In September the local paper carried an article detailing a march to promote Certified Professional Midwives to attend births in the state of Alabama (being one of 11 states who specifically prohibit such). As a physician I can see both sides of this debate. On the one hand, we have overmedicalized the birth process. The United States has a rate of delivery via c-section of 31% and state of Alabama has a C-section rate of 35% (10% is the rate considered optimal and achievable). There is a lot of variation among hospitals with the highest rate for a Mobile hospital being 50% (and this is not the USA Children’s and Women’s Hospital that cares for complex patients). There is anecdotal evidence that at least some of these variation are a consequence of physician and patient convenience (the failed induction syndrome).

On the other hand, midwives were utilized when the birth rate was much higher as was the infant mortality rate, it being 44/1000 births in 1945 and 8/1000 in 2008. Medicalizing the birth process introduced many different interventions in a brief period of time (most were introduced between 1950 and 1975). It may be that the lowering of the maternal and infant mortality rates was completely unrelated to any of our interventions but that is doubtful. Concomitant with the fall in birth rates has been the expectation that every pregnancy will end in a perfect baby. Part of the medicalization is the pressure physicians may feel to intervene when faced with perceived risk to the unborn child.

I didn’t even feel compelled to respond when Dr Wiley, the president of the Alabama Academy of Pediatrics,  weighed in regarding the need to continue the medicalized status quo. His concern for the citizens of Alabama is touching, especially when he says

The next time someone suggests to you that home birth with a lay midwife is a good idea because birth is a natural process, remember this — death is also a natural process. If even one baby or mother is lost due to this legislation, isn’t that too many?

There have several doctors who have written in support of Dr Wiley, and again I was determined to sit on the sidelines on this one. Dr Mozley’s letter, published yesterday, has led me to break my silence. He is a retired obstetrician and reiterates the need for physicians to be in charge of the birth process in a hospital setting. He points out that

When I came to Alabama in 1984 as professor and chairman of the department of obstetrics at the University of Alabama School of Medicine, Tuscaloosa Branch, I found that there were 27 counties in Alabama where no physician would deliver a baby. To overcome this problem we established a one- year fellowship in obstetrics for board- certified family practice physicians. This fellowship has been well received throughout the U.S. and now is recognized by the American Board of Physician Specialists.

The practice of obstetrics requires sophisticated machines and surgical skills and should not be delegated to any lay person who does not possess these abilities and support facilities.

Interestingly, there are now 35 counties in Alabama with no ability to provide a medically assisted delivery.  Using this logic, the fellowship has actually reduced access and we should eliminate it.

As a health care consumer, it is important for an expectant mother to explore all of her options and to make the best decision possible for herself and her unborn child. Although it’s not Alabama, English physicians have studied the homebirth process and determined that it offers safety and efficacy equal to a hospital delivery for selected patients. In addition, these women would not expose themselves or their unborn child to risks associated with the possibility of an unnecessary c-section. She should ask her physician what his or her rate is and look up the hospital.

Of the 63,500 births in Alabama in 2008, less than 300 of them were at home or in a hospital that does not ordinarily deliver obstetrical care. That suggests that midwife certification and licensure may not be needed to solve an access problem. It is unclear if it will lead to improved care though it almost certainly will lead to fewer c-sections. On the other hand, Dr Wiley and Dr Mozley have missed the point. It turns out that despite increasing intervention, maternal and infant mortality rates have been stable since 1980.  More important to further reduction is not increasing technology at delivery but facilitating the delivery of preconception care. Listed below are the conditions which, if attended to prior to conception, lead to improved outcomes:

Chronic diseases: Diabetes; heart disease; high blood pressure; thyroid disease; asthma; anemia; kidney disease; metabolic and hematological disorders; depression and other mental disorders; autoimmune disease; and physical disability (access)

Infectious diseases: Vaccine-preventable diseases (rubella, hepatitis B, varicella, influenza, and tetanus); HIV/AIDS; syphilis, chlamydia, and other sexually transmitted diseases; periodontal disease; toxoplasmosis, and cytomegalic inclusion virus

Reproductive concerns: Unplanned pregnancies; contraception; infertility; adverse past pregnancy outcomes (preterm delivery, birth defects, fetal/infant death, maternal complications)

Genetic/inherited conditions: Sickle cell anemia; thalassemia; Tay-Sachs disease; fragile X syndrome; Down syndrome; cystic fibrosis; muscular dystrophy; hearing and vision loss associated with genetic predisposition

Medications and medical treatment: Prescription medications contraindicated in pregnant women (FDA’s Category X Drugs, 117 products in 2001 PDR, antiepileptic drugs, oral anticoagulants for maternal clotting disorders, and Accutane); diagnostic radiation exposures

Personal behaviors and exposures: Smoking; alcohol consumption; illicit drug use; overweight/underweight; folic acid supplement use; domestic violence; eating disorders; exposure to infections; exposures to chemicals and other environmental toxins; consumption of over-the-counter medications; hyperthermia (e.g., from sauna use)

What these have in common is that they are amenable to primary care intervention. The Affordable Care Act will allow women who to have access either through Medicaid (those with an income below 133% of FPL) or through the health exchanges (the other women of childbearing age). I hope to see Drs Wiley, Mozley and the rest educating Alabamians about the important care  that they will soon be able to access thanks to President Obama.