An interesting concept, no? My first thought has always been, “well, that’s nice when it works out and when there are actually studies available”, but my second thought is always, “midwifery is NOT medicine, nor should it be conflated as such”.
I’ll say it again: Midwifery is NOT medicine. But what about nurse-midwives? These are people who have a nursing degree and have completed additional schooling to obtain a midwifery certificate; nursing and midwifery are NOT the same thing and neither healing art is practising medicine. Medicine, Nursing and Midwifery are all completely separate and different things and should NEVER be treated the same, nor should attempts at regulations be the same for each. All three professions operate from very different models of client/patient care, that yes, do occasionally overlap one another. (no citations here, because anyone can look up the definition and general scope of practice of each of these professions quite easily)
So, now that we have established that medicine, nursing and midwifery are all vastly different professions, we can move on.
If you are anybody even slightly involved with the world of birth then you have come across the phrase ‘evidence based practice(s)’. What does this mean exactly? In a nutshell: that one uses practices, usually in a professional sense, and modalities that are backed by scientific studies. There are differing opinions as to what makes a study qualify as evidence, but I won’t bore you with that here. Just know that the simplistic idea is that, for instance, a doctor shouldn’t prescribe a treatment for a specific ailment if there isn’t evidence, backed by studies, that supports such an action. There are times when things are done that there is no evidence to support AND do not fall into the realm of “that’s how we’ve always done it” — I’ll address these often ‘intuitive’ actions in a minute. (again, no citations here, as anyone can look up “evidence based practice” and see just how convoluted the process is, so much so, that it almost borders on what some might call pseudoscience.)
Now, a slight disclaimer before this next part: I know that other professions besides medicine and nursing encourage each other to enact their model of care/business in such a way that their actions are evidence based whenever humanly possible. I am aware that psychology and even architecture make use of evidence based protocols. And I do not think evidence based protocols are wrong, not at all; I think the more you can point science at something and things work out more in the positive than the negative, the better.
However, so much of what traditional midwifery, traditional ‘with woman’ care, employs is not evidence based or backed by studies. Mostly because the studies haven’t been done. And why haven’t the studies been done? Here’s a list off the top of my head:
- Traditional midwives trust and believe in the inherent functionality and natural unfolding of pregnancy and childbirth (it’s hard to test/study this).
- In the course of a typical pregnancy and birth, midwives don’t (or shouldn’t) *do* anything to altar the course of the perinatal path.
- Midwives advise basic non-medical self-care and nutrition for expectant persons.
- Midwives, as a whole, lack the financial lobbying power to have studies done to provide scientific evidence to support their protocols, some of which date back thousands of years and have stood the test of time. (example: placentophagia — see below for more information)
- The world of medicine doesn’t want to fund studies that might support the midwifery model of care, for obvious reasons (yes, this is an opinion, but one based in reality).
- And Midwives, unless their protocols have been influenced by medical-model training or licensing requirements, rarely engage in medicine based practices.
I haven’t mentioned one of the truly controversial parts yet! Some of the most powerful tools that Traditional midwifery employs are Trust in the process of birth, Connection to the birthing mother and family, and Intuitive instincts (both the midwife’s and clients’). Three things that are not easily studied in the same way that the effectiveness of a medicine on a disease can be studied or whether or not foetal monitoring positively effects the outcome of births. A very lengthy article written about midwifery and intuition by Robbie Davis-Floyd can be found here. The article explains and explores the unique dance of Connection and Intuition that a midwife and their client take part in. Midwives recognise that birth is not pathological and that its physiological nature is greatly influenced by a client’s state of mind, level of trust in the birthing process and attending midwife, the connectedness of a client and midwife, and the energy present at a birth (contributed to by everyone present). Birth is as much psychological as it is physiological and this is something that medicine (obstetrics in particular), ignores, devalues or outright dismisses. (citation? read the article I linked to)
The interesting thing about Intuition is that, admittedly or not, doctors utilise it as well. Doctors, nurses and midwives could spend eternity swapping stories about actions they’ve made based on intuition — actions and decisions, that in hindsight, often seem illogical, usually break protocol and are rarely instances that can be post-dated as evidence based. I haven’t met a birthworker of any stripe yet who has told me that they don’t rely on their intuition, especially when things don’t add up in the usual or scientific way. Intuition is a hard thing to really explain. Some people describe it as a ‘gut-feeling’ and those who are more religiously inclined even say that it’s G-d speaking to them. Whatever/whomever it is, it is an amazing force and I’ve seen it save lives. (nothing to cite here. move along or go talk to some birthworkers about their own experiences)
There is so much about the process of birth that we still can not wrap up with a neat scientific bow. And anyone can access Google Scholar to see the myriad studies done concerning pregnancy and childbirth. Part of me, at this point, just wants to stop writing about this, because I feel like this is about to make a turn in the direction of “throw hands up, exclaim that it just works and move along”. However, that’s just lazy and unhelpful. But, birth works and we don’t know all of the reasons why. There are things that we have learned to do and not do that help ensure it works and we don’t always know why this is the case. Unfortunately, studies are now done in the name of money and there is no money to be gained from studies that prove birth works and that interference is risky — the medical establishment can not afford to allow birth to be returned to women, their families and their midwives. (opinion, I suppose, but you can take any study and see the point of view it originated from. Studies that claim homebirth is dangerous are almost always set up from the beginning on a premise that they are dangerous and the reverse is true for studies pointing positive fingers at obstetrical practices. Remember, ‘twilight sleep‘ was peer-reviewed ‘science’ working for us in the past — enough said)
I mentioned placentophagia above. This is the act of most mammals eating the placenta after birthing it. While it makes perfect sense for wild animals to do this, to possibly hide the fact that helpless and easy prey might be around or for purely nutritional reasons, that doesn’t begin to explain why humans might do it. In my research, very little science and surely nothing considered evidence exists to back up the practice of encouraging mothers to consume their children’s placentas. However, this is a practice that myself as a midwife and many midwives and mothers before me have engaged in. Besides the nutritional and general hormonal benefits that are said to be true of eating placenta, there’s another benefit, a life-saving benefit, that I want to touch on. Postpartum haemorrhaging is a complication that can happen in childbirth. It’s often quick and silent and at times, can come seemingly without cause. Typically, this is a complication that occurs after the birth of the placenta and this is a time for the placenta to be put to work. Placing a piece of placenta roughly the size of a quarter or slightly larger under the haemorrhaging mother’s tongue or between her cheek and gums, allows her to absorb the hormone oxytocin from the piece of placenta. Due to the sublingual dosing of the placental oxytocin, the hormone enters directly into the women’s bloodstream and goes to work immediately aiding her uterus to contract — in effect slowing or stopping her bleeding altogether. I have never seen this not work to save a mother’s life, even when other measures, like uterine massage, are not used. The peer-reviewed ‘evidence’ is not there to back up my claims or hundreds of other midwives claims as to the life-saving qualities of the placenta. And for many midwives and their clients, when there are herbal tinctures and sometimes illegal vials of pitocin (synthetic oxytocin) at hand, why bother with the placenta, but I digress. (While it is true that in some states, it is not illegal for non-nurse midwives to carry pitocin, that is usually only the case for licensed and regulated midwives, who are expected to use the pitocin over other methods such as sublingual placental oxytocin — you can find this information by looking up the laws concerning midwifery in your state)
I have found it hard to preach to expecting and new mothers to ‘trust their instincts/intuition’ and not do the same myself. Some people might tell you that the difference between a good doctor/midwife and a bad one would be their intuition — do they take their scientific and empirical knowledge and apply it to the individual directly in front of them, tailoring it, using their intuition, or do they treat all their clients the same way regardless, because that’s the ‘correct’ and scientific way? The typical obstetrician in a hospital setting is not going to break the time constraints of their protocol and take things on a case by case basis — why would they? For example, if it *can be* risky to allow a woman to labour beyond 24 hours post rupturing of her membranes, then clearly, the default is to augment labour and get the baby out before time is up. I actually don’t blame doctors, as most of them have their hands completely tied by malpractice insurance and lawyers, not to mention that most of them don’t want to deal with a labouring woman, with ruptured membranes or not, for days at a time. But, we know, from countless years of observation AND scientific research that 24 hours is an arbitrary number, a decent number, but arbitrary just the same. What the science and empirical evidence points to is that women should be monitored for signs of infection and internal exams should only be done when absolutely necessary after the rupturing of membranes. And actually, as a side note here, internal exams are so incredibly subjective with results varying between those administering them that I’m not sure why obstetrics insists on continuing them as common practice. I can think of no better way to cause an infection in a mother and possibly her baby, not to mention the obvious invasion of privacy and possible physical and emotional/psychological trauma. Midwives know that membranes can reseal and that mothers can labour, quite safely, for days after their membranes have ruptured. (blah, citations — there are so many studies I could cite, both for AND against the 24 hours labouring period, internal exam frequencies and effects, and monitoring for infections, that I honestly don’t know where to begin — I think it’s best to visit Google Scholar or the Cochrane Consumer Network and see for yourself)
I would like to take this moment to point out that I did not set out in writing this post to point a finger at evidence based practices. On the contrary, I hope that all professionals use as much well thought out and sound science in their practices as humanly possible. However, I did want to point out that intuition is a powerful source of knowledge, which shouldn’t be ignored.
I have purposely written this post citing or linking to as few outside sources as possible. In an effort, to make the reader do some hunting of their own. It might sound lazy, but the exercise is a good one. If I were to thoroughly cite this post, amazingly, few people would do their own research, assuming I’d done it for them. I’m not one to try and make things difficult for others, but I have always encouraged clients and other people to not just take my word for things, to go and do their own research and soul-seeking. Because, in the end, even with stacks of studies in front of us, we make our own informed decisions with the help of our intuition.
The only time my intuition has ever ‘failed’ me, has been when I have ignored it.
**Full disclosure and disclaimer statement as follows: While I respect science, I approach it cautiously like anything else, much like I would a religion or dogma, especially now that practically all science is ruled by money. I have seen and been on the receiving end of ‘bad science’ (also known as ‘bad medicine’ by some) and I’m here to tell you that it exists. Spinning a study and its numbers to suit one’s needs is quite easy and done all of the time, by all sorts of people. I am a traditional homebirth midwife and in both my professional and personal life, I utilise natural remedies associated with herbology, homeopathy and naturopathy, as well as ancient and folk medicine and Appalachian mountain magic that has stood the test of time. I am not a religious person, so I can’t speak on ‘the voice of G-d’ claims, but I have been known to rely on my intuition, gut reaction or ‘sixth sense’ — sometimes, the universe causes us to just act, we can’t explain why, but things work out and that’s the important part. I do not fear or hate modern allopathic medicine and I make use of it in the forms of surgery, life saving medications and sometimes antibiotics and over-the-counter (OTC) medications. Does this mean that I am a professional who’s practice is solely evidence based? The short answer is no (and I’ve never led anyone to believe otherwise).**
—->I have decided to monitor comments on this post with a heavy hand. I don’t normally do this, but I haven’t the time for anti-homebirth and anti-midwife trolling or hate speech. And, this is *my* blog, not yours. This is NOT a scientific journal, nor would I ever want someone to conflate my personal thoughts with sound evidence for their actions. In an effort to keep things civil, if you think I am a quack, irresponsible or way off base, and you are incapable of expressing such ideas without vitriol, do us both a favour: refrain from commenting and just move along.<—-