Don the Imagination Hat

This post is inspired in part by Jill's "Lamenting the System" series at The Unnecesarean.

In late elementary and middle school I used to say I wanted to be an obstetrician, and if I put on my imagination hat, I can think about what it might have been like for me to have been an obstetrician when I came to learn about midwifery and physiologic birth.

I think I would have reacted in one of two ways: denial, or identity crisis.

Imagination Hat from here. 

I sometimes feel like trying to change current obstetrics so massively is a project similar to trying to make the oceans more user-friendly, when you should just be swimming in a river instead. ... That metaphor definitely sucked, but what I'm trying to say is: midwives.

Or like this: given the goal of all birth-related professionals providing optimal care to support physiological birth, and the reality of two (economically) competing professions that (at least to some extent) define themselves in opposition to each other, is it more realistic:

1. to try to get them to become more similar to each other, aiming to have both types of practitioners meet a single EBM standard (remember we have our imagination hats on)

2. to try to sort out separate spheres for them, eliminating or reducing the competition but perhaps dramatically shifting the number of practitioners in each (imagination hats I say!)

In scenario #1, we have something like midwives and midwives+ (who can provide surgical birth procedures when called for). We also have a style of practice that is completely unique within medicine (for all the talk about zebra hoofbeats and watchful waiting, at heart medicine is about acting to fix pathology; it is also not about preventative care and not about holistic health) and hence to get this kind of practitioner is going to require a total retooling of medical education for OBs. (The topic brings to mind Robbie Davis-Floyd on obstetrics education. Saying this makes me feel like a broken record, but I can't deny how big an impact Birth as an American Rite of Passage had on me.)

In scenario #2, we have midwives in charge of nearly all births from the get-go (home or hospital), with care transferred to OBs when there's a need for surgery. Of course, the sticking point here is that there are currently some 52,000 OB/GYNs and maybe (very rough) something like 10,000 midwives (in the US I mean). Because midwives have lower patient loads than OBs, this ratio would need to flip dramatically in order for all women to have access to midwifery care. The number of needed OBs would shrink while the number of needed midwives would skyrocket.

Frankly, both scenarios seem wildly unrealistic. I do acknowledge that there are doctors who provide care that looks very much like the midwifery model, but I think it's acknowledged that this is a personal choice and not a result of their training. In fact, obstetricians who practice like midwives probably experience a lot of censure from their colleagues, e.g. see here. And of course, a profession (especially one with a powerful trade organization) will not allow a huge shift in provider responsibilities without a fight.

Thoughts? Questions on this structure-less ramble? More recent stats on provider numbers? Anything? Shout it out in the comments.