Editorial: Two Important Keys: Autonomy and Working Together
by Jan Tritten

[Editor's Note: This editorial originally appeared in Midwifery Today, Issue 68.]

Is our profession a barrier to instinctive birth? Are we, whose calling it is to protect and care for motherbaby in the birth year, actually forming a barrier? If so, how do we change our profession to meet the real needs of women in pregnancy and birth? We have enough evidence to support the fact that women, along with their babies, have within their bodies and souls the ability to give birth. As naturally as the baby gets in, so can it get out. Usually. This is the big question. What part of "usually"? How can we tell? When problems arise, how do we apply as few interventions as possible and only as necessary?

The ultimate question is: "Where is our profession going?" At this time in our herstory, we can define midwifery as being with woman and as protector of normal birth. About five or six years ago, I asked Marsden Wagner, MD, "What is the greatest issue facing midwifery?" He answered unequivocally: autonomy. As the years have marched on, I see this becoming ever more important. Without the ability to apply the knowledge and intuition we have gained and to make decisions within each birth that protect and encourage the motherbaby, we will lose midwifery as we understand it. In many areas of the globe, the midwife who carries this holy mantle, the highest calling indeed, is no longer recognizable as the protector and caregiver of women and babies. We have fought too hard to bring midwifery back from the ashes to let it go without a fight.

In the middle of the news that New York's Elizabeth Seton Birth Center was closing because of malpractice insurance quadrupling, I recently e-mailed a few of my CNM friends. I asked simply, "What are the issues in nurse-midwifery?" The closing of a very successful 30-year-old birth center is a huge issue in itself. I have spoken to many CNM students who want to have a birth center. It seems that for each one that opens, one closes. How can we make change in birth when politics beat us down? Often it comes back to the autonomy issue, which is vital for midwives to facilitate women's birthing process.

As you read your sisters' list of issues in nurse-midwifery, please jot down your thoughts on the issue and ideas about how to solve the problems and how we can all work together in love-CNMs, CPMs, lay midwives, doulas, educators and activists. Just as we all give motherbaby love and respect, let's give it to each other. Although we may differ philosophically, our bottom line is the same: the health and wellbeing of motherbaby. We can move midwifery and instinctive birth forward, but only in harmony with one another. The good that can come out of the horrendous situation midwifery finds itself in is a sense of unity, as we fight these battles for our very survival together. There is no other way. Taking the rudder of this ship, we must work together and take turns on watch for the safety of all. If the ship goes down, we will all be on it. Most mothers and their babies are already on the sinking ship. Midwifery is the only rescue unit around.

Here are the issues four of your CNM sisters shared (not in any order). Please consider writing on these or other issues in midwifery or birth.

  1. How to handle malpractice insurance: getting it; dealing with the cost if we have an independent practice; finding support and good advice from other midwives if we are involved in a lawsuit.
  2. Maintaining the midwifery model in an atmosphere permeated with the medical model. How to successfully interact with OBs when we need their input and services.
  3. How to have more control over our practices so they are not dissolved at the whim of administrations, corporate health care institutions or MD department heads. How to have a bigger role in the decisions that get made about our services.
  4. Maintaining the midwifery model and standard of care when employers are demanding high volume for both office visits and births. ("I see 30+ people in a 12-hour clinic day.")
  5. Burnout in the corporate health care arena, while trying to do the above.
  6. Working in settings that require us to do primary care for women. Having to be a midwife "Jill of all trades." ("What do I know about hypertension?")
  7. Reimbursement.
  8. Lack of independent practice.
  9. Real social support for out-of-hospital birth by labor and delivery nurses, who have the power to destroy midwifery.
  10. Education for midwives that encourages individual choice instead of blind following. Know "why" we do what we do.
  11. The new ACOG rules on VBAC, which have made many small hospitals stop offering VBAC. (The new guidelines require the ability to operate within 20 minutes of making the decision, or as they say, "20 minutes decision to incision.") This means nurse-midwives need to turn these women away or go outside of the system.
  12. Long hours, sleep interruptions, difficulty getting time off.

Are these issues just the tip of the iceberg? Would autonomy help with these issues?

My friend Suzanne Colson, a midwife from the U.K., calls midwifery "a profession looking for a philosophy." That philosophy should be instinctive birth. Let's join with mothers. We can do what midwives have done in New Zealand and define midwifery as an equal partnership with women. While claiming our autonomy, women could claim theirs as well. What a block of power we would have if we truly worked with each other and with women and men willing to fight the fight with and for us! If we could forget our petty battles and work together to solve the problems, what a fantastic strength we could gather.

Toward Better Birth,
 jan

Jan Tritten

Jan Tritten is the founder and editor-in-chief of Midwifery Today magazine and a midwife who was in active practice from 1977–1989. She became a midwife in 1977 after the powerful homebirth of one of her daughters. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world! [ PHOTO BY ANDREA NOLL ]

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