An obstetrician recommends midwifery care [PODCAST]

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“By denigrating midwifery care, pathologizing the natural process of birth, and instilling fear of complications and pain, doctors persuaded women to give birth at the hospital under their care. By touting the benefits of anesthesia, forceps delivery, episiotomy and promoting in-hospital birth, doctors and hospitals were able to capitalize on the new specialty.

Interventions of increasing risk and complexity, and their routine use — without proof of benefits for the 80 percent of birthing people who are low risk — have caused harm not just because of their invasive nature, but because the birthing person is subjected to various forms of persuasion and coercion (without informed consent) to do what doctors believe is best for them and their babies. Many of the practices employed on labor and delivery interfere with the natural process of birth. When patients ask to avoid those interventions (which often make life easier for the staff or more money for the hospital), they are told they are not allowed to do what they want for their labor and birth. In a 2019 survey of women who gave birth in U.S. hospitals, 28 percent reported mistreatment. Black people report discrimination in about one-third of their medical encounters.”

Leslie Farrington is an obstetrician-gynecologist.

She shares her story and discusses her KevinMD article, “This obstetrician recommends midwifery care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Leslie Farrington. She is a retired obstetrician-gynecologist, and she wrote the KevinMD article “This obstetrician recommends midwifery care.” Leslie, welcome to the show.

Leslie Farrington: Thank you for having me, Kevin.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Leslie Farrington: My parents were an interracial couple in the 1950s, when that was illegal in many states. My father was a dark-skinned Black man. My mother was a white lady with blue eyes, and I came out looking white, basically. But my father instilled in me a strong Black identity, and those who are familiar with this, this is something called the one-drop rule, or if you have one-eighth African American in you, you’re considered Black. Culturally, I grew up in a Black family. Everyone else was obviously Black, and my mother sort of assimilated.

This was during the ’50s and ’60s, when the civil rights movement was growing, and my parents experienced quite a bit of racism, so the whole family experienced it. So I was pretty familiar with it. Even though my father did not have a high school diploma, he was self-taught about U.S. history and how racism impacts the society, economics, politically, everything. So I learned a lot about this growing up, but I didn’t think about it much during my career.

I wound up getting married as a sophomore at Johns Hopkins University and having a baby nine months later, and I was attending the midwifery clinic. They were training student midwives at Hopkins at the time, and giving birth with the support of a midwife turned me away from humanities and toward the medical field. My pre-med husband at the time said, “You don’t want to be a midwife. You’re not going to get a job.” This was his perspective as a, you know, wannabe doctor. And so I wound up going to medical school at Howard University, knowing I wanted to be an obstetrician, and that was after two more babies were born.

During my career and training, and throughout my obstetrical career, I was not thinking about racism. I was busy. But I did notice, and I was in a unique position to observe, that many of the professionals, nurses and doctors, harbored prejudice. But I didn’t recognize how that affected maternal health, and Black maternal health specifically, until I was part of the beginnings of the Council on Patient Safety in Women’s Health Care, which was started in 2014 because of the explosive news about maternal mortality in the United States being so much worse than in the other developed countries.

What was puzzling at these meetings that I was attending with experts in the field, what was puzzling to them, was why Black women were dying at three, four times the rate of white women. And this applied to well-to-do, well-educated women with good insurance, who were not the typical patients you would blame for their outcomes, which was a very common thing for obstetricians to do: to blame the patients, especially Black patients. So the experts didn’t understand why this was happening, but everybody I knew, my family, said, “Leslie, it’s racism. Of course Black women are having worse outcomes.” And so I sort of went back to what I learned growing up, and I started to see how it was happening.

So I decided to form an organization and develop a curriculum to educate the community, the Black community, as to how to speak up and get better health care. The curriculum that we developed is called the ACT curriculum: Ask questions until you understand the answers, Claim your space, both physical and mental, Trust your body, and Tell your story. So we’re about empowering, you could say, women, birthing people, and their supporters, also doulas, midwives, whoever wants to learn to impart this curriculum to their clients. This is something that I’m promoting through an organization we formed called the Black Coalition for Safe Motherhood, and I formed the organization basically to promote the ACT curriculum.

Over the course of putting this curriculum together over the past several years, I’ve been learning about the history of obstetrics and the history of midwifery. I didn’t realize how young a specialty obstetrics was, how really young Western medicine was, in fact. So I’ve been learning about that, and that’s what contributed to the article.

Kevin Pho: I want to touch on one of the things you said, about the prejudice of some of the health care professionals that you observed over your career. Can you give some examples of what you saw?

Leslie Farrington: Oh, sure. So a nurse might come back to the nurses’ station, where doctors and nurses were congregating, and start talking about the patient that they were triaging in on labor and delivery. You know, people came in with all kinds of emergencies, and if it was a Black person or a Latino person, they might say something like, “Oh, you know how they are.” It wasn’t necessarily explicit, but somebody like me would recognize that they harbored bias.

There was also a tendency to label patients, especially Black patients, as poor historians or noncompliant. And if you think about some of the terms that we have in obstetrics, it sort of goes with the whole culture: incompetent cervix, failed induction, and other terms that don’t come to mind that readily now that I’ve been retired for a while. But looking back, and seeing the paternalistic and judgmental attitudes that doctors had, and nurses too sometimes, toward the patients, even white patients, you know, women would just, or not. The way I label it is it’s doctor-centered, not patient-centered or person-centered.

And we know from the book from the Institute of Medicine, “Crossing the Quality Chasm,” that person-centered care is one of the six pillars of quality improvement, and that’s something that’s been ignored all these 20 years since that book came out. Basically, public health recommendations have been ignored, and assessments of racism in medical care have been ignored until recently. “Unequal Treatment” was put out by the Institute of Medicine also around 2001 or so, and medical professionals didn’t pay attention. So what’s been going on in public health is like in a silo. That’s why the obstetricians who were discovering these awful maternal health statistics didn’t really understand what was going on with their Black patients.

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. It’s titled “This obstetrician recommends midwifery care.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Leslie Farrington: Well, I decided to write it because there’s such a lack of awareness of the benefits of midwifery in the United States, and there’s a lack of awareness of the fact that in our country, 90 percent of births are attended by obstetricians, and everyplace else in the world, the majority of births are attended by midwives. Obstetricians took over the midwives at the end of the 1800s and the beginning of the 1900s, basically outlawing midwifery, and this is something that advantaged them and the hospitals that they worked in, so that all the women would gradually, because midwives were thought to be not as good practitioners as doctors, because of the stories that doctors would tell. Plus, doctors were offering anesthesia. They would say that they were shortening the birth by using forceps, and they were supposedly more educated.

So this is what I wanted to expose: that these were the origins of obstetrics, that obstetrics is fairly new, that it was based on interventions and the pathologizing of birth, saying that this was dangerous, that women were at risk, and so they should be in the hospital. Essentially, that was totally untrue, but it took off, and it has become entrenched in the United States. We’ve also seen some of the impacts of that, and that is increasing C-section rates. And to what extent all of this intervention affects the outcomes and the statistics that we’re now seeing, we really don’t know.

Kevin Pho: Can you comment in general on the relationship between obstetricians and midwives?

Leslie Farrington: Well, in general, obstetricians basically wanted to put midwives out of business so that they could capture that business of birthing. And so there were virtually no midwives in the United States when we got to the 1960s. Midwives were looked down upon. They were not welcome on labor and delivery until maybe the last 20 years or so, maybe a little bit longer, but that’s been very gradual.

And the consumers of care, women in the ’50s, ’60s, and ’70s, started to look and say, “Hey, we need to get control of birthing for ourselves. We want to have more autonomy.” They started to recognize that the interventions, the hospitalization, the medicalization of birth, if you will, was harmful and taking away from their experience. So they started to look for midwives, and midwives made a comeback. But it’s hard to make a comeback unless you’re a nurse and then a certified nurse-midwife.

Kevin Pho: Can you contrast the birthing process from a midwife standpoint versus an obstetrician standpoint?

Leslie Farrington: So a midwife centers the patient. They are aware of the power that the vast majority of women have within their own bodies to safely birth their babies. So they’re there to support the mom, and do so in a way that empowers that mom, and they’re there to deal with any issues that come up and to make sure the baby’s OK. They’re supporting the natural process, put it that way. It’s supporting the physiology of birth.

Kevin Pho: And you mentioned one of the effects of obstetrician control you see over the birthing process. Is there data that suggests that it leads to an increased number of C-sections?

Leslie Farrington: Oh, definitely. If you have the support of doulas and the care of midwives, you will decrease, and that’s the key. And 80 percent of women are low risk and entitled to, or should be able to access, that kind of care. Then you’re reducing C-sections. There’s plenty of data there.

Now, the problem is the public is not aware, and it’s hard to grow, to increase the supply of midwives at this point, when you don’t have the collaboration that there should be between hospitals. There are not enough birthing centers. There are a lot of obstacles to being able to find a midwife, especially a Black midwife for a Black patient, and studies also show that culturally congruent care improves outcomes for Black women.

So the answer to the Black maternal health crisis, and to maternal mortality in the United States overall, is to increase midwifery care and to let the public know that you really don’t need an obstetrician most of the time. But, you know, women are convinced that the doctor is better, and so it’s going to take a long time before we can make this shift happen to a more physiologic birth process that more women deserve to be able to access.

Kevin Pho: So from the patient’s standpoint, how much control do they have in terms of choosing a midwife versus an obstetrician for the birthing process?

Leslie Farrington: There are many places in the country where there’s a shortage of any kind of obstetrical or midwifery provider, so it depends on what part of the country you’re in. In New York City, there’s only, I think, one birthing center, so those who don’t want to birth at home but don’t want to go to the hospital don’t have many options. So we really need more birthing centers. I would like to see obstetricians opening birthing centers and hiring midwives and getting this going, taking leadership in this role, if they really want to improve maternal health, and especially Black maternal health.

Kevin Pho: And is one of the reasons why midwives are suppressed in terms of their growth, is it purely economics and the way our health care system pays for procedures?

Leslie Farrington: Oh, the payment. There is a problem with paying for doula care, midwifery care. If you go to a birthing center and then you happen to transfer to the hospital, the birthing center loses out. And the fees, yes, there are lower fees for midwifery care, lower payments. And then the folks who would like to be midwives are often not as well-to-do as they need to be to be able to pay for school. There are many obstacles to becoming a midwife.

And still, I’m happy to say that there’s a movement in the Black community, that women are following the path to become midwives and doulas in order to save ourselves. Some say SOS: save ourselves. So let’s get more Black midwives, more Black doulas, and push for the omnibus act to be passed, which is sitting in Congress right now, that would address all of these issues that I mentioned.

And obstetricians can learn to do a better job if they start to learn their history and start to look at what is evidence-based. Does everyone need to be on the fetal monitor? Electronic fetal monitoring is one of the main causes of increased C-section rates, and that was even when I was a resident. I was told there’s really no evidence of benefit for doing this, but they started doing it routinely for medical-legal reasons. So putting people in bed, making them nervous, all of this, becoming a patient, being told what you’re allowed to do and not allowed to do, this is really, like you said, the word you used, controlling the birth. And that doesn’t foster good outcomes. It fosters more C-sections.

Kevin Pho: We’re talking to Leslie Farrington. She’s a retired obstetrician-gynecologist, and she wrote the KevinMD article “This obstetrician recommends midwifery care.” Leslie, where do you see this conflict going in the foreseeable future?

Leslie Farrington: Well, because of the pandemic exposing racial inequities in health care and causing people to be sick, because racism makes people sick and there’s racism in medicine, this is being recognized now by the American College of OB/GYN. They have a strategic plan to eliminate racism in obstetrics and embed equity, and so does the American Medical Association. So I see changes at the top in terms of recognizing the problem.

I hope that they will also recognize how midwifery would, how incorporating midwifery into women’s health and collaborating between midwives and obstetricians, would improve the chances that obstetricians would start to adopt the midwifery model in their practice, so that there will be plenty of providers who can support birthing people in getting their preferences and their needs and their values centered, and having better outcomes and more joy and a spiritual experience when they give birth, instead of a medicalized one.

Kevin Pho: And my final question, what’s your take-home message that you want to leave with the KevinMD audience?

Leslie Farrington: Listen, listen to your patients as individuals. Be a human and not just a doctor who’s on automatic. Mindfully listen and center your patients. You will have a better experience in caring for them as well.

Kevin Pho: Leslie, thank you so much for joining me and sharing your time and insight.

Leslie Farrington: Thank you, Kevin. Have a good day.

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