There appears to be an ongoing effort to pit obstetricians and midwives against one another as if the two can’t both play important parts in optimizing pregnancy and birth outcomes and women’s reproductive health.

A couple of years ago, Time magazine published a piece called, “Doctors Versus Midwives: The Birth Wars Rage On.”  Wars?  Really? What is this, the sequel to Monsters vs. Aliens?  How can doctors and midwives be at war when every licensed, practicing midwife has to work with an obstetrician as back up for births that exceed her scope of practice?  And when many states require midwives to work under the direct supervision of a physician?  So how do these midwives practice if they are spending all of their spare time laser blasting obstetricians?  Or hiding from the obstetricians who want to laser blast them?

And even though physicians’ organizations do sometimes fight against licensure of midwives or expanding midwives’ scope of practice, many obstetricians include midwives in their own practices or work with them side by side in hospitals, birthing centers, and even at homebirths (4 to 5% of homebirths are attended by obstetricians).  Again, working together like this is hard to do for people trying to kill each other.

In a recent article in Slate, Laura Helmuth concludes,

For individual simple, low-risk births, having a home birth overseen by a highly trained midwife isn’t necessarily a clearly terrible decision. But when you take a world-historical look at childbirth, it’s not midwives and cozy home births that get credit for making maternal death such an unthinkable outcome today. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. It’s modern medicine for the win. Doctors may have killed a lot of women in the first part of the 20th century, but they can save your life today.

Note that Helmuth does not out-and-out condemn homebirth (though she certainly doesn’t provide a ringing endorsement).  However, Helmuth, while lauding advances that have indeed made birth safer, does not note that (1) the vast majority of midwives practice exclusively in hospitals and  (2) that the Cochrane review of the most recent research indicates that pregnant women have better pregnancy outcomes when their care is provided by a midwife and recommends that most women receive their prenatal and birth care from a midwife.  The Cochrane review also points out the important role obstetricians can play in high-risk situations.  That does not mean that birthing with an obstetrician when her/his high level of expertise is superfluous is safer.

Anti-homebirth activist and blogger Amy Tuteur (a former obstetrician) responded to Helmuth’s piece with a post with the gleeful title, “Obstetricians for the Win!”  I’m not sure what they won.  I guess the good graces of Laura Helmuth?  I doubt most obstetricians know who she is.

Tuteur is convinced that the technocratic model of childbirth (rather than a model based on actual science) is the savior of womankind.  In her post on Helmuth’s piece, she says

Not surprisingly, as technology drove down rates of maternal and perinatal mortality, women flocked to hospitals to give birth. Midwifery has never really recovered.  But midwives have fought back, mainly by pretending that the massive decreases in maternal and perinatal mortality didn’t actually occur, and that childbirth was always as safe as it is today.

Tuteur does not appear to have read the original article, which notes that obstetricians killed a lot of women by promoting technology not based in science, that they sold women a bill of goods regarding their skills, and successfully pushed midwifery to the sidelines even when hospital outcomes were consistently worse than homebirth outcomes.  Women flocked to hospitals before they became places where birth was safe. In one of her many posts denigrating those who do not agree with her adherence to a technocratic model of childbirth, Tuteur makes her argument (which is repeated throughout her blog) that midwives, doulas, and others with humanistic and/or scientific approaches to childbirth are only in it for the money:

Midwives, doulas and childbirth educators can only make money from births that involve minimal or no technology… The promotion of “normal” birth is a marketing strategy, no more and no less… NCB [Natural Childbirth] advocates recognize that increasing their profits involves creating a demand for their product. They are no different from the myriad of other purveyors in the marketplace who imply that their products will lead to social success and approbation. “Buy PearlyWhite toothpaste and you will get the girl!” translates to “Have a normal birth and you will be happier, empowered and have healthier children!”

I don’t particularly like the term “normal birth” myself, as concern about women’s bodies deviating from established “norms” (e.g. the stubborn adherence to Friedman’s curve for determining “normal” labor time) is what makes contemporary obstetrics such a mess.  Most midwives actually use the term physiologic birth, and while individual midwives may detour from practice guidelines, practice guidelines for midwives do not eschew technology or interventions when there is a demonstrated need for them.  The idea that “NCB advocates” are in it for the money is laughable.  On average, the salary of a certified nurse midwife is about a quarter to a third of that of an obstetrician.  Certified Professional Midwives (CPMs) earn less, and a doula may earn as little as a minimum wage worker.  While obstetrics requires substantially more investment in training, the payback is huge.  And even obstetricians say that it is OBs who feel financially threatened by midwives, not the other way around.

The British obstetricians and midwives have practiced together for a long time, and British OBs don’t seem threatened by midwives.  Here is the Royal College of Obstetricians and Gynecologists’ response to the Cochrane review on midwifery.  Basically it says all women should have access to midwifery care but should see an obstetrician if they need to.

So who wins in this manufactured “war” between doctors and midwives?  Somehow I don’t think it’s women.

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