5 December 2011
It is a great honor to have been chosen as the first midwife to receive the Right Livelihood Award. In accepting this award, I feel a deep sense of responsibility to my fellow midwives throughout the world. Most of us necessarily share an awareness of powerful forces that now threaten the continued existence of the profession of midwifery in many parts of the world. Rates of cesarean section are rising rapidly in most countries, far beyond the upper limits recommended by the World Health Organization. As cesarean rates increase, rates of maternal death and serious injury rise as well, and women's fears of birth increase. At the same time, time-honored knowledge and skills begin to vanish. I have visited private hospitals in Brazil where the cesarean rate was 95%, because women (and their doctors) had become so afraid of the normal process of birth that the cesarean became the default.
When surgical and technological interventions in birth become the norm rather than the exception, the profession of midwifery loses its basis for existence, and obstetrics itself no longer encompasses the skills and knowledge that were once considered essential competencies of the profession. I'm speaking of the skills and knowledge necessary for assisting vaginal breech birth, the birth of a second twin, the ability to manually assess fetal weight, to distinguish between normal labor pain and pain that warns of complication, to determine the position of the baby in the womb, to change it when it is unfavorable, and even to accurately diagnose pregnancy. To explain what I mean by this last-mentioned skill, we in the U.S. have already come to the point of discovering several cases of false pregnancies diagnosed only after a woman's abdomen was opened for a cesarean, an order of mistake that could hardly have been imagined two or three decades ago, when physicians' education in manual skills was still considered important. The shrugging off of traditional knowledge in the U.S. had progressed to the point that by the 1990s, the two major obstetrics textbooks no longer included any reference to the phenomenon of false pregnancy (pseudocyesis), even though it has always been known to exist in humans, as well as other mammals. Only a country which has become superstitious in its use of technology could imagine that the use of imaging technologies could eliminate the need for teaching traditional manual diagnostic skills and all of the phenomena that occur in women's reproductive lives.
The history of birth in the U.S. during the 20th century illustrates well how essential a strong midwifery profession is if women are not to be held within a web of fear concerning their bodies' supposed defects when it comes to giving birth. The elimination of the profession of midwifery in the U.S. in the early 20th century paved the way for a factory model of hospital-based maternity care that by the mid-century had two-thirds of all babies pulled from their mothers' bodies with forceps. Such a radical overuse of forceps did not happen in countries in which the value of a strong midwifery profession was recognized. With no midwives present in hospitals to instruct medical students in the wise ways of nature, men with the least understanding of the conditions necessary for women to give birth in a humane way soon came to believe that birth was necessarily a brutal and bloody affair and that human females actually represented a serious failure on the part of nature - one that could only be remedied by routine use of technology and medication. Now the profit motive really began to emerge vis-à-vis birth, and fear, greed, and ignorance have combined to make a nasty brew, as well as a witch-hunt against midwives who work according to the rhythms of nature.
The belief soon grew that babies would be most safely born when the mother's body was intentionally injured in order to free the baby, with the further rationale that such an injury would prevent worse injuries that would otherwise occur. Such myths, unfortunately, are perpetuated through Hollywood films, which usually focus on birth complications for dramatic value, while physiological birth is not depicted because of taboos against showing the relevant portions of the female body.
As one of the mothers who knew there was nothing wrong with my body and that the birth of my first child by forceps had been unnecessary - risky for me and my baby, with no discernible benefit, and psychologically harmful as well - I was left to find an escape route for myself for my next pregnancies. This dilemma prompted me to arrange for my own midwifery education (as I was unaware of that any other way was available), an arrangement that I was able to accomplish with the timely help of four physicians who also saw the need for midwives in our country. Free to learn from any sources I considered relevant, I learned from non-literate traditional midwives, from old books, and animals, as well as from kind physicians.
From the beginning of the Farm Midwifery Center, my colleagues and I placed women's needs at the center of our policy-making and found that this way of organizing care yielded huge benefits for our babies as well as their mothers. We learned how to prevent complications by providing good antenatal care and we developed practical methods for preventing unnecessary cesareans and inductions of labor.
Looking around, I found some other midwifery services backed by supportive physicians in other parts of the world with outcomes that were nearly identical to ours. The midwives who worked with the late Dr. John Stevenson in south Australia, those who worked with Dr. Alfred Rockenschaub in Vienna between the mid-60s and the mid-80s, and those still working with Dr. Tadashi Yoshimura in Okazaki City, Japan, all reported cesarean rates well under 5% with good newborn outcomes - just like ours. This was especially interesting, since we hadn't previously been aware of each other's existence. Unfortunately, in each case, these physicians - instead of being saluted by their peers - were treated as if they were hopelessly out of tune with the times and therefore irrelevant. We need to honor these men, who are still writing and teaching anyone willing to listen.
Now that many industrialized countries are reporting cesarean rates of 30% or more, despite the fact that midwives have always been accepted members of maternity care staff, it's important to recognize other factors that drive up rates of intervention in birth. Popular culture, the profit motive, fear, prudery, and ignorance all play a role and should be addressed.
What is often missed is that excessive cesarean rates have other negative consequences than the loss of midwifery and obstetrical knowledge and skills. Simply put, as rates rise beyond 15-20%, more women die from complications such as pulmonary embolism, infection, hemorrhage, and a sharp increase in placental complications in subsequent pregnancies. None of the countries with the highest cesarean rates can report on low maternal death rates. This is especially true of the U.S., where women now face at least twice the chance of dying from pregnancy-related causes as their mothers did. In California, between 1996 and 2006, the maternal death rate tripled, with much of the increase being attributed to an excess of cesareans. Don't expect the U.S. to report these telling facts with any accuracy, though, because the current lack of an infrastructure that requires and produces accurate and consistent reporting, and analysis of maternal deaths, means that the official maternal mortality figures represent possibly only a third to a half of the actual numbers.
To avoid facing the problems that we are now experiencing in my country, I have some recommendations to propose:
Countries with increasing cesarean rates should consider taking positive steps to reverse this trend, including stepped up efforts if rates rise about established limits. Midwives should be placed at the gateway to maternity care, instead of being introduced to women late in pregnancy and grudgingly if at all. This model of care recognizes that a woman's confidence and ability to give birth, care for, and breastfeed her baby and the baby's ability to feed effectively can be enhanced or diminished by every person who gives them care and by the birth environment. Because of this, all care given during the time surrounding birth should give the needs of the mother-baby pair precedence over the needs of caregivers, institutions, and the medical and insurance industries. Individual hospitals should consider implementing the 10 Steps to Optimal MotherBaby* Maternity Services (www.imbci.org).
Midwives must have an important say in the formation of maternity care policy. Care should be individualized and founded upon consideration and respect for every woman. When not under threat of a dominant medical profession, which is itself dominated by a powerful insurance industry or a powerful hospital industry, midwives can provide care that is organized around the principle that women?s and children's rights are human rights and that access to humane and effective health care is a basic human right. Independent midwives must be able to make a living from their work, which means that insurance companies should not be permitted to charge such high premiums that it becomes impossible for them to make a living.
We must wake up to the fact that it is easy to scare women about their bodies, especially in countries in which midwives have little or no power in policy-making, relative to physicians and the influence of large corporate entities. This takes no real talent. Given such imbalance, fear, ignorance, and greed begin to reinforce each other, and rates of unnecessary intervention soar, with women and the babies suffering the consequences. Birth care must not be profit-driven. This makes incentives to cause problems, not prevent them.
For this reason, there should be no more fee-for-service payment - for instance, financial reward for the unnecessary use of a vacuum extractor.
If all countries put the welfare of mothers and babies at the center of maternity care policy, midwifery would have to grow strong again. In some countries, such as my own, it will be necessary to greatly increase the number of midwives as just one of the ways to prevent complications and to reduce rates of medical intervention in birth. We'll need lots of doulas as we make this transition. Midwives need to have a say in the major issues surrounding birth. In countries where they currently work under the intense domination of obstetricians, the work will be to bring the relationship back to one of balance. Midwives cannot allow obstetricians to bully them, because doing so is almost certain to mean that laboring women will be the next ones to be bullied.
Attempts to make home birth illegal in any country will only distract from the real problems and exacerbate them, since planned home birth for healthy women provides a necessary safety valve for women who want a wider range of choice than their hospital might offer and a learning opportunity for midwives to learn about women in their natural state. Home birth midwives must be able to make a living from their work, and insurance companies should not be permitted to keep home birth midwives from being compensated for their work. Home birth midwives are being persecuted in almost every country, even in The Netherlands, where home birth services have a long and honorable tradition. I believe the development of a country can be measured by the degree to which it respects the right of a birthing mother to receive a woman centered birthing experience, whether the birth occurs in a home or hospital setting. In this regard the current situation in Hungary greatly disturbs me. There, the failure to fully provide and protect this important right is highlighted by the prolonged discrimination and mistreatment of the independent midwife Dr. Agnes Gereb. Agnes has spent more than 20 years trying to defend the fundamental rights of mother and child and in doing this she has been imprisoned, recently received a further 2-year prison sentence and has been held under house arrest for the past year. I now ask the Hungarian government to intervene to stop the abuse and unjust treatment of this internationally respected homebirth expert.
Birth shouldn't be thought of as money-making commodity or condition in which large institutions or governments control and dictate how women will give birth, ignoring individual mother's wishes and needs. Inevitably, this too often puts bullies in charge of women's bodies, something no other mammalian species allows. Some countries have midwives who are totally subordinate to physicians. In these countries, it's typical for very harsh methods of birth care to be applied, and outcomes show this. It's time to stop this sort of behavior. Traditional peoples, indigenous people don't permit such behavior. We need to learn from them.