Midwife Legislation in SC

Legislation has been proposed in SC that would severely restrict and possibly eliminate the option for out of hospital birth in South Carolina.  http://www.supportscmidwives.com  The following letter is what I have written in support of the certified midwives.

To Our Legislators:


Re: H3731


I am a family physician practicing in Greer, SC.  I have been delivering babies for more than 25 years.  When I started my practice in Greer in 2005, I was approached by one of the certified midwives and asked to see their patients as needed and to be available for phone consultation when the need arose.  I was initially hesitant because I had heard all of the horror stories and been told how these unqualified ladies were endangering moms and babies with their poor quality care.  At that time most of the traditional obstetrical community had frozen them out, but their popularity among patients was growing so cooperating physicians were badly needed.  The attitude of most obstetricians was that if they refused to cooperate, the certified midwives would go away.  However, because the midwives were filling a need their practices were increasing in size.  For those who claimed they were giving the cold shoulder because they were concerned about quality, I did not understand how making access to traditional care more difficult improved the quality of care for those women using the certified midwives.


I decided to make myself available to the certified midwives and their patients.  In working with these ladies I have found, quite contrary to my prior perception, that they are well educated in pregnancy and birth.  They are compassionate providers of quality care and they know their limits and when they need help.  They are not bungling, hicks killing moms and babies.  Just because their training process is based on an apprenticeship model, rather than the college model, does not make them untrained.


There is no evidence based data that shows these providers of maternity care are dangerous practitioners.  Studies such as this http://www.bmj.com/content/330/7505/1416   in the British Medical Journal have shown otherwise.  While I am sure that those championing this bill will site anecdotal cases, the reality is the only cases  that most practitioners see are the challenging ones, which gives a false impression as to the risk associated with birthing with a certified midwife.  The average practitioner does not see the hundreds upon hundreds of good outcomes.  The NICUs across the state are full of babies whose mothers were cared for by obstetricians.  Every doctor providing obstetrical care has fetal demises, life threatening postpartum hemorrhages, postpartum infections.  There is even the occasional maternal death.  Does this mean obstetricians should be regulated out of existence?  More likely it means that the certified midwives are being judged by a tougher standard than the obstetricians.  If the obstetricians are so much better at providing care to pregnant women, why do they have a cesarean section rate that exceeds 30%, while the midwives have a rate significantly under 10%.  Maybe the obstetricians have something to learn from the midwives?


What is really happening is that the certified nurse midwives are providing an alternative for women from the highly medicalized environment of birthing in a hospital.  This option is being chosen by an ever increasing number of women and the obstetricians do not like the competition.  It is amazing that in the Upstate, where even nurse midwives were resisted for many years, all of a sudden they have opened a nurse midwife practice.  Over the last year the Greenville Health System has begun changing their practices so that they are promoting breastfeeding, immediate bonding between mother and infant and a more natural approach to birth.  The certified nurse midwives have been providing this kind of care for many years, while they have been seriously criticized for doing so.  Now all of a sudden traditional medical care is acting like they discovered it and its benefits.


The proposed legislation would effectively eliminate these providers of care for pregnant women.  This would be harmful for all parties:


1)   Our political leaders should be working to promote freedom and choice for the citizens of South Carolina.  If the certified midwives are regulated out of existence, freedom has been diminished and choice has been eliminated.

2)  It is being argued this regulation is needed to protect women from unsafe practitioners.  However, other than out of context anecdotal stories, it has not been proven the way things are currently being done is harming women.  One thing is sure, because it is happening in other states, if these practitioners go out of business, not all of their clients will go to the hospital.  The elimination of these practitioners will dramatically increase the number of unattended births or births attended by individuals who have no means to easily access the medical system.  If you want to increase the number of injured and dead moms and babies, this legislation will do it.

3)  The American way is the free market and competition, because it makes all parties provide better and less costly services.  The elimination of this option for women will diminish this needed pressure on the hospital systems to provide the best possible care for all patients.  As I mentioned above, we have seen the positive influence these providers have had on obstetrical care in the Upstate.  Do you really want to go back to the way things were?

4)  Today all policy makers are struggling to find means of providing lower cost, quality medical care.  These practitioners are providing quality obstetrical care for a fraction of the cost of traditional, hospital based care.  You should be looking for ways to promote their care, rather than eliminate it.

5)  A significant number of the women who use the certified midwives do so because they cannot afford hospital based obstetrical care.  What are these families supposed to do if this is no longer an option?


What is the REAL objective of this legislation?  If the real objective is to eliminate certified midwives, than this legislation will accomplish that goal. The obstetricians will NOT in any way assist them in carrying out their mission.  Several times I have personally been threatened, that I will lose my ability to practice obstetrics as a result of the assistance I provide to them.  You can be sure, the obstetricians will not provide direct assistance to them.


On the other hand, if the real goal is to provide the best quality care possible for the pregnant women of this state, than we need to increase the voluntary corroboration between the traditional obstetrical world and the out of hospital midwives.  Both groups have things they can learn from the other.  Joint conferences where real people talk to each other and cases are reviewed will do much more to improve everyone’s view of the other and improve care than will increasing the regulatory straight jacket.


One of the major criticisms of the midwives is they wait too long to get help.  Is it any wonder this happens when they meet with such hostility when they try to get help.  The fix to this is to provide easy, friendly access to obstetricians and hospitals.   In our local area this approach has already proven to be very helpful.  It should be expanded and carried out in other areas.


I applaud the legislators desire to have safe medical care in our state.  I contend this legislation will not accomplish that, so it should not be enacted.


Keith Stafford, MD

Greer, SC

Really Cool Delivery

I had a lot of positive feedback from my last post on “my birth plan.” A few months ago I had a delivery that really made an impression on me and I wrote it down, so that I could remember the details.  It illustrates the style, I wish was more prevalent in obstetrics today.  This is the birth story, as I wrote it down.

“I had a really neat delivery this AM for a super sweet couple.  It was the mom’s 3rd baby and she  was laboring on her side.  (I have delivered all of her babies.)  When it came time to push, I left her on her side as she was quite comfortable in this position.  Baby was occiput posterior, so it took some work for her to push it out.  Dad was sitting on a chair next to the bed on the side mom was facing doing very encouraging, support person stuff.  I was sitting on the bed, behind the mother.  There were no interfering drapes or sheets.  Because of mom’s position, as the baby was coming into view, the father was as close to her perineum as I was, so he got to see his child’s birth in detail, rather than peaking from up above.  The really cool thing was that since the baby was OP, as it was born, it had its eyes wide open and was looking right at his father, so his father was the first person he saw instead of me.  Then this baby took a big breath and began audibly crying while the head was still the only part delivered, which added another unusual twist to the delivery.

It felt so right to me,  because with me behind mom and dad being so close and involved, I felt like I was not even integral to this delivery, It was just something, very personal, that this family was doing together.  Then the icing on the cake was that instantaneous eye to eye contact between father and son as the head emerged.  I so wish I had it on video.”

When one feels all of the pressures with this kind of job, it is this kind of experience that reminds one as to why you keep doing it.

My Birth Plan

I have been delivering babies now for 25 years.  Birth plans have been around for that whole time, but they are certainly presented by couples to their doctors more frequently today than they used to be.  The increase in birth plan development is a consequence of couples trying to influence what happens in a hospital where one frequently becomes swept along by events out of their control.

I certainly do not mind being presented with a birth plan and using it to review a couple’s expectations and preferences.  However, in my opinion, it is far more important that one find an accoucheur (birth attendant) whose default style is in line with your birth plan, than trying to get someone to change their style to match your preferences.  In light of this I decided to write down my birth plan from the perspective of the professional who is being entrusted with caring for an expectant couple.  Here are my goals and preferences:

  1. Give the couple the type of birth that THEY want to experience.  While most overt birth plans are produced from those who are looking for a natural birth experience.  Not everyone is looking for this.  I have some moms who want no medications at all and I have some who want an epidural placed in the parking lot.  Whatever the preferences, I will do my best to accomodate them.
  2. Explain all interventions and get the mother’s permission, before doing them.  One of the biggest complaints I hear about unpleasant birth experiences is that things were done to them without them knowing what was happening.  While it is easy for a doctor to go into automatic mode, I do my best to not let that happen.
  3. Alleviate fear.  One of my frequent statements about pregnancy is that it is the permanent state of paranoia.  Couples are often plagued by the “what ifs”  and modern obstetrics often adds to this with the constant pursuit of worst case scenarios.  While it is certainly true that bad events can occur during pregnancy, thankfully this is the exception and not the rule.  My job is to be alert for  problems without turning every visit into a worry generating experience and to reassure moms when there is no reason to worry.
  4. Avoid Inductions.  I hate inductions.  Sometimes, inductions cannot be avoided, but even then I still hate them and really try not to do them.  No one knows what actually triggers labor, but one thing I do know is that forcing a uterus not yet ready to labor to labor is asking for trouble.
  5. Encourage mothers to stay out of bed and in motion.  The best way to reduce discomfort and to move labor along is to stay out of bed and move about and frequently change position.  One can also use birthing balls, whirlpool tubs, showers, hypnobabies.  Doulas are welcomed as part of the birthing team and a great help in keeping the labor moving along in a productive manner.
  6. Prefer no epidural.  If women want to have an epidural, they may, but my preference is no epidural as this allows for the most physiologic beneficial labor possible.
  7. Keep the stirrups stowed.  When someone is ready to have their baby, the nurse’s automatically reach for the stirrups.  I tell them to put them away.  In my opinion, the stirrups serve no useful purpose and they impede a mother’s ability to find the most comfortable position in which to give birth.  I deliver women in whatever position they are most comfortable and have delivered ladies on their side, hands and knees, leaning over bed, standing, squatting, whatever works.
  8. No episiotomy.  I avoid episiotimies.  (Hint:  when a doctor says they only cut an episiotomy when it is needed, they probably cut episiotomies on most of their deliveries)
  9. Put baby on mother’s chest as soon as baby is born.  The baby goes from me to the mom, not the nurse.
  10. Delay cord clamping.  I cannot say, that this is something that I fully understand, but it is frequently requested so I have incorporated it into my routine.
  11. View Cesarean section as a negative outcome.  Again sometimes cesarean sections are unavoidable, but I never view them as equivalent to vaginal birth for delivering a baby.  Whenever, I have a pregnancy ending with a cesarean section I review the various aspects of the pregnancy and labor to see if I could have done something different to have ended with a vaginal birth instead of a cesarean section.
  12. Maintain a relaxed environment.  Sometimes things can get pretty tense in the birthing suite, but it is my job as the team leader to keep things relaxed and low key.  I have no use for all of the drapes and masks.  I do  not even wear scrub suits (though my wife wishes I would).  This is how I got my nickname “Dr. Polo Shirt.”  I work at calling everyone involved in the birth by their name and try to treat them the way I would want to be treated.  
  13. Care for the baby I deliver.  I really like it when I get to take care of the baby that I have delivered.  This is one of the services that is unique to family physicians who do obstetrics. Keeping the pediatric care with the same doctor who one has gotten to know throughout the pregnancy provides a level of comfort not available with most other care providers.