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Making Room at the Table for Obstetrics, Midwifery, and a Culture of Normalcy Within Maternity Care

Akileswaran, Chitra P. MD, MBA; Hutchison, Margaret S. CNM, MSN

doi: 10.1097/AOG.0000000000001493
Contents: Current Commentary

The principle of avoiding the worst possible outcomes guided the enormous successes of modern obstetrics in reducing the morbidity and mortality of childbirth. The challenges of improving the quality of childbirth today has prompted health care providers, policymakers, and patients to ask whether this principle is in fact preventing us from supporting the normal processes of childbirth, resulting in undue intervention and potentially causing harm. In this commentary, we suggest that recognizing the strengths of the medical model of childbirth does not preclude looking outside of it to meet the maternity care needs of the majority of healthy, low-risk women. Obstetricians have the good fortune to have a partner in their work among midwives, who hail from a long tradition of incorporating a perspective of “normalcy” in the care of childbearing women. Given the many evidence-based practices demonstrating the strengths of midwifery to actualize patient-centered, low-intervention birth, we advocate for the explicit establishment of professional standards for team-based physician–midwife care. More than merely introducing midwives into a physician-dominated setting, this means elevating the contributions of midwives and meaningfully incorporating a culture of normalcy to standardize practices such as intermittent auscultation, continuous birth support, nonpharmacologic pain management, and positional flexibility in labor. The literature suggests that a woman's health care provider is the most powerful determinant of her birth outcomes; striking the balance between averting poor outcomes and normalcy compels us to make room at the table for both obstetricians and midwives.

Striking a balance between the cultures and contributions of midwifery and obstetrics is imperative to improving the quality of maternity care.

Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; the Department of Maternal-Child Health, Highland Hospital, Alameda Health System, Oakland, California; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California.

Corresponding author: Chitra P. Akileswaran, MD, MBA, Department of Obstetrics, Gynecology, and Reproductive Biology, 330 Brookline Avenue, Boston, MA 02215; e-mail:

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.