THE RISE IN THE NEW MILLENNIUM
Marsden Wagner MD, MSPH
Former Director of the Department of Maternal and Child Health of the World Health Organization
HISTORY The delivery has always belonged to the world of women. It has always been midwives to assist women in childbirth. The word midwife, "midwife" in Old English means "with woman" "Sage femme", the French term, means "wise woman" and its origin goes way back in time. The current word to describe Danish midwife, "jordmor" means "Mother Earth" and its use dates back to Viking times.
From the beginning, midwives have developed a central role in the world of women, not only with acts that go beyond the maternity care, but also acts that encompass much more than health care. When I visited Povungnituk, a native Inuit people in far northern Quebec, Canada, I saw this myself. Canadian health authorities had decreed that all women were pregnant Inuit fly very far south from his home, several weeks before the due date for giving birth in large hospitals. As a result of this policy, we lost the tradition of Inuit midwives, which involved the gradual destruction of their culture. The Inuit protested and managed to change this measure.
With the new policy, midwives were sent north to educate Inuit women as midwives and allowed the low-risk pregnant women gave birth in their villages. When I visited Povungnituk this project had already been running a couple of years. Midwives who taught there told me that although his program was only prenatal care, perinatal and postnatal, after a year of education, noted that Inuit women began to come to them with their problems of women, such as, abuse by husbands. Again, midwives were taking their crucial role in the lives of village women.
two hundred years ago, men began to invade the maternity care. Gradually there was a profound change with a great paradigm shift about the birth and care delivery. Midwives have always understood that the woman in the throes of childbirth should remain in the center with the midwife who assisted at his side, not only to monitor the progress of your delivery, but also support social and psychological. However, men need to be in the center and control and manage everything that goes on around them. As a result, obstetricians birth control today and we can find, for example, the extreme situation: the "active management" of birth, where "active" means that the doctor develops an active role and the woman in labor is all less active, since it is completely stripped of control over their own labor.
The midwifery is based on the belief that the birth process in humans is part of nature and that, clearly, has evolved over millions of years. Midwives believe that most women are able to give birth with minimal support and assistance. However, men rely on machines, not the bodies of women. One of the fundamental aspects of midwifery is the expected calm and alert, with consciousness. This is not part of the male world and has been replaced by the anxious need to "do something" for those who do the delivery, preferably with machines. This trend started at the beginning of the invasion male birth, when a Scottish surgeon barber hid his invention, the forceps, under her skirt (had to change his clothes to get admission in childbirth) and started to remove her babies .
medical confidence in the technology and lack of confidence in the nature has led, unsuccessfully, a number of attempts during the twentieth century of improvements in social and biological evolution. The doctors have replaced midwives in low risk deliveries that science only proved that midwives are safer. The hospital replaced the households in low-risk deliveries only for science to conclude that the home is as safe and to implement a series of interventions clearly unnecessary. The hospital team took the place of the family and labor support for science only to find that birth is safer if the family is present. The lithotomy position shifted to vertical positions for the sole purpose of science to conclude that the vertical positions are by far more secure. The examination of the newborn in the first 20 minutes replaced maternal contact that science only recognized the need to create a link at that time. Artificial milk replaced breast milk with the sole purpose of science to realize that breastfeeding is superior. The central nest replaced the mother so that science will find that staying with her is, of course, the better. The incubator replaced the body of the mother in the care of children under weight for science eventually came to the conclusion that Kangaroo care is better in most cases.
Another twist on the paradigm of the concept of birth that goes even further is the one that concerns life and death. Midwives have always understood that birth is part of life and how life has no guarantees. The mortality rate in the world is 100%. Nowhere in the world there perinatal mortality rates that approach zero. However, since for the two great enemies doctors are pain and death, as part of its attempt to deal with maternity services, began to promise to women and their families a painless delivery and a perfect baby. As a result, the public has lost the understanding and acceptance that sometimes happens that babies die. If you play to be God, I blame natural disasters. The epidemic of litigation against obstetricians in many countries is partly a consequence of the promise of a perfect baby and legitimate feelings of disappointment in the family when the baby is born with disabilities or even die.
After the Second World War came the technological age. If we can reach the moon, of course we can save all the babies if we all births in hospitals with all the technology available. Despite having no scientific evidence, then or now, that hospitals are safer for women without complications during pregnancy, childbirth, moved to the hospital and started the stampede toward high technology. So spread the use of many interventions, including the application of new drugs such as diethyl-estilbesterol (DES) and thalidomide and new machines such as ultrasound and electronic fetal monitoring, without adequate scientific evaluation. In the 70
the serpent entered the garden of high-tech hospital births. We found that both thalidomide and DES caused defects in babies. Gradually began to realize that the fall in perinatal mortality was mainly due to social factors such as improvements in housing, better nutrition and family planning, to the extent that the alleged role of saving the lives of babies who had held the doctors and hospitals, was in the basic medical background factors such as antibiotics or blood transfusions safe and not any high-tech interventions, as intended. The women's movement became aware about how motherhood had been stolen and started a reaction against the medicalization of childbirth and dehumanization.
The 80's saw the recognition of what evolved as two different concepts about maternity care: the medical model advocated by doctors, and social model, supported by most midwives, scientists and many perinatal health professionals. It concluded that the medical model works well for illness and accidents, but that does not fit within the cycles of life as birth or death.
The scientific assessment of maternity services was going strong and revealed startling truths about the use of technology as an example, that the routine use of electronic fetal monitoring increased sharply unnecessary cesarean section rates. The fundamental change from standard practice always equal to the evidence-based practice had begun. The World Health Organization consensus conferences organized and developed recommendations on appropriate perinatal technology, based on evidence. The Oxford Group Perinatal Epidemiology published a text that became a milestone, "Effective Care in Pregnancy and Childbirth", using only the best scientific evidence. And increasingly, the evidence tended to support the need to expand the medical model to include the social model as well.
Without this constituted a surprise to anyone, there was a strong reaction from the medical establishment. All these events accounted a serious confrontation with the medical monopoly of maternity care provided for so long. The control, status, and in many cases, the financial benefits that impact on the obstetricians were in danger. Began a fierce struggle.
The 90's witnessed the continuation of the struggle and its acceleration in many places. Gradually, the evidence-based medicine became the goal, including obstetric organizations, at least on paper. Centered maternity care in the family arrived in places where the medical model still had the control in the form of curtains and rocking chairs in the delivery room, and putting all the technological machinery behind the curtains and calling it "Birthing Center." However, elsewhere, as in Germany, developed rapidly independent houses deliveries (outside hospitals) and everywhere increased the number of independent midwives. In the UK, parliamentary debates leading up to the maternity services support some background whose main idea was to better medical and social mix. In New Zealand, a new law has treated the midwives with medical doctors specializing in general in terms of responsibilities and salary. Most women choose to have their own midwife during pregnancy and childbirth. In Japan, the independent delivery homes hospitals increased in number everywhere.
However, in other countries, the medical model retained its hegemony. Normal births attended by obstetricians in the United States and Canada, a system that doctors and midwives in most countries consider insane. The rate of caesarean sections in Brazil continued to increase until it became a 100% in some hospitals and 50% of all births in some states. In many countries, including USA, Canada, Ireland, Italy or Australia, there was a witch hunt by doctors who accused the midwives who were then arrested and tried.
proclaimed
The medical model the use of high technology in maternity care in rich countries was real progress, but the scientific evidence in these countries suggested otherwise: He had fallen cerebral palsy rate in the last 30 years, had not reduced the rate of low birth weight in 20 years and had not reduced the maternal mortality rate in 10 years and yet had a probable slight increase in some countries like the U.S. or Brazil. There was a slight decline in perinatal mortality rate in 10 years not due, however, no decrease in fetal mortality itself, but a slight improvement in mortality neonatal intensive care associated with neonatal and obstetric care not to. THIS
Today there are three types of maternity care: high-tech assistance very medicalized, focused on the doctor that provided by midwives, marginalized, for example, United States, Ireland, Russia, the Republic Czech, France, Belgium and Brazil, with the model of a social approach with midwives predominantly stronger and more autonomous and lower rates of intervention that we find, for example, in the Netherlands, New Zealand and the Scandinavian countries and a mix of both ways of looking at motherhood, as countries like the United Kingdom, Canada, Germany, Japan, Australia and Spain. In the Third World-style services are medical model in the large cities, while services still remain social model rural areas where the medical model is not yet penetrated.
The struggle between these two conceptions of labor and globalization has intensified in recent times. A review of obstetric practices that are made in Spain serves to illustrate the type of maternity care currently provided.
The scientific evidence is clear: the delivery is safer if a person assisting him throughout the process of labor, third stage and delivery. But this is not the case of English hospitals, where midwives, nurses and physicians share care delivery and, when shift changes, a new team does not know the woman suddenly appears. Science has proven that routine fetal monitoring during labor does not reduce perinatal mortality. Only leads to too many unnecessary Caesarean sections. However, the fetal routinely practiced in most English hospitals during childbirth. Routine intravenous fluids are not necessary during normal labor and interfere with the important need for women to facilitate their delivery through movement. However, medication routine IV applies in most English hospitals. The scientists tested more than 20 years ago that put a woman on his back in the second stage of labor is the worst of all possible positions, but women are placed in this position in virtually every hospital Spain.
cutting to open the vagina during delivery (episiotomy) is never needed more than 20% of deliveries and science has found to cause pain, increased bleeding and cause long-term sexual dysfunction. For all these reasons, make too many episiotomies have been properly labeled as a form of genital mutilation in women. The episiotomy rate of 89% in Spain is a scandal and a tragedy.
Regarding surgical delivery, not more than 10% of babies need the use of forceps or vacuum to be born, but in English hospitals 18% of babies born to these surgical instruments is not without risk. Drawing on the best scientific evidence, the World Health Organization has recommended that no more than 10% of caesarean sections in general hospitals and not more than 15% in specialized hospitals which tend to shift special cases. However, in Spain there is a 23% Caesarean section in public hospitals and 31% in hospitals private. These data reveal the number of caesarean sections three serious issues about obstetric care in Spain. 1) There are unnecessary cesareans 36.000 each year in Spain, they do run serious risks to all those women and their babies and also are a waste of a lot of money. 2) 40% of women in Spain did not give birth to their children because they are extracted by these means and surgical instruments. It is ridiculous to think that 40% of women in Spain are unable to give birth. 3) Women with fewer economic resources generally have a poorer health and therefore a priori more obstetric complications than women who attend private hospitals. For this reason, women who give birth in public hospitals need more caesarean sections than women who give birth in private hospitals. The fact that a higher percentage of cesarean section in private hospitals than in public in Spain can only be explained by the need for private hospitals and doctors to make more money.
In view of hospital maternity care as aggressive intervention in Spain with such unnecessary and dangerous, not surprising that many women prefer to give birth at hospitals. The relevant question is not whether the extra-hospital birth is safe, but whether the hospital births in Spain without risk.
observed the gap between obstetric practices and scientific evidence of this in Spain and other industrialized countries, there are two key issues for the attempt to improve maternity care: who attend low-risk deliveries? What is the best place for low-risk deliveries?
Who will attend low-risk deliveries?
Midwifery Midwives are right in the middle of the struggle between two ways of viewing the birth. And the key issue of midwifery is autonomy. Are midwives can practice midwifery genuine respect nature and women's bodies, which facilitates the delivery type that enriches and empowers women and that allows the birth belongs to the realm of women and the family? Do you really midwives are "with women?" And are merely assistants to obstetricians?
autonomy of midwives has gone through a strange cycle of evolution in the last 200 years. Before the men invaded the domain of childbirth, postpartum women and their midwives were independent. As the medicalization of childbirth progresses, both midwives and women in labor are increasingly losing autonomy until women no longer have control over their own birth and midwives become in little more than a slave of physicians.
reaction then arises when women and midwives begin to reclaim their autonomy. Although everyone knows the power of the medical profession, where women and midwives joined forces and organized, are more powerful and gain more and more independence. In some cases, midwives and parturients recover their full autonomy, and with it control of maternity services and their own birth. Today, there are places in the world that illustrate all stages of this evolution, which generally progresses to the autonomy of midwives attending women in childbirth, independent, in a system combines the best of the medical model and social model of birth.
A considerable scientific research has proven 4 major advantages of independent midwifery, midwives are safer in cases of low-risk deliveries, perform fewer unnecessary interventions, they are cheaper and provide greater satisfaction.
First, we can not doubt any longer that midwives are the safest birth attendants in low-risk deliveries. A meta-analysis of 15 studies comparing births attended by doctors and midwives found no differences in outcomes in women or babies, except that midwives had fewer babies with low birth weight. Two randomized studies conducted in Scotland, and 6 made in North America concluded that no increased adverse outcomes in cases of births attended by midwives.
The most enlightening about the safety of midwife-assisted delivery, published in 1998, examined all births in the U.S.: about 4 million births. We selected only non-multiple births (one baby delivery), vaginal and excluding cases with social risk factors and / or medical and compared the outcomes of births attended by midwives with those treated by doctors. Compared with births attended by physicians, births assisted by midwives as a result gave an infant mortality rate 19% lower neonatal mortality by 33% lower and an index of low birth weight 31% lower.
After reviewing the extensive evidence of the safety of midwives, a paper recently published in an obstetric journal concluded: "The scientific literature search fails to finding a single study showing worse outcomes with midwives than doctors low-risk women. " The evidence shows that primary care provided by midwives is as or even safer medical care.
The second advantage of doctors and midwives on primary care at delivery is a drastic reduction in the rates of unnecessary invasive procedures. Scientific evidence shows that compared with births attended by physicians, attended by midwives, according to statistics presented amniotomy much less, much less use of intravenous fluids or medication, unless routine electronic fetal monitoring, less use of narcotics, less use anesthesia, including epidural block for labor pain, less induction and acceleration of labor, fewer episiotomies, fewer forceps, fewer removals for suckers, fewer caesarean sections and vaginal deliveries after cesarean.
data showing the relationship between midwifery and lower rates of intervention suggests a hypothesis: the degree of reduction in the rate of unnecessary interventions on the degree of autonomy of midwives. For example, in U.S. hospitals where midwives have little autonomy, the rate of caesarean sections in a recent year was 24%, while the same year in the U.S., independent birthing homes where midwives have more independence , the rate was 12%, and even that same year, planned home births in the United States, where the midwife has a range Overall, the caesarean section rate was reduced to 6%. In randomized trials conducted recently in Scotland, the decline in rates of assistance to be given to midwives compared with physicians was irregular, with a significant reduction in some interventions but not others, suggesting that the possibility of midwives to reduce the interventions is influenced by the surrounding doctors in the hospital.
The third advantage of using midwives as the primary delivery assistance for the majority of deliveries is cost reduction. Although it varies from one country to another, in general, midwives' salaries are almost always considerably lower than those of doctors. And, of course, lower intervention rates that occur with midwives also means a greater savings. This information about the economic cost reduction has also been revised in the case of midwifery in industrialized countries where, for example, a study found savings of U.S. $ 500 per case of births attended by a midwife.
Another advantage of the assistance of midwives, often maligned by those who prefer to follow the medical model is the satisfaction with the assistance of the pregnant woman and the mother. The way to address this stage by the midwifery places its emphasis on the importance of women's satisfaction. The evidence in the scientific literature is overwhelming: care by midwives is, according to statistics, more satisfying for the woman and her family in a very meaningful.
[...]
Where does low-risk childbirth? Extra-hospital childbirth homebirth
have always been and always will be women everywhere who choose home birth and need a midwife to assist. However, at present, as a result of decades of propaganda about how dangerous it is delivery by doctors, who in turn need the security of hospitals There are many women who have fallen into the myth that home birth is dangerous.
It is incredible that some organizations still practice the same obstetric official policy against home birth who signed back in the 70's. At that time, planned home births did not differ from non-hospital births unplanned and abrupt, of course, had a high mortality due to birth in taxis, etc. Back then, when they split deliveries planned at home, it was proved that perinatal mortality rates obtained as or lower than the low-risk hospital births. A large scientific literature documents this, including situations in which the person attending home birth is a nurse midwife or a midwife shortcut. A meta-analysis of the safety of home birth, published in 1997, demonstrates conclusively the safety of home birth and includes an excellent review of the literature. Many physicians and their organizations continue to believe in the risks of childbirth outside the hospital organized, either in a house or home deliveries and reject the undeniable evidence that the expected deliveries outside the hospital in case of low-risk women are insurance. Unfortunately, many obstetricians continue citing anecdotal horror stories and scripts unscientific situations what would happen if, for example, delivery occurs outside the hospital? Since most physicians do not has never attended an extra-hospital childbirth, their questions of "what if?" containing several false statements. The first idea is assumed that at birth, things happen quickly. In fact, with very few exceptions, things happen slowly during labor and delivery and emergency where seconds count are extremely rare and, as discussed below, often in these cases, the midwife deliveries at home or at home can take charge of the emergency.
The second false claim that when problems arise there is nothing that a midwife outside the hospital can do, only can be expressed by someone who has never seen the midwives in non-hospital births. A well-trained midwife can often anticipate problems and prevent them from happening in the first place, since you are providing constant care from you to you to the laboring woman, not as in hospitals, where it is common that nurses or midwives can only keep an eye on an occasional basis to the various women in labor for which they are responsible. If problems arise, with few exceptions, the midwife outside the hospital can do everything that can be done in the hospital, even giving oxygen, etc. For example, when the baby's head out, but the shoulders get stuck, there is nothing you can do in the hospital that certain maneuvers with the woman and baby, that can also perfectly midwife outside the hospital. The latest successful maneuver for these cases of shoulder dystocia in the medical literature collection named for a midwife attending home that first described (Gaskin maneuver).
The third false claim is that the hospital can act faster. The truth is that even in more private care, the health of women is not even in the hospital most of the time during labor and has to be told by the nurse when problems arise. The time spent moving the hospital doctor is the same it would cost to get a woman is giving birth at home or in a home delivery. Even in the case indicated a cesarean, it takes about 20 minutes on average to prepare for surgery in the hospital, locating the anesthesiologist, etc. and during these 20 minutes, both doctors, like the woman in the house or home births are on the way to hospital. This is the reason why it is so important to good cooperation between the extra-hospital midwives and the hospital when she called the center to inform them of a shipment, and the hospital will not lose any time to prepare to receive the mother. All this gives reasons for there are no data to support a single anecdotal case scenario "what if?" used by some doctors to scare the public and politicians about the extra-hospital birth.
often lectured at conferences of Obstetrics and when I start talking about home birth, I can feel the bad vibes in the room. Already have an idea and do not want to be confused by the evidence. In such cases usually asks the audience if anyone in the room who has ever witnessed a birth planned at home to raise your hand and without surprise me, no one raises his hand. Then I quote a paragraph from a medical textbook published in 1968: "The doctors have never seen a birth at home and feel competent to argue against, are similar to those geographers who described a bunch of countries that have never visited.
So the real question about home birth is not security but the regard to freedom and the sacredness of the family. For more than 80% of women who have no medical complications during pregnancy, childbirth at home is planned perfectly safe choice. Any physician, hospital or medical organization that is to deter a home birth is, in essence, denying the basic right of women to control their own reproduction, which includes the freedom to choose where to give birth. The Childbirth is one of the most important events of family life as the family decides to have a home birth, you must honor the sacredness of the family. The attempt by some obstetricians to gain control of supervision of midwives and scare women and families on non-hospital deliveries is not an issue about safety, but an attempt to protect their territory and scientifically unjustified to maintain its monopoly on maternity care.
Marsden Wagner MD, MSPH
Former Director of the Department of Maternal and Child Health of the World Health Organization
HISTORY The delivery has always belonged to the world of women. It has always been midwives to assist women in childbirth. The word midwife, "midwife" in Old English means "with woman" "Sage femme", the French term, means "wise woman" and its origin goes way back in time. The current word to describe Danish midwife, "jordmor" means "Mother Earth" and its use dates back to Viking times.
From the beginning, midwives have developed a central role in the world of women, not only with acts that go beyond the maternity care, but also acts that encompass much more than health care. When I visited Povungnituk, a native Inuit people in far northern Quebec, Canada, I saw this myself. Canadian health authorities had decreed that all women were pregnant Inuit fly very far south from his home, several weeks before the due date for giving birth in large hospitals. As a result of this policy, we lost the tradition of Inuit midwives, which involved the gradual destruction of their culture. The Inuit protested and managed to change this measure.
With the new policy, midwives were sent north to educate Inuit women as midwives and allowed the low-risk pregnant women gave birth in their villages. When I visited Povungnituk this project had already been running a couple of years. Midwives who taught there told me that although his program was only prenatal care, perinatal and postnatal, after a year of education, noted that Inuit women began to come to them with their problems of women, such as, abuse by husbands. Again, midwives were taking their crucial role in the lives of village women.
two hundred years ago, men began to invade the maternity care. Gradually there was a profound change with a great paradigm shift about the birth and care delivery. Midwives have always understood that the woman in the throes of childbirth should remain in the center with the midwife who assisted at his side, not only to monitor the progress of your delivery, but also support social and psychological. However, men need to be in the center and control and manage everything that goes on around them. As a result, obstetricians birth control today and we can find, for example, the extreme situation: the "active management" of birth, where "active" means that the doctor develops an active role and the woman in labor is all less active, since it is completely stripped of control over their own labor.
The midwifery is based on the belief that the birth process in humans is part of nature and that, clearly, has evolved over millions of years. Midwives believe that most women are able to give birth with minimal support and assistance. However, men rely on machines, not the bodies of women. One of the fundamental aspects of midwifery is the expected calm and alert, with consciousness. This is not part of the male world and has been replaced by the anxious need to "do something" for those who do the delivery, preferably with machines. This trend started at the beginning of the invasion male birth, when a Scottish surgeon barber hid his invention, the forceps, under her skirt (had to change his clothes to get admission in childbirth) and started to remove her babies .
medical confidence in the technology and lack of confidence in the nature has led, unsuccessfully, a number of attempts during the twentieth century of improvements in social and biological evolution. The doctors have replaced midwives in low risk deliveries that science only proved that midwives are safer. The hospital replaced the households in low-risk deliveries only for science to conclude that the home is as safe and to implement a series of interventions clearly unnecessary. The hospital team took the place of the family and labor support for science only to find that birth is safer if the family is present. The lithotomy position shifted to vertical positions for the sole purpose of science to conclude that the vertical positions are by far more secure. The examination of the newborn in the first 20 minutes replaced maternal contact that science only recognized the need to create a link at that time. Artificial milk replaced breast milk with the sole purpose of science to realize that breastfeeding is superior. The central nest replaced the mother so that science will find that staying with her is, of course, the better. The incubator replaced the body of the mother in the care of children under weight for science eventually came to the conclusion that Kangaroo care is better in most cases.
Another twist on the paradigm of the concept of birth that goes even further is the one that concerns life and death. Midwives have always understood that birth is part of life and how life has no guarantees. The mortality rate in the world is 100%. Nowhere in the world there perinatal mortality rates that approach zero. However, since for the two great enemies doctors are pain and death, as part of its attempt to deal with maternity services, began to promise to women and their families a painless delivery and a perfect baby. As a result, the public has lost the understanding and acceptance that sometimes happens that babies die. If you play to be God, I blame natural disasters. The epidemic of litigation against obstetricians in many countries is partly a consequence of the promise of a perfect baby and legitimate feelings of disappointment in the family when the baby is born with disabilities or even die.
After the Second World War came the technological age. If we can reach the moon, of course we can save all the babies if we all births in hospitals with all the technology available. Despite having no scientific evidence, then or now, that hospitals are safer for women without complications during pregnancy, childbirth, moved to the hospital and started the stampede toward high technology. So spread the use of many interventions, including the application of new drugs such as diethyl-estilbesterol (DES) and thalidomide and new machines such as ultrasound and electronic fetal monitoring, without adequate scientific evaluation. In the 70
the serpent entered the garden of high-tech hospital births. We found that both thalidomide and DES caused defects in babies. Gradually began to realize that the fall in perinatal mortality was mainly due to social factors such as improvements in housing, better nutrition and family planning, to the extent that the alleged role of saving the lives of babies who had held the doctors and hospitals, was in the basic medical background factors such as antibiotics or blood transfusions safe and not any high-tech interventions, as intended. The women's movement became aware about how motherhood had been stolen and started a reaction against the medicalization of childbirth and dehumanization.
The 80's saw the recognition of what evolved as two different concepts about maternity care: the medical model advocated by doctors, and social model, supported by most midwives, scientists and many perinatal health professionals. It concluded that the medical model works well for illness and accidents, but that does not fit within the cycles of life as birth or death.
The scientific assessment of maternity services was going strong and revealed startling truths about the use of technology as an example, that the routine use of electronic fetal monitoring increased sharply unnecessary cesarean section rates. The fundamental change from standard practice always equal to the evidence-based practice had begun. The World Health Organization consensus conferences organized and developed recommendations on appropriate perinatal technology, based on evidence. The Oxford Group Perinatal Epidemiology published a text that became a milestone, "Effective Care in Pregnancy and Childbirth", using only the best scientific evidence. And increasingly, the evidence tended to support the need to expand the medical model to include the social model as well.
Without this constituted a surprise to anyone, there was a strong reaction from the medical establishment. All these events accounted a serious confrontation with the medical monopoly of maternity care provided for so long. The control, status, and in many cases, the financial benefits that impact on the obstetricians were in danger. Began a fierce struggle.
The 90's witnessed the continuation of the struggle and its acceleration in many places. Gradually, the evidence-based medicine became the goal, including obstetric organizations, at least on paper. Centered maternity care in the family arrived in places where the medical model still had the control in the form of curtains and rocking chairs in the delivery room, and putting all the technological machinery behind the curtains and calling it "Birthing Center." However, elsewhere, as in Germany, developed rapidly independent houses deliveries (outside hospitals) and everywhere increased the number of independent midwives. In the UK, parliamentary debates leading up to the maternity services support some background whose main idea was to better medical and social mix. In New Zealand, a new law has treated the midwives with medical doctors specializing in general in terms of responsibilities and salary. Most women choose to have their own midwife during pregnancy and childbirth. In Japan, the independent delivery homes hospitals increased in number everywhere.
However, in other countries, the medical model retained its hegemony. Normal births attended by obstetricians in the United States and Canada, a system that doctors and midwives in most countries consider insane. The rate of caesarean sections in Brazil continued to increase until it became a 100% in some hospitals and 50% of all births in some states. In many countries, including USA, Canada, Ireland, Italy or Australia, there was a witch hunt by doctors who accused the midwives who were then arrested and tried.
proclaimed
The medical model the use of high technology in maternity care in rich countries was real progress, but the scientific evidence in these countries suggested otherwise: He had fallen cerebral palsy rate in the last 30 years, had not reduced the rate of low birth weight in 20 years and had not reduced the maternal mortality rate in 10 years and yet had a probable slight increase in some countries like the U.S. or Brazil. There was a slight decline in perinatal mortality rate in 10 years not due, however, no decrease in fetal mortality itself, but a slight improvement in mortality neonatal intensive care associated with neonatal and obstetric care not to. THIS
Today there are three types of maternity care: high-tech assistance very medicalized, focused on the doctor that provided by midwives, marginalized, for example, United States, Ireland, Russia, the Republic Czech, France, Belgium and Brazil, with the model of a social approach with midwives predominantly stronger and more autonomous and lower rates of intervention that we find, for example, in the Netherlands, New Zealand and the Scandinavian countries and a mix of both ways of looking at motherhood, as countries like the United Kingdom, Canada, Germany, Japan, Australia and Spain. In the Third World-style services are medical model in the large cities, while services still remain social model rural areas where the medical model is not yet penetrated.
The struggle between these two conceptions of labor and globalization has intensified in recent times. A review of obstetric practices that are made in Spain serves to illustrate the type of maternity care currently provided.
The scientific evidence is clear: the delivery is safer if a person assisting him throughout the process of labor, third stage and delivery. But this is not the case of English hospitals, where midwives, nurses and physicians share care delivery and, when shift changes, a new team does not know the woman suddenly appears. Science has proven that routine fetal monitoring during labor does not reduce perinatal mortality. Only leads to too many unnecessary Caesarean sections. However, the fetal routinely practiced in most English hospitals during childbirth. Routine intravenous fluids are not necessary during normal labor and interfere with the important need for women to facilitate their delivery through movement. However, medication routine IV applies in most English hospitals. The scientists tested more than 20 years ago that put a woman on his back in the second stage of labor is the worst of all possible positions, but women are placed in this position in virtually every hospital Spain.
cutting to open the vagina during delivery (episiotomy) is never needed more than 20% of deliveries and science has found to cause pain, increased bleeding and cause long-term sexual dysfunction. For all these reasons, make too many episiotomies have been properly labeled as a form of genital mutilation in women. The episiotomy rate of 89% in Spain is a scandal and a tragedy.
Regarding surgical delivery, not more than 10% of babies need the use of forceps or vacuum to be born, but in English hospitals 18% of babies born to these surgical instruments is not without risk. Drawing on the best scientific evidence, the World Health Organization has recommended that no more than 10% of caesarean sections in general hospitals and not more than 15% in specialized hospitals which tend to shift special cases. However, in Spain there is a 23% Caesarean section in public hospitals and 31% in hospitals private. These data reveal the number of caesarean sections three serious issues about obstetric care in Spain. 1) There are unnecessary cesareans 36.000 each year in Spain, they do run serious risks to all those women and their babies and also are a waste of a lot of money. 2) 40% of women in Spain did not give birth to their children because they are extracted by these means and surgical instruments. It is ridiculous to think that 40% of women in Spain are unable to give birth. 3) Women with fewer economic resources generally have a poorer health and therefore a priori more obstetric complications than women who attend private hospitals. For this reason, women who give birth in public hospitals need more caesarean sections than women who give birth in private hospitals. The fact that a higher percentage of cesarean section in private hospitals than in public in Spain can only be explained by the need for private hospitals and doctors to make more money.
In view of hospital maternity care as aggressive intervention in Spain with such unnecessary and dangerous, not surprising that many women prefer to give birth at hospitals. The relevant question is not whether the extra-hospital birth is safe, but whether the hospital births in Spain without risk.
observed the gap between obstetric practices and scientific evidence of this in Spain and other industrialized countries, there are two key issues for the attempt to improve maternity care: who attend low-risk deliveries? What is the best place for low-risk deliveries?
Who will attend low-risk deliveries?
Midwifery Midwives are right in the middle of the struggle between two ways of viewing the birth. And the key issue of midwifery is autonomy. Are midwives can practice midwifery genuine respect nature and women's bodies, which facilitates the delivery type that enriches and empowers women and that allows the birth belongs to the realm of women and the family? Do you really midwives are "with women?" And are merely assistants to obstetricians?
autonomy of midwives has gone through a strange cycle of evolution in the last 200 years. Before the men invaded the domain of childbirth, postpartum women and their midwives were independent. As the medicalization of childbirth progresses, both midwives and women in labor are increasingly losing autonomy until women no longer have control over their own birth and midwives become in little more than a slave of physicians.
reaction then arises when women and midwives begin to reclaim their autonomy. Although everyone knows the power of the medical profession, where women and midwives joined forces and organized, are more powerful and gain more and more independence. In some cases, midwives and parturients recover their full autonomy, and with it control of maternity services and their own birth. Today, there are places in the world that illustrate all stages of this evolution, which generally progresses to the autonomy of midwives attending women in childbirth, independent, in a system combines the best of the medical model and social model of birth.
A considerable scientific research has proven 4 major advantages of independent midwifery, midwives are safer in cases of low-risk deliveries, perform fewer unnecessary interventions, they are cheaper and provide greater satisfaction.
First, we can not doubt any longer that midwives are the safest birth attendants in low-risk deliveries. A meta-analysis of 15 studies comparing births attended by doctors and midwives found no differences in outcomes in women or babies, except that midwives had fewer babies with low birth weight. Two randomized studies conducted in Scotland, and 6 made in North America concluded that no increased adverse outcomes in cases of births attended by midwives.
The most enlightening about the safety of midwife-assisted delivery, published in 1998, examined all births in the U.S.: about 4 million births. We selected only non-multiple births (one baby delivery), vaginal and excluding cases with social risk factors and / or medical and compared the outcomes of births attended by midwives with those treated by doctors. Compared with births attended by physicians, births assisted by midwives as a result gave an infant mortality rate 19% lower neonatal mortality by 33% lower and an index of low birth weight 31% lower.
After reviewing the extensive evidence of the safety of midwives, a paper recently published in an obstetric journal concluded: "The scientific literature search fails to finding a single study showing worse outcomes with midwives than doctors low-risk women. " The evidence shows that primary care provided by midwives is as or even safer medical care.
The second advantage of doctors and midwives on primary care at delivery is a drastic reduction in the rates of unnecessary invasive procedures. Scientific evidence shows that compared with births attended by physicians, attended by midwives, according to statistics presented amniotomy much less, much less use of intravenous fluids or medication, unless routine electronic fetal monitoring, less use of narcotics, less use anesthesia, including epidural block for labor pain, less induction and acceleration of labor, fewer episiotomies, fewer forceps, fewer removals for suckers, fewer caesarean sections and vaginal deliveries after cesarean.
data showing the relationship between midwifery and lower rates of intervention suggests a hypothesis: the degree of reduction in the rate of unnecessary interventions on the degree of autonomy of midwives. For example, in U.S. hospitals where midwives have little autonomy, the rate of caesarean sections in a recent year was 24%, while the same year in the U.S., independent birthing homes where midwives have more independence , the rate was 12%, and even that same year, planned home births in the United States, where the midwife has a range Overall, the caesarean section rate was reduced to 6%. In randomized trials conducted recently in Scotland, the decline in rates of assistance to be given to midwives compared with physicians was irregular, with a significant reduction in some interventions but not others, suggesting that the possibility of midwives to reduce the interventions is influenced by the surrounding doctors in the hospital.
The third advantage of using midwives as the primary delivery assistance for the majority of deliveries is cost reduction. Although it varies from one country to another, in general, midwives' salaries are almost always considerably lower than those of doctors. And, of course, lower intervention rates that occur with midwives also means a greater savings. This information about the economic cost reduction has also been revised in the case of midwifery in industrialized countries where, for example, a study found savings of U.S. $ 500 per case of births attended by a midwife.
Another advantage of the assistance of midwives, often maligned by those who prefer to follow the medical model is the satisfaction with the assistance of the pregnant woman and the mother. The way to address this stage by the midwifery places its emphasis on the importance of women's satisfaction. The evidence in the scientific literature is overwhelming: care by midwives is, according to statistics, more satisfying for the woman and her family in a very meaningful.
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Where does low-risk childbirth? Extra-hospital childbirth homebirth
have always been and always will be women everywhere who choose home birth and need a midwife to assist. However, at present, as a result of decades of propaganda about how dangerous it is delivery by doctors, who in turn need the security of hospitals There are many women who have fallen into the myth that home birth is dangerous.
It is incredible that some organizations still practice the same obstetric official policy against home birth who signed back in the 70's. At that time, planned home births did not differ from non-hospital births unplanned and abrupt, of course, had a high mortality due to birth in taxis, etc. Back then, when they split deliveries planned at home, it was proved that perinatal mortality rates obtained as or lower than the low-risk hospital births. A large scientific literature documents this, including situations in which the person attending home birth is a nurse midwife or a midwife shortcut. A meta-analysis of the safety of home birth, published in 1997, demonstrates conclusively the safety of home birth and includes an excellent review of the literature. Many physicians and their organizations continue to believe in the risks of childbirth outside the hospital organized, either in a house or home deliveries and reject the undeniable evidence that the expected deliveries outside the hospital in case of low-risk women are insurance. Unfortunately, many obstetricians continue citing anecdotal horror stories and scripts unscientific situations what would happen if, for example, delivery occurs outside the hospital? Since most physicians do not has never attended an extra-hospital childbirth, their questions of "what if?" containing several false statements. The first idea is assumed that at birth, things happen quickly. In fact, with very few exceptions, things happen slowly during labor and delivery and emergency where seconds count are extremely rare and, as discussed below, often in these cases, the midwife deliveries at home or at home can take charge of the emergency.
The second false claim that when problems arise there is nothing that a midwife outside the hospital can do, only can be expressed by someone who has never seen the midwives in non-hospital births. A well-trained midwife can often anticipate problems and prevent them from happening in the first place, since you are providing constant care from you to you to the laboring woman, not as in hospitals, where it is common that nurses or midwives can only keep an eye on an occasional basis to the various women in labor for which they are responsible. If problems arise, with few exceptions, the midwife outside the hospital can do everything that can be done in the hospital, even giving oxygen, etc. For example, when the baby's head out, but the shoulders get stuck, there is nothing you can do in the hospital that certain maneuvers with the woman and baby, that can also perfectly midwife outside the hospital. The latest successful maneuver for these cases of shoulder dystocia in the medical literature collection named for a midwife attending home that first described (Gaskin maneuver).
The third false claim is that the hospital can act faster. The truth is that even in more private care, the health of women is not even in the hospital most of the time during labor and has to be told by the nurse when problems arise. The time spent moving the hospital doctor is the same it would cost to get a woman is giving birth at home or in a home delivery. Even in the case indicated a cesarean, it takes about 20 minutes on average to prepare for surgery in the hospital, locating the anesthesiologist, etc. and during these 20 minutes, both doctors, like the woman in the house or home births are on the way to hospital. This is the reason why it is so important to good cooperation between the extra-hospital midwives and the hospital when she called the center to inform them of a shipment, and the hospital will not lose any time to prepare to receive the mother. All this gives reasons for there are no data to support a single anecdotal case scenario "what if?" used by some doctors to scare the public and politicians about the extra-hospital birth.
often lectured at conferences of Obstetrics and when I start talking about home birth, I can feel the bad vibes in the room. Already have an idea and do not want to be confused by the evidence. In such cases usually asks the audience if anyone in the room who has ever witnessed a birth planned at home to raise your hand and without surprise me, no one raises his hand. Then I quote a paragraph from a medical textbook published in 1968: "The doctors have never seen a birth at home and feel competent to argue against, are similar to those geographers who described a bunch of countries that have never visited.
So the real question about home birth is not security but the regard to freedom and the sacredness of the family. For more than 80% of women who have no medical complications during pregnancy, childbirth at home is planned perfectly safe choice. Any physician, hospital or medical organization that is to deter a home birth is, in essence, denying the basic right of women to control their own reproduction, which includes the freedom to choose where to give birth. The Childbirth is one of the most important events of family life as the family decides to have a home birth, you must honor the sacredness of the family. The attempt by some obstetricians to gain control of supervision of midwives and scare women and families on non-hospital deliveries is not an issue about safety, but an attempt to protect their territory and scientifically unjustified to maintain its monopoly on maternity care.
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