A reader alerted me to a debate going on over at the Exceptional Marriages (aka HMS) blog. It is kind of confusing to follow the thread if you haven't been a regular reader, but it has to do with a case where a midwife is about to go to jail for saving a woman's life by treating her with a drug that she obtained illegally. If you search the archives using the keyword 'midwife' you will find the debate. It starts with an article in National Review Online. Take a minute here and go read the article and the thread over at HMS.
Both Kevin Miller and Greg Popcak give reasoned defenses of their opposing positions. Duncan Anderson has a rather impassioned response to his experiences with hospital birth policies and procedures. All of these gentlemen have a lot of light to contribute to what is actually a quite complex situation encompassing politics, power,money, fear, and human life. None of them are midwives, and none of them are mothers. I don't know for sure, but I also doubt that any of them are lawyers.
It wasn't that long ago that midwifery was regulated by canon law, and midwives were seen as performing a valuable ministry in the service of life.
I am a midwife. I am a mother. I am not a lawyer, or a moral theologian, or a clinical psychologist. I have been involved with pregnant women and their families on a professional level for more than 20 years. I have studied the physiology, psychology, ethics, sociology, theology, anthropology and just about every other -ology of birth over the last 30 plus years. I have worked in women's homes, in birth centers, in hospitals ranging in size from 22 beds total to 18 thousand births a year (LA County/USC medical center Women's hospital).
As I posted earlier, in the early years of the 20th century, a concerted effort was made to completely eliminate the midwife. Part of the strategy was to turn nurses and midwives against each other, and it nearly succeeded. Even now, dominance games are being played over the bodies of pregnant women, as various providers of prenatal and birth care attempt to protect their own corner of 'the market' by bad mouthing the others. The behaviors of some care providers provides plenty of fuel. It may not matter whether the provider is the hospital labor nurse, a family physician, a traditional birth attendant, a perinatologist (specialist in medically difficult pregnancies), a professional midwife, an obstetrician/gynecologist (that's a weird marriage - medicine and surgery do not mesh well in the same body!), a certified nurse-midwife, or even a chiropractor or naturopath. (See my article What is a Midwife? for descriptions as well as some of my opinions). There will always be some who through pride or greed exceed their level of competence, or who are simply so attached to a certain ideology that they can not see any other paradigm.
There are unacknowledged issues in the Freida Miller case, as in so many other midwifery cases that have percolated through the courts since the 1960s. One is simply to define what constitutes the practice of midwifery. Is it a branch of medicine, a branch of nursing, or a discipline in its own right? If (as I and many others believe) midwifery is a separate discipline with borders and connections to both medicine and nursing, who should regulate midwifery (if indeed it should be regulated) in the public interest? What provisions should be made for the areas where midwifery intersects with medicine, nursing, and surgery?
Midwifery is a body of knowledge that does not require a nursing diploma or a science degree to be accessable. It requires both didactic (book or classroom) learning and experiential (apprenticeship, internship, preceptorship) learning. For a nurse to become a midwife often involves unlearning as much it does learning. It actually would make more sense to require a nursing credential and experience for medical school than it does to require nursing for midwifery. There is much more common ground (especially pathology) between nursing and medicine than there is between nursing and midwifery. The normal physiology of a pregnant, birthing, post-partum and lactating woman changes week by week, and is so different from that of a man or a non-reproducing woman that basics like what are normal vital signs and normal common lab values must be relearned. Just one example - at 28 weeks of pregnancy, if the hemoglobin and hematocrit do NOT drop to levels that in the non-pregnant would be considered fairly severe anemia, there is something wrong with the pregnancy.
In 90 to 95% of cases, pregnancy, labor, and birth can be handled, and handled well, without needing prescription drugs. Good nutrition, a healthy lifestyle, marital chastity, and watchful waiting are all key factors. Hemorrhage, one of the 'big three' killers of women through the ages, can often be prevented with good midwifery skills (especially in the delivery of the placenta), but is one of the conditions for which most midwives prefer to have medication available. A real issue is that the same drugs that stop hemorrhage after the baby is out can also induce labor or abortion. Therefore, there are certain precautions needed when giving them. That is why they are prescription items. There are also non-drug ways that can help slow or sometimes stop excessive bleeding, and many midwives who do not have prescription privileges use only non-drug methods. (BTW - there are a few states where even nurse-midwives cannot prescribe medications). However, most midwives do carry and have been trained in the use of these drugs for hemorrhage. And many will continue to carry them, even knowing it is a violation of the state law, in the unlikely event of a situation like the one Freida Miller found herself in. They get these drugs in various ways. Some get them from physicians. Some get them from abortion clinics. Some go to Mexico where they can be purchased by anyone in a pharmacy. Some steal them. A few tell the women to get a prescription from their own family doctor, if possible.
Due to the politics of home birth, many physicians risk their own career and livelihood by providing any help to a home birth midwife, regardless of the midwife's credentials, licensing status, or other qualifications. A midwife who refuses (as Freida did) to divulge the source of her life-saving if illegal drugs, is probably protecting not only that physician but any others who may see it as their duty to assist those who attend women birthing at home.
In some ways, this is similar to the journalism jailings for refusing to name sources. Many see these actions, and the many other situations that have caused miwives to end up in jail, as a form of legitimate civil disobedience, similar to blocking abortion clinics, violating Jim Crow laws, smuggling slaves north before emancipation, and so on. Others see it as just being stupid or criminal.
It is not unusual for outside observers to be puzzled by the seeming intransigence of midwife defendants. Where licensing of some kind is available, they think, why don't these people just jump through the hoops to get the license? The answer to that is another whole story, one I will try to get to when I can.
