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One of the most difficult areas in referral and consultation is the relationship between obstetricians and midwives in states that allow the independent practice of midwifery. Some states allow midwives to practice only under a physician's supervision. In these states, the relationship between physicians and midwives is governed by the principles discussed in Chapter 15. Midwives pose unique problems because of the view that pregnancy is a natural function that does not require sophisticated medical attendance.

The level of maternal and fetal morbidity and mortality is unacceptable for any woman accustomed to modern medicine. An effective midwifery system depends on the patients of independently practicing midwives' being assured of access to necessary medical and surgical care. European midwifery practice is often touted as a model of such a system, but the model is not directly applicable to the United States because of profound differences in the underlying health care systems.

Except for women having contractions, there is no guaranteed access to medical care for pregnant women in the United States. (See Chapter 32.) In many states, there is little regulation of the training and competence of lay midwives. The underlying morbidity and mortality of the population generally, and pregnant women in specific, is higher than in Europe, and it is dramatically higher in many low-income areas. These factors increase the percentage of women who will need physician-directed care during pregnancy or delivery. Most problematically, women who choose midwives because they believe that the perfect baby results from a natural pregnancy will be especially intolerant of pregnancy-related morbidity or neonatal mortality. The anger, and litigation, will be directed at the obstetrician because the midwife will usually transfer the patient before the disaster.

These factors contribute to, and reflect, the lack of a rational system for midwifery practice in the United States. This makes it legally risky for obstetricians to work with independently practicing midwives. Midwives also pose ethical problems for the physicians who are called on to treat their patients. It is not unusual for lay midwives in states with weak regulations to avoid physician referrals until there is a crisis, and then to refer the patient to the emergency room. Many obstetricians want to help the patients of such midwives but do not want to be seen as endorsing their practices.

Financial issues complicate the relationship between obstetricians and midwives. Some obstetricians oppose midwife practice as unwanted competition, while others employ midwives to increase their patient base. In smaller communities that can support only one or two obstetricians, extensive midwifery practice drains off the routine deliveries that are the financial base for obstetric practice. This increases the pressure on the obstetricians to shift to gynecology-only practices or to leave the community, compromising the availability of surgical deliveries and other medical interventions for all pregnant women in the community.

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