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 general principles governing the relationship
between physicians and other medical personnel. 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 ensured 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 medical care systems.
Except for women having contractions, there is no guaranteed access to
medical care for pregnant women in the United States. 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, whereas 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.