Currently, we have 2 Swiss midwifery students interning with us. When they look at the practices that we follow at Healthy Mother, they are pleasantly surprised. This is what they had studied as “physiological normal birthing practices” as they were studying in their first year of Midwifery School in Switzerland. Then came the actual clinical practice in their second year of school, and they found it to be diametrically opposite. The actual practice that they see, centers around routine scheduling of C-sections at 39 weeks for mothers with breech babies, not waiting beyond 41 weeks for labor to start on its own, and routine augmentation of labor if active labor does not progress according to the midwife’s schedule of 1 cm per hour. If a postdates labor has to be started, induction with Misoprostol (Cytotec) is common, followed by repeat doses of Cytotec every 4th hourly. If that does not work, then protocols call for artificially breaking the bag of waters, followed by Syntocinon drip. The mother now does not withstand the strong contractions, asks for an epidural, which slows her labor down; so she is given more Syntocinon, which can cause distress and a C-Section. If miraculously all goes well despite all of these interventions, the mother is then “delivered” in the “gynecologic position” – meaning flat on her back with her legs pushed back and spread apart. What in all of this resembles the practice of midwifery? Sounds very similar to active management of labor in the OB practice. And, the C-section rates in Switzerland are rising – does not take much imagination to understand why.
In the 1970s, Kieran O’Driscoll, the chief obstetrician at National Maternity Hospital in Dublin, Ireland, developed a set of standard practices for his unit that became popular in the hospitals across North America. One of the goals that O’Driscoll had was to guarantee women (and his staff) that all births would occur within a specific time limit. His need was an orderly system to deliver babies – “military efficiency with a human face”!! The name for these set of policies that he designed was “active management” and this is still followed in many OB practices across the world today. What these practices and hospitals are not following, is the good one-to-one midwifery (the midwife actually became a doula under the O’Driscoll protocol) support, care and comfort that the woman got once she was admitted in active labor, to help her manage the labor pain. Considering all the interventions that were done to make her progress at the prescribed rate of 1 cm per hour, this was what made the difference, and Dr. O’Driscoll was still able to keep his C-section rates to under 5%. Many current OB practices, revolve around the active management of labor, minus the midwifery/doula support. Is it any surprise then that the woman feels powerless and overpowered by the system, and lands up with a “vaginal delivery” or a “delivery by C-section”? And, what will happen when the midwives themselves are trained in different parts of the world to follow similar protocols? Who will the mother turn to then? Who will really advocate and provide the gentle, supportive encouragement and care during labor and birth, so that the mother has the best possible birth experience and her baby the gentlest possible transition into this world?
Last week, I had the pleasure of meeting Joyce Pula who is a doula, childbirth educator and birth advocate who resides and works in Holland. She came to see our Birthing Center, and was very happy to see and hear about out practices and the changes that we have been able to bring to birthing practices in our community in India. She was sharing with me that in Holland – which at one time was the home-birth capital of the world – things are not what they used to be. Most young couples have been persuaded to believe that hospital births are better. Many midwives in Holland are also practicing the same active management of labor, and birth is no longer what it used to be in Holland. This to me was shocking and sad.
So, back to the midwifery students who are interning with us – They got to watch a woman birthing on her hands and knees, which was the position that this mom was most comfortable in; & today they found out that waiting for 3 days for a mom with broken bag of waters to go into labor is okay, as long as the mother and baby are well! Routine midwifery practices based on good evidence-based practice.
Does midwifery practice differ from obstetric management of labor and delivery? Of course it does …. The best labor neither has to be the shortest nor the most painless … Midwifery sees labor and birth as important rites of passage for the woman and her baby.