Midwives, Obstetrics, Fear, and Trust: A Four-Part Invention

Abstract

When done well, maternity care brings together four “voices”: the voice of midwifery, which sees birth as a healthy physiological process; the voice of obstetrics, which can manage pathology; the voice of fear (or respect), which encourages vigilance; and the voice of trust, which allows a woman to have confidence in herself and her caregivers. Our goal is to keep these voices singing in harmony.

Maternity care is a four-voice invention.¹ When care is given to women, four voices are singing: midwifery, obstetrics, fear, and trust. When maternity care is well delivered, these voices sing in harmony, much like Bach’s three-part inventions. Each line in Bach’s compositions can be played as an independent melody with its own voice, but when the lines are played together, they produce something beautiful, the result of a productive tension between the voices. If one line disappears, or if one line is played too loudly, that beauty is lost.

It’s the same with maternity care. When all four voices are balanced, the result is something beautiful: a healthy baby, parents prepared for parenthood, a happy family, a satisfied caregiver, and careful and wise use of health-care resources. But when these voices are out of balance—when fear overwhelms trust, when midwifery overwhelms obstetrics (by being too reluctant to intervene), when obstetrics overwhelms midwifery (with too much unneeded intervention)—that beauty is lost.

For a complete transcript of Dr. De Vries’s address (excerpted here), go to http://www.av-m.nl/File.aspx?id=583491fc-888d-4a3f-9ddb-9a433e110e71

If you want to know what happens when obstetrics dominates midwifery and when fear dominates trust, take a look at the United States, my home country. As many of you know, U.S. midwifery is nearly extinct (midwives attend about 8% of births), and many women fear birth (nearly two-thirds use epidural anesthesia). The results are not surprising: poor outcomes measured in terms of health, costs, and satisfaction. One third of all births are done surgically, our rates of infant mortality are among the highest in the developed world, and our rates of maternal mortality are going up. The problems are serious enough that Amnesty International (2010) called on Barack Obama to do something about the problems of maternal mortality in the United States.

I have spent enough time in the Netherlands to know that things are not, and never were, perfect here. There has always been a touch of discord—you might say “productive tension”—in Dutch maternity care. But to the rest of the world, the Netherlands has been seen, at least since the 1970s, as the only modern country where midwives and obstetricians sang in harmony, where women trusted their caregivers and their bodies and did not fear birth. Today, however, discord is growing. Obstetricians and midwives seek to drown out the voice of the other. The Netherlands—once a model of a healthy approach to birth, a model of cooperation between professions, a model of care that gave choice to women on where and how to give birth—is moving toward the hospitalization of all births.

I first came to the Netherlands in 1994 to listen to the melody of Dutch maternity care—particularly to the voice of the midwife—and to learn more about a culture that helped to create and preserve the unique Dutch way of birth. Seventeen years ago, the four voices were singing more or less in harmony, supported by Dutch culture, government policy, and the organization and attitudes of maternity caregivers (see De Vries, 2004).

More recently, here in the Netherlands, the voice of midwifery is being overcome by the voice of obstetrics. As has long been the case in the United States, public policy and political opinion about birth are now dominated by an obstetric science that fears normal birth.² The voice of obstetrics is singing too loudly, and Dutch birth is becoming increasingly medicalized, reducing women’s choices and allowing the voice of fear to take the lead.

If fear is not balanced with trust, women are driven to make unwise choices. A safe, healthy, and satisfying birth requires trust on several levels. A woman must trust that her body is designed to give birth, and she must trust her caregivers. Her caregivers must also trust the ability of a woman’s body to give birth and, equally important, they must trust each other. Trust can drive out fear. But fear can drive out trust. At present, the voice of trust is being overwhelmed by the voice of fear in Dutch birth.

Like Bach’s intricate composition, maternity care is a (four-part) invention.

• •Midwifery teaches us to trust our bodies and to be watchful and reactive.
• •Obstetrics teaches us to respect the birth process and brings the impressive and helpful tools of medicine to cases of pathological birth.
• •Fear keeps us on guard.
• •Trust promotes cooperation and drives out unhealthy fear.

The challenge before us is to harmonize the voices of maternity care, keeping the melody of a safe and healthy birth for mother and baby at the forefront of our work as childbirth educators, midwives, and obstetricians.

The challenge before us is to harmonize the voices of maternity care, keeping the melody of a safe and healthy birth for mother and baby at the forefront of our work as childbirth educators, midwives, and obstetricians.

Biography

RAYMOND G. DE VRIES is a professor at the University of Michigan Medical School (in the Center for Bioethics and Social Sciences in Medicine, the Department of Obstetrics and Gynecology, and the Department of Medical Education) and professor of Midwifery Science at University of Maastricht, The Netherlands. He is the author of A Pleasing Birth: Midwifery and Maternity Care in the Netherlands (Temple University Press, 2004).