In December of 2016, I wrote an essay for Nursing Clio called Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth. In the piece, I advocated that all women be given the option of delivering with hospital-based nurse-midwives, whose evidence-based practice results in safe births and, in some settings, significantly lower rates of interventions such as cesarean section. I only recently, quite belatedly, realized that OB-GYN Amy Tuteur had responded on her blog to my essay. She offered a belittling (and inaccurate) representation of my position on hospital-based nurse-midwifery, specifically invoking the specter of “white privilege.” Why? As far as I can see, it was an attempt to shut me down with highly-charged language that was intended to shame me and alienate those likely to be my allies.
In a different political environment, I would not bother to re-open a stale debate. But given the state of our current political and social discourse, I think it is important to call out Tuteur’s inappropriate use of an important concept.
Tuteur claims that nurse-midwifery could only possibly be appealing to middle-class white women such as myself, who she believes are inordinately attached to the idea that women might value a low-intervention birth experience, and therefore, when I advocate that nurse-midwives be available to all pregnant and birthing women who want them, I am cluelessly advocating from a position of white privilege.
As I explained in the essay, nurse-midwifery was originally developed to serve lower-income women who could not afford physicians’ fees. Midwives continue to disproportionately serve low-income rural and inner-city women, many of whom have difficulty accessing care otherwise. The Institute of Medicine has emphasized the relevance of nurse-midwives for improving outcomes among low-income women, and highlighted nurse-midwifery practices such as the Family Health and Birth Center in Washington, D.C. that caters to a primarily low-income clientele and is dedicated to reducing racial and class differentials in birth outcomes.
Middle-class women may be the loudest advocates for midwifery care, simply because they have the most access to public forums such as this one. And midwives certainly do serve middle-class women too. But they are by no means only good for middle-class women. Some elements of midwifery care, such as a substantially lower rate of cesarean section and better psychosocial support during pregnancy, may be particularly valuable to low-income women, who care for themselves and their families in considerably more complex and demanding situations with substantially less financial and social support than most middle-class women.
All women should be able to choose their birth practitioners, whether they choose obstetricians or midwives, and all women should have access to the psychosocial, medical, and surgical care they need. This means that all women should be able to get care from both midwives and obstetricians, as their preferences and medical needs indicate.
Tuteur will never accept evidence that any form of midwifery is safe. She is completely committed, at least publicly, to advocating for OB-GYNs at every birth, and no evidence of nurse-midwifery’s safety will ever be enough for her. That means that, at least as long as the evidence available to me supports the safety of nurse-midwife care for low-risk women, we will have to agree to disagree about the role of nurse-midwives.
The language with which we disagree, however, matters too, and I do not accept Tuteur’s mis-use of the critical terminology of “white privilege.” Specious arguments based on claims about white privilege are pernicious because they weaken and discredit the concept. We urgently need to accurately and perceptively identify the workings of white privilege. We will have trouble dismantling it if we let it be used as a vague and convenient slogan to indiscriminately smear opponents.
For those interested, the recent NY Times article about the alarmingly and shockingly high mortality rates for African-American mothers, https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html, has some great info on how access to midwives and doulas might help alleviate this crisis. I’ve delivered with two different midwife groups who delivered in hospitals, and both groups had a diverse range of clients (as well as an African-American midwife, in the first group), and I’ve also received services from a midwife group in Houston that works primarily with Latina clients. I have to agree with Dr. Freidenfeld that while white, middle-class women might be the primary advocates in public fora for these debates, they effect women of color, too.
Absolutely. Thank you for sharing the link. New York City is planning to fund the expanded use of doulas to reduce deaths in childbirth: https://www.nytimes.com/2018/04/22/nyregion/childbirth-death-doula-medicaid.html. I hope they really do it, and that they rigorously collect data so we have a clear understanding of their impact. It is easy to fail to recognize the importance of high-touch aspects of care for outcomes.
Ms. Tuteur makes no sense at all. Good for you for taking her on.
Coming from a German background, having done some historical research on midwifery and conflicts over medical expertise regarding birth and pregnancy and after experiencing births with midwives and with as well as without obsetricians, I am glad, that until today birth remains in most cases an unpathological event, not necessarily in need of an ob-gyn etc.
Keep fighting and don’t let Ms Tuteur nor others derail your important contribtions to this important debate.
So, Nurse-Midwives serve the poor by being better than nothing. Therefore, the ideal is merely better than nothing? Midwives-led births tend to have fewer interventions. Is this actually a GOOD thing? Interventions are used when birth is not going right. Those with the tools can intervene and prevent a catastrophe from happening. Those who don’t have the tools can only soldier on and pray that things will resolve before they become catastrophic.
In an ideal nurse-midwife model, the midwife passes on the patient to an OB at the first sign of trouble. It’s a great idea in practice — but as we are seeing in the reports from various hospitals from England and New Zealand, egos get in the way of this model. The midwives decide to retain control of their patients and simply soldier on, refusing to call in the OB even when things turn catastrophic.
And then there is the question as to whether the midwives are trained enough to spot the danger signs as early as the doctors do. As my GYN pointed out, a Nurse-Midwife may have delivered a couple of hundred of babies, but the doctor participated in over 4000 before she finished her residency. The doctors have more than tools, they also have the experience.
Nurses — of all sorts — do work with patients to give a more personal treatment. The question is really one of whether the nurses will work with the doctor, and let the doctor oversee each patient by 1) meeting the patient, 2) reviewing patient charts, 3) staying in contact with the nurses during labor, and 4) being physically present at birth — or if they will let the nurse-midwives make all the medical decisions on their own, coming in only to act as a consultant during an emergency, without any prior contact with the patient.
As to the question of why birth is treated as a pathological event — it’s because it has the ability to turn into a pathological event in a heartbeat. We can watch for and prepare for these catastrophic, pathological events, or we can just let them happen and then shrug when they do. In the words of a midwife in the Foxfire series, “Those babies usually died.” But hey, for the ones that lived, she was better than nothing.
C-sections are a good thing when they are used appropriately, and a harmful thing when they are used in births that would otherwise be routine and healthy. And so on, for any number of interventions in birth. Midwives do good work because they use interventions judiciously. It’s like any medical treatment: drugs, surgeries, etc. are much better than leaving a sick person to be ill and maybe die, but much worse than leaving a healthy person alone. I’d be angry if my doctor failed to prescribe chemotherapy for my cancer, but I’d also be angry if he misdiagnosed me and gave me chemo when I didn’t have cancer, because I’d suffer a lot of unnecessary damage. Obstetric interventions are fantastic when they are used appropriately, and damaging when they are used unnecessarily. Nurse-midwives often get that balance better than OBs. Nurse-midwives also typically have much longer appointment times with patients, so they have a better chance of catching problems early and preempting them with preventive methods. Yes, OBs see a ton of deliveries, but they only see the last few minutes of each one, so it’s not exactly more experience than nurse-midwives, so much as different experience. And all in all, nurse-midwives have excellent track records (per links in my post). I agree with obstetrician Neel Shah of Harvard Medical School: the best care happens when midwives are routinely incorporated into obstetric care. You can see more about his research here: https://scholar.harvard.edu/shah/home.
In fact, a midwifery-led model of care has better outcomes than the obstetric model (check out the most recent NICE guidelines from Britain). Something like 2/3 of maternal and infant deaths worldwide could be prevented by scaling up the midwifery force (check out the Lancet series on midwifery). But for some reason, the evidence seems to be viewed as “fake news” or simply ignored and I think it’s worth looking at why access to birth attendants is such a highly charged issue. Why is the prejudice against midwifery so entrenched? My guess is it has something to do with the historical war on midwifery by male physicians who wanted to take over the childbirth market. The idea that women trained by women could care for other women better than men who went to medical school is difficult for many people to conceptualize. Midwifery long predates medicine, and when medicine began to supplant it, it was not because care by doctors in hospitals was safer–quite the contrary. Take a look at the history around how doctors organized around sexist, racist campaigns to discredit and eliminate midwifery. I believe much of our discussion today is informed by this, and we don’t even know it.
The history of nurse-midwifery in this country is somewhat obscured and has been traded for a romanticized version that touts ’empowerment’ of women and a style of maternity care that caters to ‘wants’ not ‘needs’ of mostly white middle-class women.
I say this as a practicing CNM. We are very good at catering to white women, and white affluent women. It is a privilege (earned by nothing more than whiteness) to have a laundry list of desires (AKA the Birth Plan) that include many non-medical requests: father wants to cut the cord, I want to give birth underwater with no one speaking, I want flower petals from organic roses floating in my birthtub water, I want to hem and haw over every decision and have every detail explained to me as if I was the only person in the world, I want to be prioritized and pampered and treated as special in every way. Nurse-midwives are very good at providing this type of care. We cater. This has become, for some of us midwives, our brand.
BIWOC are often served by CNMs in larger hospitals and OB practices, this is true. My suspicion is because CNMs are paid a lower salary than OB/GYNs. For BIWOC, the care provided by a CNM is not by their choice, but how they are shunted in the system to the lowest-cost (for the institution) provider.
BIWOC and their babies are not suffering poor outcomes due to increased obstetrical interventions, but due to barriers and obstacles to receiving appropriate increased levels of obstetrical and medical care. Implict biases and racism play a huge role in BIWOC not receiving timely and appropriate care in the obstetrical setting.
Midwives – CNMs in particular – could fill this needed role of ensuring that the most vulnerable women in our population are appropriately referred to increased medical care. I do see a role for CNMs in minimizing the incidence of mortality and injury to BIWOC, but we need to let go of the natural fallacy that says that interventions cause harm. They do not.
It only seems that way to the most privileged, healthy, and self-centered among us.
And the privileged among us – CNMs – we are mostly white, affluent, privileged – can’t even see the problem.
BIWOC would like to live, and they’d like their babies to live.
All we can focus on is: “Did you have an emotionally fulfilling birth experience?”
This is the epitome of white privilege.
Thanks for sharing your perspective as a CNM, Liz. I totally agree with you that we need to be doing better for African-American women, who are routinely let down by our maternity care system. I also agree that interventions per se are not the problem, and African-American women often fail to receive care they need because their expressed concerns are ignored. But I still think that this needs to be fixed by serving all women with appropriate interventions, and avoiding the interventions (and their side effects) that they don’t need, and that midwives are often better at using interventions judiciously than are obstetricians. The African-American c-section rate is the highest of all groups, and it’s not clear the extra c-sections are helping: http://www.blackwomenbirthingjustice.org/single-post/2015/04/23/Call-to-Action-Reducing-Cesarean-Rates-for-Black-Women-by-Lakeisha-M-Dennis. I had my first birth with an Oakland midwife who served an ethnically and socioeconomically diverse population, and she promised to all of us to do her best to get us through the birth safely and without surgery. Her very low c-section rate and excellent safety record showed that she delivered on that promise, to all of us. I’d rather have her practice replicated on a larger scale than automatically send everyone to an OB.
“I also agree that interventions per se are not the problem, and African-American women often fail to receive care they need because their expressed concerns are ignored.”
The needs and signs and symptoms of African-American women, and WOC, are not only ignored, the system itself – the entire healthcare system – caters to whiteness. It caters to suburbanism, it caters to affluence.
We have a healthcare system that allows, on one level, (attempted) equal access to buildings and institutions, but the care received within those systems differs based on the race and ethnicity of the patients within them.
So I can appreciate and understand the argument made by BIPOC that if the care within the system is not providing equal outcomes, then a solution might be to take the care outside of that system. To birth centers, to community centers, with midwives.
But these low-resource environments cannot provide the higher levels of technological medical services that save lives.
I think there is some appeal to blaming the system, and therefore leaving the system entirely, but the problem is not the technology within the system, but the inequitable access to increased levels of care when they are needed.
You are right that all women need access to specialized, high-tech care when they have complicated pregnancies and/or births. CNMs and doulas also work within high-tech settings, and they can be especially beneficial to at-risk women as an integral part of high-tech obstetric care. It should not be an argument of “high-tech vs. high-touch;” women should get both at the moments they need them. I still think that hospital-based CNMs have the potential to be the best managers of hospital births, and should be empowered to request obstetric involvement promptly when needed. OBs don’t really have time to keep an eye on the “high-touch” needs of their patients. The article shared in the first comment illustrates a different tech-touch combo — OB plus doula — but I think illustrates well how women with medical and personal complications especially need high-touch as part of their care in order to have the best outcomes (physical and emotional), and how obstetric nurses are often not structurally equipped to provide it.
As someone who works with midwives in the U.S. and around the world, I have literally never heard one talk like Liz with such disdain about her patient group nor about their desire for an “emotionally fulfilling birth experience.” I’ve also never heard a CNM talk about her own practice in such terms, implying that she is some sort of poor substitute for an OB/GYN. CNMs are autonomous providers who are *part of a team* in the hospital and as primary care providers, see better outcomes overall than obstetricians. As far as Black women being “shunted” to CNMs, that’s simply not true–access to CNMs is extremely limited in the U.S. (less than 10% of births happen with midwives) and no, doctors are not sending business to the competition. Also, if Liz is a midwife, she is missing a huge piece of her training: that the psychological health of a woman is integral to the safety of her birth, and that the way a woman is treated in birth plays a significant role in her postpartum mental health. I also work with women who have PTSD from their births, as well as severe physical injuries from health care providers who downplayed or ignored their right to determine their own care.
But if we are talking about what is best for women of color, women of color can speak for themselves: http://www.blackwomenbirthingjustice.org/. For what it’s worth, Black midwives kept midwifery alive in the U.S. during the time it was almost completely eliminated by physicians organized against it, and there is a steadily growing movement among Black women for out-of-hospital birth with midwives who may or may not be nurses. Out-of-hospital birth is not a lower level of care; it is an entirely different model. The racism of the system is not the only reason it’s being rejected. Perhaps most relevant, the Black midwives I’ve spoken with are laser-focused on “emotional fulfillment” as essential to–not a bonus of–a safe and healthy birth. These things are not separate. Physically, emotionally, mentally healthy mothers form the basis of healthy families and communities.
A few more links that further the discussion on midwifery care for African-American women:
Dr. Neel Shah, a professor of obstetrics at Harvard Medical School, agrees with me about the importance of integrating midwives into the care of African-American and low-income mothers, in order to provide safe, appropriate, and respectful care. Links to his work are here: https://scholar.harvard.edu/shah/home.
This article shows in detail how an African-American doula provided safe and respectful birth support that allowed her African-American client to have a healthy birth with only necessary interventions:
This African-American maternity care activist is concerned that c-sections rates for African-American women are unnecessarily high (African-American women have more c-sections than any other group):