background document:  C.E.O  White Paper 2004

Wednesday February 16, 2011 01:34


Consortium for the Evidence-base practice of Obstetrics
C.E.O. is dedicated to bringing science-based maternity care to all childbearing women

A-C.E.O ~ The American College of Evidence-based Obstetrics ~
for physicians who wish to
re-establish the scientific foundation of their profession
& reclaim their expertise in the use of physiological management for normal birth

Ending Flat Earth Obstetrics
Reading time approximately 25-30 minutes

     Mothers' Day letters to Maria Shriver
     a thousand letters in a hundred days

The following "position paper" is designed to give people the type of information
 needed to write informative letters and to work for political change.

  Navigational Short Cut to Chapters  

The Primary Role
of Maternity Care

In the First Place,
Do No Harm

Evidence-based Standard for all
Healthy women

Problems & Proposed Solutions

Institutional Memory
L&D Staffed by Professional Midwives Fully Informed Consent Tort Reform
VBAC Availability Autonomous Profession of Midwifery Reforms as Interdisciplinary Process Conclusions
Instructions & Address for Letters the First Lady  2004.htm
What Every Pregnant Woman Needs to know about Cesarean Section ~ 2004 Maternity Center Association

CEO Position Paper ~ May 9, 2004

21st Century Maternity Care ~ 
Meeting the needs of our childbearing population
while remaining competitive in a global economy  

"the hallmark of obstetrical quality is the prevention of the rare disaster
  rather than the optimal conduct of the many normal cases" [Dr. Brody 1981]

"Obstetrics has been rated as the least scientifically-based specialty in medicine" [Dr Ian Chalmers 1987]. 

Stedman’s Medical Dictionary definition of “physiological” – “…in accord 
with or characteristic of the normal functioning of a living organism” (1995)

Preserving the health of already healthy mothers and babies is the primary role of maternity care. The traditional method for serving healthy childbearing women is  known as "physiological management".  Its classic principles are  “…in accord with, or characteristic of, the normal functioning of a living organism”. In this science-based system, physicians and midwives all over the world are taught to utilize physiological management for normal pregnancy, labor and birth.

These protective and preventive methods include a commitment not to disturb the natural process. This minimal-intervention approach includes continuity of care, patience with nature, one-on-one social and emotional support, non-drug methods of pain relief and the right use of gravity. Obstetrical intervention is reserved for complications or if the mother requests medical assistance.

Mothers giving birth spontaneously ~ Babies being born normally, without interventions

The scientific basis for physiological management of normal pregnancy and birth is supported by a consensus of the scientific literature. This evidence validates the safety of physiological principles while revealing the countervailing risks of medicalizing healthy women. Physiological management is actually protective of both mothers and babies, reducing the episiotomy/instrumental/operative delivery rate, along with its associated complications, from approximately 72% to approximately 5% with a virtually identical, or even slightly improved perinatal mortality rate. To become familiar with this scientific literature is to redefine the politics of this controversy.

Physiological principles provide the safest and most cost-effective form of maternity care. According to the World Health Organization, it is the preferred standard for healthy women. W.H.O. refers to this as the "social" model of childbirth; most countries depend on these low-tech / high-touch methods to provide cost-effective care. In the US, this known as "family-centered" or "mother/ baby/ father-friendly" maternity care. Approximately 70% of pregnant women in the United States are healthy and have normal pregnancies. That is approximately three millions normal births annually.

"In the first place, Do No Harm" ~ putting the Hippocratic Oath into practice

True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Our present system of obstetrics for normal childbirth does not do well in this regard. In spite of spending more money than any other country in the world, the United States is 30th in maternal mortality and 22nd (3rd from bottom) in perinatal mortality. The five countries with the best outcomes spend only a fraction of the money we do. They all have national maternity care systems that depend on physiological management as provided by professional midwives to healthy populations.

Our maternal-infant mortality record is dismal because obstetrical interventions, originally developed for complications, are inappropriately used on healthy women. This introduces unnatural risk and unnecessary complications. Avoidable problems are the result of disturbing the normal biology of labor and birth by routinely applying medical and surgical interventions to nearly 100% of the childbearing population.  

 Textbook pictures instructing medical students in the surgical technique of Episiotomy -- an incision
into the vagina during the pushing phase of childbirth. It is never medically necessary unless the
unborn baby is distressed or if the mother is exhausted and asks for an episiotomy.

blades of the surgical scissors
inserted into vagina

surgical scissors closed so as to
create a 2-3 inch incision

The Maternity Center Association of NYC recent surveyed healthy women with normal term pregnancies who gave birth in the previous 24 months. This was done in an effort to track contemporary obstetrical trends and the quality of care received by healthy childbearing women. The 'Listening to Mothers' survey revealed that 99% of healthy pregnant women do not receive science-based maternity care from their obstetrical providers. An average of seven or more serious medical or surgical procedures were performed on each laboring woman. As reflected in this study, there were virtually no spontaneous, unmedicated births (i.e., without medical or surgical interference) in institutional settings. [Listening to Mothers by the Maternity Center Association of NYC, October 2003]. That means nearly three million healthy childbearing women are exposed each year to unnecessary obstetrical interventions. Without truly informed consent, healthy childbearing women have been unwitting subjects in an unregulated medical experiment for more than a century. Non-consensual medical treatments are routinely forced on competent adults.

A healthcare system that over treats three-quarters of its patients (3 million each year) is both expensive and dangerous. It exposes mothers and babies to unnecessary physical and mental suffering and increased rates of preventable death and disability. Recently the obstetrical profession has upped the ante by promoting the strange idea that an 'elective', or medically unnecessary, 'maternal choice' cesarean is safer than normal childbirth. Many in the obstetrical profession predict that cesarean delivery will completely replace normal birth within the next decade or so to become the obstetrical "standard of care".

For society, this irrational and unscientific system misdirects scarce economic and human resources that could more properly be used to treat the ill, the injured, and the elderly. Healthcare expenditures account for 17% of the Gross National Product. Obstetrical care accounts in the US for 20% (1/5th) of our entire healthcare budget (equal to 3.4% of our GNP). Seventy percent of those maternity care expenses (2.4% of the GNP) are inflated by unneeded medicalization, which generates additional (and expensive!) complications.

The bill for this failed medical experiment is being passed on to the public and to employers through the Medicaid tax burden and the increased cost of health insurance. In order to remain competitive in a tight global economy, many industries are outsourcing manufactured goods and replacing service jobs with offshore workers. Economists have identified our inflated health care costs (compared to other countries) as a major factor in the choice of cost-cutting measures that depress our economy and deprive Americans of employment opportunities.   

To remain competitive in a global free market, the US must utilize more efficacious forms of maternity care to meet the practical needs of healthy families. Worldwide, the global economy depends on the use of physiological principles and low-tech, inexpensive methods of midwifery care for normal birth services to retain its competitive edge. The US must also utilize these safe and cost-effective forms of care in order to compete in a global economy. 

A rehabilitated policy would integrate the classic principles of physiological management with the best advances in obstetrical medicine. This would create a single, evidence-based standard for all healthy women used by all maternity care providers. Under a rehabilitated system, management strategies would be determined by the health status of the childbearing woman and her unborn baby in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (family practice physician, obstetrician or midwife). At present, who the woman seeks care from (obstetrician vs. FP physician or midwife) determines how she is cared for. 

Our tort laws currently force most doctors to provide interventionist care irrespective of  the health status of the mother or her wishes. It should be noted that this creates an asymmetrical burden of risk that falls unfairly on the childbearing woman.  The mother /baby couple is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of lawsuits for the obstetrician. This is deeply offensive and must be corrected. 

Medical journals, textbooks and scientific sources all make it clear that routine obstetrical intervention and normal birth conducted as a surgical procedure are always more dangerous for healthy women than the use of physiological principles, in conjunction with appropriate social and psychological support. Scientifically speaking, this is not a controversial finding. Reliable scientific evidence is neither lacking nor incomplete, nor is this data the subject of methodological disputes

Consider this: If planes landing at US airports crashed  five times more often than when they landed at airports in England or Japan, we would demand an inquiry of our air traffic control system, since the laws of aerodynamics are the same worldwide. Each year in the US about 8 million mothers and babies 'fly' the united service of interventionist obstetrics. Only a fraction -- under  30% -- need and benefit from this type of medicalized treatment. Isn't it time to inquire why the universal 'laws of normal childbirth,' which are the same worldwide, are being routinely suspended by American obstetricians and, as a result, American mothers and babies are crash landing at an alarming rate.   


Problems and Proposed Solutions

The following goals can be achieved by demanding that our national maternity care policy recognize the "social" model of maternity care for healthy women as the preferred standard for healthy women.

1. Recovering Institutional memory within the obstetrical profession and re-establishing physician expertise in physiological management and socially based childbirth services:

Prejudice against 'natural' birth methods and a century of routine hospitalization for all normal childbirth displaced important opportunities for doctors to learn and use physiological methods for supporting labor and spontaneous birth. In the last three decades the standard medicalization of childbearing has been greatly expanded. High-tech surveillance during the prenatal period now exposes every normal pregnancy to repetitive ultrasounds and non-stress testing and other diagnostic procedures. Premature and/or artificial termination of normal pregnancy by induction, instruments, surgical incision, or cesarean section is now the statistical norm. Childbirth for healthy women is typically accompanied by the routine use of continuous electronic monitoring (93%), inducing, or speeding up labor with artificial hormones (63%), epidural anesthesia (63%), episiotomy, instrumental delivery, and/or cesarean surgery (72%).

As a result medical educators have no knowledge or understanding of the social model of childbirth. Most hospital-based care providers have no experience in or respect for the principles of physiological management. Institutions such as hospitals and health insurance companies have no identified mechanism to authorize the use of physiological management or to economically compensate practitioners who bill for professional services associated with the "social" model of care.

The institutional memory of "normal" childbirth is now totally absent for most obstetrical units and virtually all obstetrical providers. In order to rehabilitate institutional memory, medical educators, medical students, and practicing physicians all need to be exposed to the theory and the practice of physiological management. This requires that medical educators and obstetricians familiarize themselves with physiologic principles through textbooks and other sources of information and gain hands-on experience by working with practitioners (primarily professional midwives) who are experts in physiologic management.

In a rehabilitated maternity care system, physicians who provide care to a healthy population would be required to either:

2. Hospital labor & delivery units to be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain for hospital-based midwifery practice to do so at minimal expense to themselves: 

Midwives have been the preferred provider for normal maternity care for millennia. In the history of western culture, midwives have been an autonomous profession in Europe for many centuries. There are formal training programs in Scandinavia that have been teaching midwifery to both doctors and midwives for more than 200 years. Midwife-graduates of these programs currently staff hospital labor and delivery units of all over Europe. It is a cost-effective system that works for mothers, for midwives, and for taxpayers. It appropriately utilizes the lengthy education and highly technical skills of obstetricians, who are called in when complications develop during labor and birth.

This European system, which depends on professional midwives to staff their maternity units, assures that physiological management is taught to medical students and remains the standard used by all practitioners. This system frees obstetricians from many "routine" duties, thus permitting them to be the highly trained experts their education prepared them to be.

In order to develop to this system in the US, it is important that educational "bridge" programs be developed for L&D nurses, so that any who wish may evolve into hospital-based practitioners.

3. Fully Informed consent for medicalized care -- especially for labor induction, augmentation, anesthesia, instrumental and operative delivery:  

Fully informed consent would require true informational transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedure. 

Scientifically correct information must be routinely provided to healthy women on the short and long-term limitations and complications resulting from the medicalization of labor – i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed. This severely limits or eliminates access to time-tested strategies of physiological management and right use of gravity, thus increasing artificial stimulation of labor and operative delivery and all their associated complications.

Obstetricians must provide valid information during the last trimester of pregnancy that includes the short and long term complications associated with major medical and surgical procedures performed during the labor – continuous electronic fetal monitoring, restriction of oral nourishment, IVs, labor stimulating/inducing drugs, off-label use of Cytotec/misoprostol, narcotics, epidural anesthesia, indwelling bladder catheters, episiotomy, vacuum extraction, forceps and a 27% cesarean section rate.

In particular, obstetricians must identify the lavishly documented failure of continuous electronic fetal monitoring and liberal use of cesarean section to reduce the rate of cerebral palsy and other neurological disabilities. For example, a July of 2003 report by

In particular, obstetricians must identify the lavishly documented failure of continuous electronic fetal monitoring and liberal use of cesarean section to reduce the rate of cerebral palsy and other neurological disabilities. For example, a July of 2003 report by the ACOG Task Force on Neonatal Encephalopathy & Cerebral Palsy stated that:  

"Since the advent of fetal heart rate monitoring, there has been no change in the incidence of cerebral palsy."  "... The majority of newborn brain injury does not occur during labor and delivery. Instead, most instances of neonatal encephalopathy and cerebral palsy are attributed to events that occur prior to the onset of labor.

        Textbook picture ~ EFM Scalp electrode screwed
                        into skin of baby's head ....

An August 15, 2002 report on this topic in Ob.Gyn.News stated that

 "performing cesarean section for abnormal fetal heart rate pattern in an effort to prevent cerebral palsy is likely to cause as least as many bad outcomes as it prevents." "... A physician would have to perform 500 C-sections for multiple late decelerations or reduced beat-to-beat variability to prevent a single case of cerebral palsy."   

The September 15, 2003 edition of Ob.Gyn.News stated that

"The increasing cesarean delivery rate that occurred in conjunction with fetal monitoring has not been shown to be associated with any reduction in the CP rate..." " ... Only 0.19% of all those in the study had a non-reassuring fetal heart rate pattern....  If used for identifying CP risk, a non-reassuring heart rate pattern would have had a 99.8% false positive rate...."  

The benchmark for informed consent transparency should be this same information about complications that is reported to physicians in the scientific literature and obstetrical trade papers, such as the excerpts from Ob.Gyn.News included in this document, only restated for childbearing parents in lay terms that are appropriate for their concerns. 

Legislation mandating fully informed consent (or decline) of all major obstetrical interventions, based on a true transparency model of information, in particular for continuous EFM, labor stimulating drugs, anesthetics, episiotomy, forceps, vacuum extraction and cesarean surgery may be necessary. 

4. Tort Reform:

Currently our tort laws force doctors to provide interventionist care irrespective of  the health status of the mother, or of her wishes. It should be noted that this creates an asymmetrical burden of risk that falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of lawsuits for the obstetrician. This is unacceptable. 

The unexamined theory of our tort laws induces physicians to protect themselves by  'cost-shifting', 'risk-shifting' and 'blame shifting'. This is particularly pernicious when obstetrician implement surgical "solutions" in order to reduce the legal culpability to themselves, as physicians are not legally responsible for post operative complications. For instance, they are expressly exonerated from "downstream" sequelae or time-delayed complications such as incontinence or uterine prolapse (the sequelae of forceps delivery) or placenta previa, p. percreta or stillbirth in a future pregnancy (the sequelae of Cesarean section) .

Obstetrician Peter Bernstein noted this in his essay (Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?) which noted that the law (and at present the ethical designation by society) inappropriately protects the physician who chooses to reduce the litigious risk to himself by shifting it forward to the mother and/or baby in a future pregnancy. According to Dr. Bernstein:

There may be no legal liability to the physician who performed the patient's first cesarean section when the patient winds up with a hysterectomy or worse, but that does not clear that physician of responsibility for performing a surgical procedure of unclear benefit....

In the short term, the most direct remedy to this problem is truly transparent informed consent for the use of interventive and operative obstetrics. In the long term it requires the rehabilitation of two important areas of modern life --our tort laws and of our maternity care system.  

5. Reassessment of policies severely restricting or denying obstetrical care for normal labor and vaginal birth after a cesarean (VBAC): 

#1Excellent supportive study  Vaginal Birth After Cesarean and Uterine Rupture Rates in California  for 1995; 

#2 Quotes from additional supportive study  on VBAC safety

If one counts the full spectrum of risks associated with delivery by cesarean section -- intra-operative, post-operative, delayed and downstream complications for both mother and baby, including complications arising in post-cesarean pregnancies --  the evidence is overwhelmingly in favor of spontaneous labor and normal birth. A consensus of VBAC studies published over the last 20 years has repeatedly confirmed this. A recently published California study found the very safest category  (aside from women with no uterine surgery) was spontaneous vaginal birth after cesarean, which was even safer than elective repeat CS.

However, "faith-based" reporting by the news media has poisoned the issue of VBAC safety in the public mind. Aggressive coverage of the VBAC topic by the press was precipitated by a study in the New England Journal of Medicine in June of 2000. Unfortunately, the blind faith of the press disarmed the natural inquisitiveness of responsible reporting.

According to this research,  there was a 5 to 15-fold increase in uterine rupture in post-cesarean labors when powerful uterine stimulants (especially prostaglandin drugs such as Cytotec) were used  to induce or augment labor in women with a surgically scarred uterus.  However, the press got the story backwards. Spoon-fed a physician-friendly "spin" with a hidden agenda, the press acted as a conveyor belt for obstetrical propaganda.

Instead on focusing on the real danger -- the use of powerful artificial hormones to induce labor -- newspaper stories wrongly identified the primary danger for VBAC mothers to be normal (spontaneous) labor and spontaneous birth. This story was spread across the entire country by the Associated Press and even carried by National Public Radio. The syndicated news coverage precipitated a crisis of gigantic proportions for post-cesarean families all across the country as newspaper stories urged the complete and immediate abandonment of post-cesarean labor based on safety.

The media claimed that new research identified great danger in spontaneous labor (i.e., not induced, no artificial hormones to speed it up) that had gone unnoticed until now. Obstetrical spokespersons interviewed for these stories resurrected the 1930s axiom that "once a cesarean, always a cesarean", as these doctors assured everyone that 'elective' repeat cesarean was so much "safer for the baby". However, the scientific literature on VBAC has not changed at all in the last 20 years, except to identify the added risk of labor-inducing or accelerating drugs in post-cesarean pregnancies. The consensus of VBAC research continues to find the incidence of uterine rupture associated with labor to be low -- approximately .05% -- and to identify spontaneous labor as safer than repeat cesarean surgery and anesthesia. 

In combination with the skewed reports of this study, the American College of Obstetricians and Gynecologists' (ACOG) changed their 1985 practice guidelines by re-defining normal VBAC labors as extremely high risk. They generated protocols that make VBAC more expensive for hospitals and extremely inconvenient for physicians. As a result, most obstetricians are unwilling/unable to provide VBAC care. For example, the new ACOG protocols require the obstetrician, anesthesiologist and surgical scrub team be all present in the hospital for the entire time that VBAC mothers are in active labor. Smaller hospitals cannot provide this kind of coverage. Many other simply refuse, since repeat cesareans are more profitable.

Then malpractice carriers began to charge higher insurance premiums if doctors and hospitals 'allowed' post-cesarean women to labor naturally.  Many obstetricians and hospitals eliminated the option of a VBAC in order to save money on malpractice premiums. In large geographical areas of California, previous CS mothers must drive over 100 miles to find a hospital that will 'permit' them to labor spontaneously. In large areas of the state, there are NO hospitals or doctors that will attend a VBAC.

Unfortunately, the misrepresentation of the NEJM study propelled the already excessive use of cesareans to even greater heights. Rather than protect women, it only exposed even more childbearing women to the many hazards of abdominal surgery. Today, women are routinely forced to schedule medically unnecessary cesareans, as more and more doctors and hospitals cop out with a policy of "we don't labor sit, we don't do VBAC’s". Saddest of all, these self-serving policies replace the small theoretical risk of a spontaneous birth (no labor inducing drugs) for the greater hazards of abdominal surgery.

Make no mistake about it -- it is the use of prostaglandin and other labor inducing drugs on VBAC women that should be abandoned – not normal labor.

The true risks of "elective" cesarean:  Cesarean surgery carries added dangers not associated with normal birth. This fact has always been well known by doctors but rarely admitted to the public. (ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD). The incredibly high Cesarean rate in the US is fueled by the mistaken notion that it does not matter how the baby is born “as long as it is healthy”. This discounts or ignores the risks of elective surgery to the childbearing women at the time of the operation and complications in future pregnancies, including an increase in postpartum depression.

Cesarean surgery increases maternal deaths by 2 to 4 times compared to normal vaginal birth. Maternal mortality rate associated with vaginal birth is only 1 out of 16,666. It jumps way up to 1 out of 3,225 after a Cesarean. (Lilford, 1997 et el) One popular obstetrical text reports Cesarean-related maternal deaths to be as high as one out of thousand. ( Gabbe Obstetrics, 1991) In spite of these known dangers the US has a higher CS rate than any other country except for Brazil.

In addition, there are serious health problems for post-cesarean babies not accounted for by the NEJM study, such as iatrogenic prematurity and respiratory distress. Elective repeat Cesareans have a fetal mortality of 2 to 3 per 1000 operations. (Obstetrics: Normal and Problem Pregnancies  Gabbe, 1991) The May 2004 edition of Ob.Gyn.News noted that elective cesarean is riskier to the newborn baby than vaginal birth. It stated:

"Neonates born by elective cesarean section are at greater risk of poor outcomes than those born vaginally....   14% of those from the elective cesarean group (relative risk 3.58) were admitted to an advanced care nursery [in contrast with only 5% of vaginal delivery]   ....oxygen was used ... in 73% of those in the elective cesarean group [compared to only 23% in vaginal delivery group]...   

The difference may be due to beneficial effects of the process of labor and delivery on infants and their ability to transition following delivery. Clinicians should consider neonatal effects, as well as maternal well-being, when discussing the possibility of elective cesarean delivery in patients with uncomplicated pregnancies, he said." [emphasis added] (Ob.Gyn.News May 1, 2004, Vol 39

An example of long-term health hazards was found in a recent study done in the UK, which identified that being born by Cesarean triples the risk of adult asthma. (Journal of Allergy & Clinical Immunology 107[4[:732-33, 2001) 

Another factor is the detrimental impact on the mother-child relationship from an increase in postpartum depression (PPD) and post-traumatic stress symptoms (PTSD) associated with operative deliveries. Postpartum depression is more common and more sever after the added stress of a Cesarean or other operative delivery and if the baby is premature or must be in the intensive care nursery after the birth. (Predictors, prodromes and incidence of postpartum depression. Obstet Gynaecol 2001 Jun)  

Political strategy for change: The need to rehabilitate these inappropriate and detrimental policies by doctors, hospitals and malpractice carriers is obvious. A particularly useful strategy, that would also reduce the number of primary (original) surgeries, is requiring physicians to obtained truly informed consent before any non-emergent cesarean can be performed. Legislation that prohibits the medical profession from denying normal birth services to healthy VBAC women who wish to labor spontaneously (i.e., no labor stimulating drugs or instrumental delivery) may also be necessary.    

6. Recognizing  and protecting the ethical and constitutional rights of competent adult women to have control over the manner and circumstances of pregnancy and normal birth.

7. Midwifery as an autonomous profession.

Historically and globally, the discipline of midwifery functions to guard normal childbearing and to restrain the excesses of the high tech medical model. To do this effectively, professional midwifery must be an autonomous profession in its own right.

For the last 100 years, organized medicine has used unethical and unconstitutional practices to unfairly burdened the midwifery profession. Unworkable licensing laws is one example. Written by organized medicine, these laws inappropriately place the control of the profession of midwifery into the hands of an entirely different and competing profession -- obstetricians. The obstetrical profession then use that illegitimate control to strangle midwifery by keeping it marginalized, criminalized or in a legal limbo. This directly harms the profession of midwifery and individual midwives. It also limits or eliminates access to midwifery services by childbearing women. This political situation is the political backdrop for "flat earth obstetrics". The excesses of obstetrics are the predictable consequence of preventing the corrective and humanizing influence of midwifery from being applied to the field of normal maternity care. Absolute power circumvents accountability and public oversight. Power plus secrecy corrupts absolutely.

In California, the 'physician supervision clause' in both the certified nurse-midwife and licensed midwifery acts, must be repealed. It creates unnatural and unnecessary vicarious liability for physicians, which totally blocks the ability of midwife-friendly physicians to consult with midwives or midwifery clients. Both CNM and LM licensing statutes were originally written by organized medicine. Lobbyists promised the Legislature that a law requiring physician supervision would promote public safety by guaranteeing appropriate access to medical services by pregnant women. Instead of the promised stepping stone, this provision turned out  to be a stumbling block.

Midwifery must be an autonomous profession. The law must be changed. The unworkable relationship between physicians and midwives must be replaced with a voluntary one defined as 'collaborative', in which midwives consult with physicians as needed and are respected by medical and obstetrical providers as colleagues. 

8. Interdisciplinary process of reform that includes parents / consumers & midwives as a central part of reformulation:

In order to create a single, evidence-based standard for all healthy women, to be used by all maternity care providers,  a process of negotiation that draws on the best of scientific resources and the best of human resources will be necessary. The hundred-year old, authoritarian standard must be transformed, based on criteria arrived at via an egalitarian & interdisciplinary process. This must include the wide spectrum of "stakeholders" -- interested parties, practitioners and experts in related scientific disciplines.

As an interdisciplinary process, the tradition of midwifery as an independent profession is central to the development of a "social" model of maternity care. Equally central to the process is the participation of childbearing women and their families. In fact, childbearing families must be acknowledged as a class of experts in the maternity experience. It is particularly important to receive Input from women who had complications following induction, episiotomy, instrumental delivery, cesarean surgery or who found it impossible to arrange for a subsequent normal labor and birth after a cesarean (VBAC). 



The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is a safer and more cost-effective form of care for a healthy population. In a reformed maternity care system the social model of childbirth, which depends on physiological principles, would be the preeminent standard of care for all healthy women with normal pregnancies. This leads us to the natural and compelling conclusion that our current medically dominated system of maternity care must be rehabilitated. 

This reformed standard must be based on criteria arrived at through an interdisciplinary process that includes the tradition of midwifery as an independent profession and integrates the input of childbearing women and their families into the process. 

Such a transformation in our national maternity care policy would require that:

In the reformed or social model of maternity care system, professional midwives, family practice physicians, and obstetricians would all enjoy a mutually respectful, non-controversial relationship. Appropriate maternity care would be provided by all three categories of professionals in all three birth settings as appropriate – hospital, home and birth center – without prejudice, controversy or retaliation against the childbearing family or against other care providers. By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs or that waste our economic resources.  

One way to develop an effective rehabilitative process would be to convene a blue-ribbon panel – experts from the disciplines of public health, sociology, anthropology, psychology, biology, child development, law, economics, midwifery, perinatalogy and obstetrics. This public exploration must include listening to childbearing women and their families as a class of experts in the maternity experience. Such a respected forum could study the scientific literature and provide unbiased, fact-based news for the press and broadcast media to report.  Another suggestion is a commission appointed by the California state legislature or a public policy organization such as the Pew Charitable Trust.  

A blue ribbon panel could provide recommendations for a reformed national maternity care policy and methods to reintegrate midwifery principles and practice into this expanded system of maternity care. Ultimately, such exploration and recommendations would result in legal and legislative changes affecting doctors, hospitals, midwives and the health insurance industry.  This reformed system should then be respected and used equally by all maternity care providers with the backing of hospitals, health insurance and medical malpractice carriers, and state and federal reimbursement systems (Medicaid / MediCal) etc.  

Link to: Lancet 2000; 356: 1677-80 Choosing Caesarean Section  by Dr. Marsden Wagner, MD, MSPH 
(formerly World Health Organization's director of maternal-infant health for 32 European countries


Editorial ~ Home Delivery -- Why? Michael Fleming, MD, Assistant Professor, Department of Family Medicine, School Medicine, University of North Carolina, Chapel Hill

This editorial gives an excellent perspective by a family practice physician on why and how to employ physiological principles in hospital-based obstetrical practice, including the full-time presence of the primary caregiver during active labor  (also see "Physiologically-sound practices" immediately below)


 Printable copy ~ abbreviated Instructions & Address
for letters to First Lady Maria Shriver

Archive of letters to California First Lady  Maria Shriver (5)

Complete Instructions and mailing address for Maria Shriver (4)

 Problem Statement  Reading time approx. 20 minutes (3)

Position Paper ~ May 9, Mothers' Day, 2004  (2)

C.E.O White Paper 2004 (1)
Printer-Friendly PDF Version for White Paper 2004


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