Calling All Midwives….

Midwifery Today, Issue 143, Autumn 2022.
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We have a problem! Labor induction in the United States has more than tripled since 1990.

A first-time mom told me on social media, “It wasn’t even a discussion, it was: ‘this is what’s happening.’ It’s really hard to disagree with doctors or people in positions of authority—in particular when you’re in such a vulnerable position.”

I hear this almost every day, when I spend an hour or so on a first-time mom’s support group on Facebook. Here are a few more of the tragic comments I have tried to respond to as so many women face birth in the US, where labor induction has become the norm.

“Going in for my induction tomorrow night (7/27/22). I’ll be 37 weeks exactly and they are starting with Cytotec before the Pitocin. I would love to hear about experiences, tips, and advice to help with my anxiety, thank you!”

“37 weeks 5 days and absolutely no signs of labor. My induction date is 8/8 but I would love to go naturally. Sex twice a day, curb walking, and regular walking is what I’ve been trying so far.”

“I’m being induced in 13 days and I’m straight having an anxiety attack. I’m so nervous. I’m ready for my little boy to be here but I’m scared shitless.”

“Every time I say I am getting induced, everyone says don’t do it! Did you get induced? What was your experience: good or bad?”

“39 weeks this week and wondering whether there are any tips to bring labor on or what to use. Due in 10 days.” (Facebook Group 2022).

The rate of induction of labor in the US has risen from 9.6% in 1990 to 31.4% in 2021, including 41.7% of first-time births. Induction of labor (IOL) is a common obstetric intervention that stimulates the onset of labor using artificial methods. Rates of labor induction have tripled since 1990 (Up to Date 2022). There is substantial variation in IOL rates worldwide, which can be attributed to variability in the guidelines and lack of consensus on the clinical practice guidelines on IOL. Nowadays, in high-income countries, the proportion of neonates born following IOL is estimated to be approximately 40%. In contrast, the corresponding rates are generally lower in low- and middle-income countries. As a midwife, all of my alarms are going off. I remember Dr. Michel Odent warning us that within one more generation of Pitocin augmentation for labor, women would lose their ability to naturally start labor on their own. This article is my CALL TO ACTION for all midwives who know in their soul that this is bad for humanity and birth. It is time for us to reclaim our place “with women” as the protectors of nature and the physiology of birth for future generations. We must stop begging to exist, and reclaim our ancient place as guardians of human reproduction.

I realize that while the relatively new body of knowledge known as obstetrics can be lifesaving, it is not midwifery. A clear understanding of the difference is necessary before we can intelligently discuss birth and the effects of any medical obstetrical intervention, including induction, on human reproduction with any integrity.

We know that midwives were mentioned as far back as the Egyptian Papyrus Kahun (Lopes and Pereira 2021). Midwives know that human reproduction is biological and instinctual. Midwives demonstrate a deep respect for and understanding of the natural process of creating new humans, as opposed to the new, Western, medical/surgical profession of obstetrics that sees human reproduction as mechanical and profitable. Obstetrics must be understood for what it truly is. It is a less than 100-year-old “medical specialty” that has shown no respect for the natural biology of human reproduction. Its trade association, the American College of Obstetricians & Gynecologists (ACOG), founded in 1951, is the self-proclaimed authority on maternal/child health. ACOG has not taken the time to scientifically observed the phenomenon of physiological birth, but rather has approached human reproduction and maternal/child health as something to dominate and control.

Because women themselves created midwifery—as opposed to obstetrics, which was created to profit from human reproduction—it is important to explain the difference clearly. The etymology of midwife, which literally means “with women,” defines a mindset of partnership and respect. The etymology of obstetrician is “to stand before,” and defines a mindset of distance, superiority, knowing, and control. There is a clear difference.

Statistics show that in countries with continuous midwifery care, women and babies do better than in countries with obstetricians in control. Sweden is a good example: Sweden has had a history of uninterrupted midwifery care for all women. In Sweden, the entire birth process, including prenatal and postnatal care, is managed by midwives, rather than obstetricians. This has been the case for all women, with the only exceptions for mothers with certain pre-existing health conditions or with complications that arise, in which case the mother will be referred to a hospital doctor. Sweden is one of the safest places in the world to give birth (The Local 2018).

Contrast this with the US, which has a history of oppressing midwifery and still, to this day, cannot seem to understand the difference between obstetrical care and midwifery care. Among 11 developed countries, the United States has the highest maternal mortality rate and a relative undersupply of maternity care providers, and is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period, according to a recent report from The Commonwealth Fund. Compared with any other wealthy nation, the US also spends the highest percentage of its gross domestic product on health care (Commonwealth Fund 2020).

In an issue brief, researchers assessed maternal mortality, maternal care workforce composition, and access to postpartum care in 10 high-income nations and compared findings with the United States. Data from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom were gleaned from 2020 health statistics compiled by the Organization for Economic Co-operation and Development (Melillo 2020). Their findings show that the US’s use of obstetrician lead care does not provide acceptable outcomes for women and babies.

So now, let’s consider the question of medical interventions to effect maternal child health care outcomes. First, we must remember that the obstetrical model of care sees childbirth as a mechanical process (Davis-Floyd 2003). Efficiency is seen as a goal, as is ease of scheduling, and moving women from labor to delivery and out the door with a new baby. Continuity of care, a part of the midwifery model of care, is not a concern in the mechanical model; relationships are not necessary for machines. The forced movement of birth from the home to the hospital was done quickly and forcefully. The postwar period saw the acceleration of the move from home to hospital as the usual place of birth. This trend had been gaining momentum throughout the 20th century. Nationally, the proportion of deliveries in hospital was about 64% in 1954 and only slightly more in 1960. But between 1963 and 1972 the rate rose from about 68% to 91%. From 1975 onward, it has never fallen below 95%; today it is between 98% and 99% (Davis 2013). Moving birth to the hospital was effective for the growing “medical maternal industrial complex.” Six of the 16 most common hospital procedures are for maternal or newborn care, including the nation’s most common operating room procedure: cesarean birth (National Partnership for Women and Families 2014).

Moving the process along efficiently is the metric used to measure success in a mechanical model. Just as McDonalds measures the time it takes to put the hamburger in the hand of consumers and get them out the door … the conveyor belt of maternal child health care in the US is still focused on moving consumers out the door. It appears that capitalistic birth is more concerned with turning over the bed and getting a new consumer in the door than with the health of the woman and baby. More than 50% of pregnancy-related deaths in the United States occur after the birth of the child, or postpartum (CDC 2022). But let’s get back to the issue of intervention and induction.

To address the issue of induction it is necessary to grasp the above concept: that of efficiency and time being central to obstetrical understanding of the birth process. When obstetrics first began to try to understand human parturition it set about to categorize, label, and measure all aspects of the machine it wanted to control. Obstetricians have made up number systems, and created curves and graphs to explain a process it could never experience or fully understand. It pronounced stages, averages, and parameters to control the process. To this day this absurd obsession with numbers, time, and control shapes most of the obstetrical understanding of human reproduction. It is this “Obstetrical Myth” that is taught in universities to obstetricians, nurses, and, now, midwives. Most of it is not scientific at all, and much of it is not even evidence-based or factual (Davis-Floyd 2003).

The first silly, made-up story a pregnant woman must deal with is that of a due date. Most people know how babies are made and we understand that, for the most part—excluding IVF—it is an organic, natural process. What a lot of people don’t know is that a sperm and an egg have lives of their own. A very private and uncontrollable journey that is truly a miracle of nature—conception—is not measurable. The truth is that ejaculated sperm can remain viable for several days within the female reproductive tract. And women can potentially ovulate two or even three times a month. Fertilization is possible as long as the sperm remain alive—up to seven days. Only 4% of babies are born on their due date. Eighty percent arrive between 2 weeks before and 2 weeks after this date. The rest are either premature or late (Chen and Grimm 2021). So due dates are really due periods.

Furthermore, ultrasound gestational dating is not an exact science. An ultrasound at 20 weeks’ gestation is accurate only to ±1–2 weeks’ gestational age. Combined with the fact that developmental variability exists during fetal maturation, the task of accurate gestational age prediction is even more challenging (Edwards and Itzhak 2022). Perhaps it’s time we asked ourselves some questions. Like, why all the fuss about due dates? Won’t babies be born when they are ready? What actually triggers labor? In 2004, researchers at UT Southwestern Medical Center at Dallas discovered that the baby actually has something to say about when she will be born. A protein called surfactant, released from the lungs of a developing fetus, initiates a cascade of chemical events leading to the initiation of labor (ScienceDaily). This should lead us naturally to question why anyone would want to “induce” a woman to go into labor. The sad fact is that it happens all the time. In fact, ACOG released a paper suggesting that it was a good idea for all first-time mothers to be induced at 39 weeks (Hersch et al. 2019). (To learn more, read ACOG’s comments on the ARRIVE Trial from 2018.). To sum up the conclusions, it is all about efficiency, time, and money.

Here is another example: In 1955, Dr. Emanuel Friedman, from Columbia University, published a study he had undertaken of 500 first-time mothers who had given birth at full term. The doctor plotted their labors on a graph and calculated the average time it took a woman to dilate each centimeter. This graph became known as the Friedman’s Curve and was used as the gold standard for rates of cervical dilation and fetal descent during active labor until 2010. The graph showed the average rate of cervical dilation was about 1 cm per hour. Now any seasoned midwife will tell you that this is ridiculous. To this day, this is used to put the woman on the clock when she enters the assembly line of labor. Often if she is not following this curve…she will be offered things to keep her moving along … such as rupturing her membranes or inducing her with Pitocin. A nice little way to nudge her back onto the normal curve and get the birth done.

Let’s look at one more example of how women have been forced to adapt to the cascade of medical interventions we see today, starting with the concept of induction. In 1964, Edward Bishop set forth criteria for “elective induction of labor, which included parity, gestational age, fetal presentation, obstetric history, and patient consent as well as a scoring system for the cervix to help predict successful induction of labor.” His system, which is known as the Bishop score, uses cervical dilation, position, effacement, consistency of the cervix, and fetal station. (Worm, Bauer, and Williford 2021.) Some of these things are real and some of them are part of the obstetrical myth, such as dilation progressing in a linear fashion from 0–10 cm, or the idea that all babies’ heads descend incrementally thru the pelvis uninterrupted. I share this with you here to demonstrate my point that Dr. Edward Bishop was busy in 1964—just 58 years ago—creating a system that is still in use today to make the intervention of induction seem scientific. As of this writing this system has been proven to be unnecessary, based on a study in 2017 that concluded that labor induction in multiparous women is safe and successful regardless of the initial Bishop-score. In multiparous women the Bishop score is not a good predictor of the success of labor induction, nor is it a predictor of maternal or neonatal adverse outcomes and complications (Navve et al. 2017).

How is the ancient process of human reproduction to survive in this made-up story called obstetrics? This man-made body of knowledge that our culture now perceives as superior to midwifery wisdom. It would seem that reality is telling the story. Women are dying, babies are dying … and humanity is suffering. We even have a name for this mistake; we call it “the cascade of intervention.” This cascade begins with induction and ends with the surgical removal of a human baby from its mother. Obstetrics is in crisis—and they know it.

In 2015, I had the amazing opportunity to sit in on the opening session of ACOG’s annual meeting. The theme of this annual clinical and scientific meeting, held in San Francisco was Teaming Up for Women’s Health. It was truly eye-opening. First, let me give you a brief history to put things into perspective.

In March of 2010, Amnesty International had issued a report entitled “Deadly Delivery: The Maternal Health Care Crisis in the USA,” which documented the fact that although the United States spends more on health care than any other country, it was ranked 41st (at the time of publication) in terms of maternal death. As the report demonstrated, this is not just a matter of public health, but a human rights issue. Half of these deaths are preventable, and the report clearly demonstrated many barriers women face in accessing high quality maternal care (Amnesty International 2010). In 2018, the US was 55th in the World Health Organization’s (WHO) maternal mortality rate rankings (CDDEP 2020)

At the ACOG meeting Susanne Arms, author of Immaculate Deception, and I sat in the front row as we listened to a large, white man, in a white coat, address the assembled obstetrician/gynecologists who sat in perfect rows waiting patiently for their leader to give them some hope. Here is what he said, “I have some ‘good news’ and I have some ‘bad news.’ Bad news first: we taught you wrong, we misled you, we taught you to believe that you were God, that you were responsible and the final authority and expert on maternal/child health care. We were wrong, it cannot all be left up to you.”

He went on for 30 minutes, describing all the factors that were outside the good doctor’s control when it came to ensuring outcomes in maternal/child health care. He then cleared his throat and said, “And now the good news…. The good news is a thing called multi-disciplinary teams.”

He went on to describe what these teams would look like and who they would include. He then concluded with “and we will include the ‘mother’ in our teams as well.” Suzanne and I looked at each other and cracked up! Right there in the front row, we burst out laughing. We were drowned out under the rousing round of applause, by the inspired doctors who now had a plan.

The truth is that obstetrics is lost; it has no idea why women are dying; it has no idea why birth can’t be made into a nice predictable machine that will work into their golf schedule. They keep graphing, measuring, numbering, and blindly studying, throwing money at birth, but birth will not be fixed! Human reproduction continues to elude them, and women and babies continue to suffer.

And why are they so lost? They simply do not understand nature or the complex interdependencies of human reproduction. Our health care in the US is broken in so many ways, but nowhere is it as glaringly obvious as maternal/child health care (Schmerling 2021). Pretending is no longer acceptable.

Midwives must rise up and re-claim their duty to protect women and birth.

In conclusion, birth in the United States is in trouble. Induction is an obstetrical medical intervention that clearly needs to be re-evaluated in light of the problems (Lothian 2014). Midwifery is an ancient body of knowledge, pre-literate in nature, passed down from mother to daughter. This ancient body of knowledge served humans for millions of years. Midwifery knows that human reproduction is normal, instinctive, and physiological. This is in contrast to obstetrics, which is only 100 years old, has no respect for nature, and has not observed the physiology but instead arrogantly believes it can control women and nature. Statistics show that in countries with continuous midwifery care women and babies do better than in countries with obstetricians in control (Consensus Statement ).

Thus, while obstetrics can be lifesaving and has its place, the ancient art and science of midwifery is a body of knowledge, pre-literate in nature, that understands human reproduction and has served humanity for millions of years before the obstetrical, medical, intervention into birth. This intervention has now been allowed to dominate human reproduction to its detriment. I suggest we explore what women and midwives know before we allow this obstetrical myth to go on much longer. I am now calling on all midwives to rise up and re-claim their responsibility to birth and women, Midwives can no longer beg to exist. The practice of “MIDWIFERY” must be defined and studied by humanity for the wisdom it intrinsically carries for the future of our species.

CALLING all MIDWIVES, Humanity needs us now!


About Author: Deb Puterbaugh

Deb Newberry-Puterbaugh, LM, CPM, is a woman, daughter, sister, wife, mother, grandmother, childbirth educator, doula, midwife, and community organizer. Deb has spent her adult life dedicated to personal growth, women’s empowerment, and cultural change. She is a midwife educator.

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