Science in Society Archive

Hold on to midwife, here comes the doctor

The corporate takeover of reproduction started with the medicalisation of childbearing and childbirth. This is now reaching its logical conclusion with the spectre of human cloning and germ line genetic manipulation. Sam Burcher and Dr. Mae-Wan Ho describe how women everywhere can regain control of the reproductive process and more, by holding on to their midwife.

Midwife vs doctor

The ‘mid’ in ‘midwife’ originates from the German word, ‘mit’, meaning ‘with’. A midwife is literally the woman who is with the wife for the birthing of her child.

When a woman lets go of her midwife, she is letting go of womanhood, and turning her back on a tradition that respects and values her womanhood and the infant she brings into the world. She is relinquishing responsibility and control of her own life-process that is also part of the cycle of renewal and regeneration of the community to which she belongs. Most of all, she loses an essential support system that helps to bring gestation to fruition, that nurtures mother and child both before, during and long after birthing.

Conversely, as the woman places herself in the hands of the medical doctor, she becomes a passive instrument of reproduction, to be invaded and probed by an increasing armory of other instruments, to be mutilated in the name of efficiency and progress. Her ‘labour’ turns painful and unproductive until it becomes an illness that has to be treated. She is rendered unconscious while the child is wrenched from her birth canal with forceps, or straight from her cut-open womb. Mother and ‘newborn’ are registered in the official statistics, and, except for further medical tests and interventions, abandoned to their own devices.

That is the powerful message in Naomi Wolf’s new book [1], written from her personal experience of motherhood in the United States. The trend towards making childbearing and childbirth a medical condition in industrialised countries has been spreading to the Third World with devastating consequences.

Third World healthcare and globalisation

Malaysia is one of the wealthier countries in the Third World, and her health system has long been regarded as one of the successes. Until recently, she had a network of health centres, "one within a five-mile radius of every inhabitant", according to Dr. Lye Munn Sann, Director of the Medical Research Institute, Ministry of Health. Health services were, if not free, within the means of most people.

But primary health systems all over the Third World has come under severe threat over the past decade as the result of the intensification of economic globalization.

Economic globalization has been promoted under the banner of ‘free-trade’ and laissez faire neo-liberal economic ideology in international financial institutions such as the World Trade Organization (WTO), the World Bank and the International Monetary Fund. It aims to remove all national barriers to trade, investment and, as a final straw in the latest millennium round of the WTO, the procurement of services, so that everyone can supposedly benefit from the most competitive global market.

In practice, economic globalization has perpetrated and deepened the gross inequities of colonial times, enabling corporate business to exploit people and natural resources with impunity. It has resulted in widespread increase in poverty and indebtedness, especially in the poorest Third World countries, with concomitant erosion of public health and education.

Although the major impact on healthcare is economic, much of the damage is due to misguided government policies inspired by excessive faith in reductionist models of modern western medicine that also comes with globalisation.

The plight of Malaysia’s midwives

Malaysia’s traditional midwives are facing marginalisation and prosecution for the valuable services they have given to women and children in local communities for centuries. The rich women in that country are about to experience the dehumanising, humiliating and crippling treatment that Wolf describes, while the poor will be left with no support at all.

The Association of Traditional Midwives was formed in Penang in 1992 under the registered name Persutuan Bidan Wilayah Utara [3]. Bidan is the popular name for the traditional midwives who have safely delivered babies for several centuries before the advent of modern medicine, and have enjoyed high prestige within local communities. Bidan received widespread support in their call for inclusion of traditional healers into primary health care, and for the government to recognize their services to the community.

Since the Malaysian government passed the Midwives Amendment and Extension Act in 1990, however, bidan have been forbidden from delivering babies unless they have registered with the Health Ministry. Under this law, non-registered midwives can be fined up to RM2000 (about £400) or jailed for a year, or both, if found guilty of delivering a baby. Not only are the bidan punished, but the child’s parents will have trouble getting a birth certificate [4].

In addition, the re-registration criteria disqualifies any woman over the age of 60 years, thereby excluding some of the most experienced bidan who have trained under royal midwives and delivered the countries’ political leaders. In turn, these women have trained countless other women.

The Malaysian bidan provide more than just child delivery, they act as counselors, nutritionists and masseuses for mothers before, during and after childbirth. These skills are vital to the health of both mother and child, which could never be provided so consistently in a hospital setting. These services can extend for up to 40 days after the birth, ensuring optimum health of those in their care. Since the bidan were outlawed, many women in rural communities are being subjected to the traumas caused by inexperienced government nurses. A bidan is often called to salvage the situation, only to risk punishment [5].

Nowadays in Malaysia as in some countries in Europe and the United States, a woman who has elected to have a home-birth can find herself being rushed off to hospital where she risks painful, unwanted practices such as episiotomy (cutting the birth canal) and forceps delivery. A highly trained bidan is easily able to cope with breech birth and would never shave or cut a mother’s birth canal to facilitate the natural birth processes. And, when an expectant mother displays serious complications, she is always referred to the hospital by the bidan. Why then the interference with rural womens’ rights to their traditional bidan?

The Malaysian Ministry of Health has linked high maternal deaths with rural Malays who practice home births. This prejudiced view fails to take account of the fact that rural Malays have the highest poverty and the highest numbers of births. Indeed, 40% of the deaths are in women who have had five or more children. There is no evidence that an uncomplicated birth is any safer in hospital. And this is a crucial area where the bidan and government nurses could work together to provide information and assistance to vulnerable women in the community [6].

Under the Rural Health Programme, health services have been allocated RM708.30 million of the total Plan’s health expenditure of RM5.5 billion. None of this money is finding its way to the bidan whose knowledge is irreplaceable. In Penang in 1999, the ratio of doctors to patient was 1 to1,465. With government nurses not yet up to scratch on natural birthing methods, it would seem that there are the resources available as well as public demand for the services of bidan.

A synergy between traditional and modern medicinal methods can be developed without excluding the valuable services of bidan. This would prevent the loss of a priceless cultural practice and promote the "wellness paradigm" cited in the Eighth Malaysian Plan Period where "primary health remains a focus of National Health development to improve equity and quality" [7].

Naomi Wolf in her book also emphasizes the need for equal partnership between traditional midwives and obstetricians in providing care for expectant mothers.

The Dutch experience

The one country in Europe where the autonomous profession of the midwife has survived is the Netherlands, where one third of babies are home-births. Midwives are part of the primary healthcare system, having the authority to decide which women can have a home birth, which women can deliver in short stay hospitals known as a "polyclinics" attended by midwives and which women must be referred to a specialist. Such is the power of the midwife that the specialist who coerces a woman into having a hospital birth against her wishes will no longer receive referrals. The obstetrician who is not "woman-friendly" is ostracised by the midwives, and is only re-connected to their system when he asks what can he do to ensure that he receives referrals. If a midwife is in town, then, by law, she is given precedence over the GP as the birth attendee. This level of authority has come about through the 1865 Act of the Practice of Medicine in which the profession of midwifery was defined and protected. Other factors are the social/cultural environment that regards pregnancy and childbirth as normal physiological processes, a well organized maternity home care system that facilitates continuity of home births, and careful screening systems for high-risk pregnancy.

Dutch midwives are being encouraged to be more scientific with a post graduate year being added to their three-year training course. Current statistics show that of an annual birth rate of 74,500, 46% are attended by midwives, 46% by obstetricians and 8% by GP [8]. A study in 1986 found a perinatal mortality rate (PRM) of 2.2 in 41,861 women having first babies in hospital, compared with a PMR of only 1.5 in 15,031 women having first-time babies at home.

Similar results have been found in a British study in 1970 [9]. The hospital PMR was 27.8 per 1000 births versus 5.4 per 1000 for homebirths. This was not because hospitals handled more high-risk births. When PMRs were standardized on age, parity, hypertension/toxemia, prenatal risk prediction score, method of delivery and birthweight, the adjusted hospital PMRs for each category ranged from 22.7 per 1000 to 27.8 per 1000 while homebirth rates ranged from 5.4 per 1000 to 10.5 per 1000.

British data collected in 1985 confirmed the earlier study. At a lower level of risk, PMR was seven times higher in hospital. At a higher level of risk, the perinatal death rate was four and a half times higher in hospital [10]. The British author examined 1986 birth data from the Netherlands, where one-third of births are at home. The country as a whole has excellent maternity care and outcomes. However, PMR for hospital births was six times higher than for homebirths. For pregnancies of normal length, PMR was ten times higher for obstetricians than for midwives.

In the United States, a study comparing 2,092 home births and 2,092 hospital births revealed that the hospital group having six times higher fetal distress rate [11]. Maternal haemorrage were three times higher. Limp, unresponsive newborns arrived three times more often. Thirty permanent birth injuries were caused by doctors along with lacerations to the mothers, neonatal infections, forceps deliveries cesarean sections and nine times more episiotomies. There was no difference in PMR between hospital births and home births. Research also reveals that unnecessary interventions have been linked with birth trauma and interferes with mother and child bonding [12].

Natural childbirth versus medical childbirth

Natural childbirth is something that many women all over the world want, which is to experience birthing as free of fear and pain as possible.

Ina May Gaskin is a "naturalist and a realist" as Naomi Wolf discovered when she visited her natural birth "Farm" in Tennessee. Gaskin is the author of a classic childbirth manual "Spiritual Midwifery". She trained herself as a lay midwife from 19th Century birthing guides and has been delivering babies for more than 30 years. Now over 60 years old and regarded as an icon in her field she lays claim to a success rate 20-30 times higher than the national average. The hands and knees position so frowned on by obstetricians is known as the "Gaskin manoevre". In a study conducted on the 1 319 births on the Farm between 1970 and 1994, only 35 or 1.8% were cesarean. There were 60 breech births, none of which had to be referred to hospital and were all successfully, naturally delivered. Sixteen women that had previously delivered by caesarian all completed a vaginal delivery. The midwives on the Farm have a good working relationship with local medical authorities in difficult birthing cases.

In contrast, surgical instruments dominate the delivery room. Anesthesia, early forceps delivery, foetal heartbeat monitoring, caesarians, episiotomies and epidurals are all part of the time pressured modern birth, with traumatic consequences for both mother and child. Starting with the epidural, further interventions are inevitable. Once the woman is "numbed out" physically and emotionally she becomes "a magnet for medical equipment". Fetal monitors, IV lines, catheters are minor problems compared to other risks. Maternal fever is a complication under epidural – in one study 11.8%-28% women developed fever against 0.2% of women without medication. A by-product of maternal fever can mean the baby being taken from the parents immediately after birth for treatment. Twice as many women under epidural receive severe perineal lacerations, increased chances of forceps or vacuum assisted delivery and higher rates of cesarean sections. Babies born to women under epidurals are 400 times more likely to need antibiotic treatment. Epidurals kill the pain of labour, but they also kill the experience.

In the United States, between 50% and 80% of women giving birth for the first time are given episiotomy, said to be a "minor surgical procedure" that widens the birth canal. In reality, it is a deep tissue cut that weakens the entire perineum, an area rich with nerves and blood vessels. Surgery in this area can cause pain during sex and loss of sexual sensation for up to seven years. But it gets the baby out quicker and is easier to suture than any natural irregular tear that the mother-to-be might suffer.

Caesarians are increasingly common. UK rates of cesareans have trebled since 1970. The latest Department of Health figures quote an average national rate of 18-20%. With cesarean rates at 40% for some maternity clinics, exceeding WHO recommendations of 10-15%. There are 870,000 caesarians per year in the United States. A study by the Public Citizen Research Group involving 906,000 cases estimated that half of these were unnecessary, resulting in 142 avoidable maternal deaths. When midwives rather than obstetricians attend births, cesarean rates drop to less than half the national average. Indeed, in one New York hospital, midwives were faulted for their cesarean rate of 12.9%, well below the city’s average of 23.1%[12]. If the 50% of unnecessary cesareans were avoided American hospitals would lose $1.1billion in revenue a year.

The middle way

To get the best of both traditional midwife support and hospital backup, freestanding birth centres are emerging in the US and the UK (available on the NHS and privately). Wolf visited one of these in New York and was moved to tears. It was devoted to the needs of mother and child down to furniture designed to encompass the pregnant form comfortably. The birthing rooms are safe and private, warm with dimmer-switch lighting, almost womb-like. There are floor mats and cushions to kneel or squat on, birthing rockers support your weight, but enable you to move around to find that all-important comfortable position. Hydrotherapy suites are provided where two people can sit in a jacuzzi or just have a soothing shower or massage. Water, during the birth process is recognised as an efficacious analgesic. A dining room is adjacent where the mother can eat and drink normally. There are no restrictions on the amount of visitors and birthing feasts are positively encouraged. Why shouldn’t birth be a joyous celebration with the mother and baby as the fulcrum of love and attention?

At the centre, there are home visits for the mother and child the day after delivery, providing all kinds of help and advice with postpartum problems such as breastfeeding. The centre has a 9% cesarean rate and a 3.7% episiotomy rate. The key to their success lies in their faith that a healthy woman, having no contra-indications to a normal birth can expect to experience a safe, careful, intimate delivery with support before, during and after.

Here we are approaching the standard of care and attention given by the Malaysian bidan. So, women everywhere, hold onto your bidan!

Article first published 22/09/01

  1. Wolf N. Misconceptions: Truth, Lies and The Unexpected On The Journey To Motherhood. 2001. Chatto & Windus. ISBN 0 7011 6727 0.
  2. See many chapters in The Case Against the Global Economy & For a Turn towards Localization, Ed. By Edward Goldsmith and Jerry Mander, Earthscan, London 2001.
  3. Idris. SM. Press Release. Association of Traditional Midwifes. Consumer Association of Penang. 15 October 1992.
  4. Jessy. S. The Traditonal Bidan Fight Back. New Straits Times. 1.7.93.
  5. Report. Workshop with traditional midwives of traditional health and midwifery practices. Consumer Association of Penang. October 1992.
  6. Ramly. B. Village Midwives : Driven out of practice and bidan – an essential service. Utusan Konsumer, June 1989.
  7. Raman. M. National Conference on Privatisation & Health Care: Financing in Malaysia. Emerging Issues & Concerns. "Ensuring universal access to reliable and affordable health care". 1997 MMA USM CAP.
  8. Smulders B. Future birth- A place to be born. Presented at A Place To Be Born Conference, Australia for Birth International. February 1999.
  9. Henci Goer, Obstetric Myths Versus Research Realities, A Guide to the Medical Literature, Bergin & Garvey, 1995.
  10. Tew M. Place of birth and perinatal mortality. Midwifery Today JR coll gen pract 1985 35 (277): 390-394.
  11. Smit L. Is Homebirth Safe? Storknets Homebirth
  12. Schlenka PF. "Safety of Alternative Approaches To childbirth. August 15 1999.
  13. Baquet D. Fritsch J. New York hospitals fail and babies are the victims. New York Times 1995 vol 144 March 5, 6, 7.

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