in uncomplicated birth. The fact that DEMs are barred from hospitals and other healthcare facilities because they are not competent has been turned on its head to a claim that they are "experts" in homebirth. It's not even clear what that means. Are we supposed to consider them "experts" in dialing 911 to bring the real medical professionals in order to fix the life threatening blunders they make at home?

The second rhetorical trick is to blur distinctions between different types of midwives. DEM advocates insinuate, imply and even claim that licensing of DEMs is necessary to provide women with access to midwifery care, although women in all 50 states already have access to midwifery care. DEM advocates falsely claim that American direct entry midwives are similar to other direct entry midwives in the industrialized world. Neither are have nursing degrees, but the similarity ends there. The differences, which are never acknowledged, are far more important. European midwives receive a far more rigorous education, have extensive training in identifying and managing childbirth complications, and are qualified to work in hospitals. American DEMs waste time on pseudoscience "courses", have NO training in managing complications and are unqualified to work anywhere, so by default they are restricted to private homes.

The third rhetorical trick is to misuse statistics. The claim is made that the US trails many other industrialized countries in infant mortality, though infant mortality is the WRONG statistic to use in evaluating obstetrical care. The claim is made that countries with higher homebirth rates have lower rates of infant mortality, although homebirth rates have nothing to do with mortality rates (most perinatal deaths occur in high risk groups), infant mortality is the wrong statistic, and the correct statistic, perinatal mortality, reveals that the US actually has lower rates of perinatal mortality than coutnries that encourage homebirth.

These tactics are meant to hide the lack of training of DEMs, to blur the important distinctions between DEMs and other midwives and to imply that American obstetrics is substandard and lack of midwives is the cause. As rhetorical tricks, they are quite successful. Even homebirth advocates often don't realize that what they are claiming is not true. This is just the tip of the iceberg. In a future post, I'll review the rhetorical trickery of the appeal to "choice" and "rights".


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