What a Midwife Wishes People Knew About Her Job | Hacker News Reader

What a Midwife Wishes People Knew About Her Job

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59 pointsUltramanoid65 comments

Something I think people should be aware of is how the resurgence of midwifery in the Western world is a response to our increasing negligence in taking care of expectant and birthing mothers. In the United States, my sister giving birth today is almost twice as likely to die in childbirth as her mother was thirty years ago. A few months ago Ars Technica covered a study on the reasons why, and it boiled down almost entirely to doctors and nurses neglecting their patients or even straight-up ignoring them. https://arstechnica.com/science/2018/07/why-do-so-many-moms-...

I would absolutely urge anyone to hire a midwife to attend a hospital delivery. It's the only way to guarantee at least one professional in that room cares.

This might be true in the US but hardly in the entire "western world". Here in France you can give birth in a hospital without ever having a doctor intervening, only midwives, and it is not a new thing.

Yeah, same thing in Denmark. When my girlfriend gave birth, we had 3 midwives assisting. When she lost what they deemed to be too much blood, they called in a doctor to take a look. Everything was fine. If she hadn't passed some specified threshold for bloodloss, we would not have seen a doctor (or a nurse, come to think of it) at all throughout the birth. Only midwives.

Same in Israel. For all three of my children's hospital births, only a midwife was present. In the first two, by my request, she instructed me what to do instead of doing it herself. And being in a hospital there was a doctor on call should any issues have come up.

My wife's obstetrician's office is about half ARPN-CNMs (Certified Nurse Midwife). She saw the Dr for a few appointments, but mostly the CNMs. A CNM delivered our son in the hospital. The CNM had the Dr available to her if things went badly. For our daughter, we came to the hospital with my wife 9cm dilated and the CNM was unable to get there fast enough. In the end it was good that the Dr was there instead as she was born not breathing and eventually ended up on life-support. Even in that case the CNM was the primary care provider for the entire pregnancy.

We live in the US. I think not enough women use CNMs, but it's not some universal thing that you have to use an obstetrician in the US.

Is this in the US? Are midwifes an optional thing? I've had experience with births in Australia and the UK where hospital midwifes led the process, from antenatal to birthing and postnatal.

I think he is confusing midwife with doula. You don't hire a midwife to join you at the hospital. I think in the US, they are referred to as nurses more than midwives in hospitals. Here in Aus it's all midwives. Therein lies a bit of the problem as the profession should be seen as different to conventional nurses.

I don't think he's confusing anything; doulas aren't medical personnel.

Not sure how much this is regional, but in Poland, you absolutely can hire a midwife at some maternity hospitals. It's an extra private service, through which you can select a particular midwife from the hospital to be available to you for consultations and be there to lead and care for you during birth.

In the US it depends on what your obstetrician's office has in many cases. The practice my wife chose has about 50% APRN-CNMs (Certified Nurse Midwife). We had a CNM for our first delivery and the Dr for the second (timing didn't allow for the CNM to make it to the delivery).

Midwifes are an optional thing in the US; lots of hospitals are OBN/GY-lead & they handle all the ante-natal, post-natal, and delivery stuff.

We found one of the few midwife-led hospitals in the Bay Area and had a very similar experience to the NHS Scotland midwife-led birthing centres.

As a counter to this point there have been scandals in England (eg Morcambe Bay, but there are others) where midwives killed babies through a combination of incompetence and arrogance, creating a dysfunctional culture that promoted midwifery to the exclusion of other professions - all because they had an unrealistic belief about "normal birth".

Normal birth is defined here: https://betterbirths.rcm.org.uk/resources/read/defining-norm...

Here's the Kirkup report: https://assets.publishing.service.gov.uk/government/uploads/...

Here's the RCOG response: https://www.rcog.org.uk/globalassets/documents/news/rcog-res...

The RCM dropped their campaign around "normal births" shortly after Kirkup, and launched "better births": http://www.rcmnormalbirth.org.uk/

A news report that's a nice summary: https://www.theguardian.com/society/2017/aug/12/midwives-to-...

In England it seems the safest option is to have a mid-wife led birth with medical help available. Having a consultant obstetrician available appears to decrease rates of intervention, not increase them.

Oh definitely. Giving birth outside of a hospital is a bad idea.

Not at all. Hospitals are lately notoriously unclean and eager to intervene and interrupt. A home setup can be very clean and healthy, and the hospital can still be there as a backup if extra equipment is required. Our midwives were quite equipped, though. Oxygen, IVs, fetal monitors, etc. Most of all, it's comforting at home, especially at such an important time

To quantify, at least in the US: your baby is twice as likely to die during birth in a birth outside of a hospital, compared to a birth at a hospital.

And this despite the fact that higher-risk deliveries are more likely to occur in a hospital, so that if the environments were equally dangerous, you'd expect the stats to tilt the opposite direction.

Source? I've never heard that and it sounds like fear mongering. Homebirth, for example, is statistically very safe

How much of that is Simpson's Paradox, though? What I'd think of as 'homebirths' are typically informed, prepared, healthy mothers with no known complications...

The US has 2 levels of obstetrics professionals -- MD/DO and Certified Nurse Midwife. CNM's are nurse practitioners with a Masters or Doctorate degree. They don't do surgery, and the smart ones don't do births outside the hospital.

In the US you also have "Professional Midwives", Doula's and Certified Professional Midwifes -- none of which have any real health care training requirements. In most other countries when they speak of midwifes, they mean nurse midwives.

Here in NZ, midwife care has taken over to the point where you can no longer get a doctor involved in your primary care at all unless you go fully private obstetric care, which isn't even available where I live.

Midwife-led care has become a weird sort of political and social issue here. It's intricately tied into a narrative about how natural childbirth is better, regardless of the evidence, and much of the culture surrounding it is basically dogma. It's also heavily gender-based - I've never heard of a male midwife here, and a lot of the muttered suggestions about the general terribleness of conventional medical ante-natal care clearly paints male doctors as the bad (or at best, uncaring) guys. There was a study released detailing that our support is not anywhere near as good as we would like to believe (see https://www.stuff.co.nz/life-style/parenting/pregnancy/birth...), which the Ministry of Health got involved in trying to quash and ultimately succeeded in having ignored. I understand the midwives' vested interest in trying to control this narrative, but the only reason I can think of for the Ministry to get involved is that they like midwife-led care because it's cheaper, or that they don't want to admit that going as far as we have down this route might not have been the best idea.

We had a terrible experience with midwife care, and if we were able to have another child (we're not, in part because of the first delivery) we would move somewhere that allowed us to have actual medical professionals involved in our care.

There's a really worrying narrative in all of this, along the lines of that doctors are either incompetent or somehow uncaring about childbirth or women's issues relating to it. Massive reduction in maternal and neo-natal death and complication rates is one of the most amazing results of modern medicine and science in general, ever. I'm still embarrassed to admit how I got sucked in by the alternative narrative despite being someone who likes to look at evidence.

Are your midwives the equivalent of APRN-CNMs in the US? Most people that talk about midwives never specify the type of midwife and that can vary wildly.

I don't know - I don't know what APRN-CNM means and I wouldn't know how to evaluate whether the training here is equivalent or not. Midwives here receive 4 years of training I believe.

> An Advanced Practice Registered Nurse (APRN) is a nurse who has at least a master's degree in nursing, and sometimes a doctorate in nursing.

> A Certified Nurse Midwife (CNM) is a medical professional who oversees every facet of a woman's obstetric care. This includes pre-conception counseling, prenatal care, labor and delivery, and post-partum care. The requirements for becoming a CNM are a nursing license, a midwife license, and a certification from the American College of Nurse Midwives.

> narrative about how natural childbirth is better, regardless of the evidence

Can you point to some sources for this?

To be totally honest I have no idea what the evidence says one way or the other. I do know that most the people I know have had more complicated births when not in midwife led units.

We had 3 natural midwife only births (the last 2 were at home). The final baby we delivered at home totally on our own. It was great to be able to say, “it’s ok, we can do this - it’s totally natural”

Sure, it's totally natural. What is also totally natural is things going seriously wrong during childbirth, with disastrous consequences for the mother and/or child. Historically, a huge number of women and children died during childbirth, or lived in pretty terrible suffering afterwards (see here for an example: https://www.theguardian.com/global-development/2014/may/07/n...). Obviously those conditions are exacerbated by primitive living conditions, but that's been the "natural" way pretty much everywhere until very recently in human history. Even here, my wife's gynaecologist said that roughly a third of all women suffer some degree of prolapse from vaginal delivery, and that rate goes up steeply with more children. Our experience confirms that - it's not something that people talk about because the side effects are embarrassing (urinary and faecal incontinence, problems with sex etc), and socially in a lot of the western world it's somewhat frowned upon to discuss anything that's negative about having kids. We received no information about the risk of prolapse during our ante-natal care, including the standard "you're going to have a baby" book they give to everyone here. But my wife refused to participate in the cone of silence and openly discussed it with people, and a lot of women we know personally have prolapses of varying degrees.

Here's a quote from the article I linked:

The differences she and Sarfati found were not small; across the five-year study of more than 244,000 babies, they found those in doctor-led care had lower chances of poor birth outcomes.

This included 55 per cent less chance of oxygen deprivation during delivery, 39 per cent lower odds of neonatal encephalopathy, and 48 per cent less chance of a low Apgar score, a measure of a baby's wellbeing after delivery.

Those are really serious consequences for the kid. We have a friend of a friend here whose daughter suffered oxygen deprivation during birth. She's 4, still doesn't talk, can't walk properly and is generally seriously mentally impaired. It is incredibly distressing for the parents. You mentioned that your friends in doctor-led care had more complicated births, but what would have happened if they didn't have that care? In our ante-natal group of 12 families, in the end 6 of them ended up with c-sections due to delivery difficulties, and none of them regret it in the slightest because at the end of the day their kids are ok.

We initially tried to have a home birth, and when things weren't working we were taken to hospital. Our hospital is literally 5 minutes drive from where we lived, but it took in total 45 minutes from deciding she should go to actually being in a hospital bed. I'm here to tell you that 45 minutes is a really long time when your wife is screaming in pain. I wouldn't recommend a home birth to anyone. I'm really glad it worked out well for you (seriously, I think it's awesome that it all went well), but there is a large degree of luck involved in that. I just don't think the risk is worth it when the potential downside is so huge.

In terms of sources, I don't have any to hand, and in general it's really hard to find good data because they inevitably end up comparing very different things in different circumstances. There was a big article in a national magazine here a while back trying to analyse the data they could find, and broadly speaking they found the risks of a birth requiring some sort of non-emergency intervention and a standard vaginal delivery were different but broadly comparable. e.g. vaginal delivery has a much higher risk of prolapse, but c-sections have a much higher risk of endometriosis. Generally speaking planned (either elective or pre-programmed due to birth risk) c-sections are very safe these days, but emergency ones are much riskier. But that might be because by definition they're used when things are already going really bad. As women get older the risks of vaginal delivery go up considerably, and for women pushing 35-40 the recommendation seems to be to seriously consider an elective c-section if that option is available to you.

Edit: found the article: https://www.noted.co.nz/health/health/trial-of-labour-is-a-c...

Maybe. I’m not sure I believe that. Recall that a greater proportion of births are now coming from poorer people in worse conditions and often worse health to begin with. If you are middle class+, You’re probably at top tier rates competitive with the rest of the world.

Mortality rates are often twice as high for non whites in America likely due to wealth effects.

https://www.kff.org/other/state-indicator/infant-mortality-r...

> It's a matter of fairness. Riskier jobs should have higher salaries.

Interesting argument which I doubt anyone here agrees with. After all, that would mean builders, miners, street sweepers and the like would be paid the highest, midwives somewhere in the middle and us right at the bottom.

Absolutely, especially artists should pay their employers for the exposure they get.

I dont see it as her claiming that riskier jobs always should be paid more than safer jobs. Only that the risk factor should have a larger impact on the salary.

Not only by risk, but by something like risk*skill, definitely.

I'm not sure why street sweepers would be risky. But the rest, sure. Miners are already paid quite a lot in many places.

The very word "should" implies that there should be some one valid opinion or source of truth on that matter. I'd rather take decentralized market-based approach where the prices of it is decided by all the small decisions of a lot of ordinary people rather than try and debate it in attempt to come to some agreement with anyone.

"Risky" is underdefined:

- who takes the risk? (employer vs employee vs employer's clients vs state vs insurance)

- how transitive is the risk? (is A on the hook for B's risk as well?)

Only two dimensions but it's already a mess to think it through.

Not sure who 'us' is; HN readership is pretty diverse. I'm a scientist and earn roughly the same as a midwife in Australia.

Having said that, my first child nearly died during birth, and having a very good midwife who knew the signs, made all the right decisions, got the emergency doctors in at the right time - that service was utterly invaluable.

I'm all for the average midwife being paid somewhat more than me if it leads to more of these outcomes.

Maybe the term "riskier job" should include the risks to everyone involved.

In which case water treatment employees would be extremely well paid.

The money goes primarily to the engineers who put in place the systems, and to the designers of those systems and the companies that built the pieces of it. The day to day work, whether in the control room or on the tools, itself should be relatively simple, and it should (in theory) be difficult to stuff things up if the system is designed well.

Struggling to see the equivalence here.

Midwifes have to make the correct decisions in a stressful situation in an extremely tight time period (seconds to minutes when it's the business end of things, so to speak), with limited information (no heartbeat readings at the end, can't see what's happening, just feel). Mother is screaming at the top of her lungs, partner has no idea what's going on (presuming not same sex). I seriously can't think of any job where the pressure is so intense for every single day of work, without exception. Maybe in triage, but that'd be about it.

A water treatment worker checks that various readings are within limits, and makes adjustments according to a set of standard operating procedures (presuming here, to be fair). I'd also presume there'd be a good number of check points during the journey of dam water to the final product in the pipes. There's no redundancy with midwifery that I can see.

The jobs are clearly very different but what we are discussing is doing direct compensation for the risk that third-party people are exposed to in the case of a failure. The theory is that by giving the operator higher pay you reduce the risk to third-parties, in which case water treatment failure is one of the top risks that can effect a very high number of people. A midwife that makes a erroneous decision kills one or two people, a erroneous decision in the water system of a city can kill and serious harm thousands if not hundreds of thousands. Similar is true for nuclear plants but those tend to be already well compensated.

If we ignore the risk aspect to third-party which parent and grand parent comment brought up, and instead focus on pressure, I can think of a few ones which might be worse than midwife and with lower pay. Highway road workers would be one. Having trucks going by in almost highway speed just meters next to you while you are focusing on the work is the kind of hell on earth that I would not want to expose myself to, and it doesn't even pay well.

Other high pressure jobs on the top of my head would be rescue swimmer, as the profession require careful psychoanalytical pressure testing to enter the training program. It also takes a special kind of person to work as a explosive chemist or at the bomb squad. I would also mention the military as an natural example of high pressure job. Each three has widely different degree of compensation compared to each other and even within the professions itself, and compared to midwifery it is all over the place.

There is no clean formula for X(Pressure) * Y(Third-party risk) = Z(Pay), and implementing one would change the compensation for a wast number of professions. I strongly doubt that midwifery would be the one that would see the biggest effect, but I would love to see a study exploring it.

Risks to other people is also known as responsibility and that should also be accounted for. But sometimes there is an imbalance. You can be putting others at risk but not be properly considered responsible. I think there is a lot of that in software, particularly when people's privacy/data is at risk.

Personal risk is a bit different because everyone has a choice about what is acceptable for them. Risk to others should not be your choice. The responsibility should be fixed and defined and therefore it's probably easier to make logical arguments about compensation rates.

If one extends this to indirect risk (i.e. financial risk to everyone involved), the paradigm gets closer to the current one: those whose jobs involve significant financial risk to themselves (investors/owners) or others (executives, managers, and -- to a lesser extent -- "talent", via the risk of shareholders losing their investment and/or employees losing their jobs/livelihoods) are paid comparably to the size of the hammer they swing with respect to risk.

> Not sure who 'us' is; HN readership is pretty diverse

Do you really believe that? 99% of us work in offices. You're in a bit of a bubble. Try going to a working man's club or the equivalent in your country to get a glimpse of the rest of society.

>Do you really believe that? 99% of us work in offices. You're in a bit of a bubble. Try going to a working man's club

I've worked as bar staff in one. Talking about a tribal bubbles, that place was insane. I have also worked in offices, factories and fields. Currently doing geeky stuff with nightclubs for a pittance and massively preferring it when compared to some of the vastly more high paid work I have done.

There is groupthink on here, but I would say that HN perhaps isn't as cookie-cutter as you may suppose.

What's your point? I didn't say anything about what HN is, I just said that it is in no way a "diverse" group of people. Honestly can't see how anyone could think this is diverse.

>I didn't say anything about what HN is, I just said that it is in no way a "diverse" group of people.

Huh?

Please stop before wading so far out into the weeds.

> Be kind. Don't be snarky. Comments should get more thoughtful and substantive, not less, as a topic gets more divisive.

https://news.ycombinator.com/newsguidelines.html

Even if you concede that point we're left with the question of why midwifery is especially risky in Ethiopia. Do they not have access to basis safety equipment?

Paying a government-funded profession based on risk creates perverse incentives. You'd have midwives campaigning against introducing surgical gloves because they've got a family to feed and don't want to lose the risk pay.

> Paying a government-funded profession based on risk creates perverse incentives

This is horrendous and depressingly, probably true. It's important to see the incentive structure from both sides and to try and consider the unintended consequences of seemly good actions.

That doesn't detract from the position that midwives probably deserve higher pay. Tragically, the system we live in is that those that help increase capital get more pay, while those that actually do the meaningful foundational work (help bringing people to life, saving lives, teaching, all the things required to actually have a workforce that can generate capital) don't get paid enough.

Train drivers tend to be paid very highly, and I've heard the reason for that is a kind of risk. If something goes wrong (which it really can do catastrophically) then they shoulder the risk.

To look at it from the other side, don't apologists for capital say that the boss should collect profit (and in perpetuity too) because of the "risk" she took to start the company?

I don't think train drivers earns high pay because of risk, but rather it takes a long time to properly train train drivers (especially freight trains), there is scarcity of skill, and the potential damages of a train crash warrants paying more for better skilled drivers to minimize the chance. The risk the driver takes on doesn't really get factored in.

Edit spelling.

Train drivers have sometimes very short careers and can’t work anymore: https://m.spiegel.de/international/zeitgeist/rail-suicide-a-...

> Interesting argument which I doubt anyone here agrees with.

Quite the contrary, I think everybody agrees that risk is one important factor in salary expectations.

But workforce availability is another important factor!

If more people are available to work on scaffoldings rather than in a cosy office, well, scaffoldings will pay less!

And yes, I do understand that working in a office usually requires some training that not eveybody has the priviledge to afford: I'm just stating the facts, but I don't want to imply that this situation is fair.

I get that you're tackling this specific argument, but it's important to remember the context too.

She makes between $56 and $85 dollars a month. Working 12 months a year, for 50 years, she'll make a total of around $42,000 dollars. It's hard to argue that is remotely fair.

Back when I worked in an office, I saw more than one coworker get carted off (heart attack) from sitting at a desk all day. These days I move around a lot and I regularly have to put on a harness for working at height, and I've never seen or heard of anyone actually falling into their pro, much less getting hurt from a fall. Heart disease is still the #1 killer in America, by a fair margin, and has been for many decades. Is my new job "riskier"?

I'm not sure I agree or disagree with the statement, but only because I'm no longer convinced that capitalism is a viable system for allocating resources. In fact, I think this is a great argument against it. Dangerous jobs often do pay more, so people who need money will take these jobs -- even though the people who are desperate for a good paycheck are also often the least able to deal with the consequences of this risk. Financial desperation makes people ignore the long term, and people simply aren't good at understanding very-low-probability events. Dangerous jobs mean people will get hurt, which further limits their earning potential, and limits economic mobility. It's a terrible feedback loop.

But then, salaries have never made much sense to me. I'm not able to look at two friends and say "Yeah, X makes 10 times as much money as Y, and deserves it". Most of the people I know doing the most worthwhile things for society are also those earning the least money.

Wow, 50/50 distribution between male/female on new midwifes, not exactly like the IT world in the west...

You make a tedious point that's not worth addressing, but it's important to point out that even in Midwiferey men get promoted faster than women, and get promoted higher than women.

In England in September 2016 in band 5 there were 2301 women midwives and 11 men midwives. At band 8c there are 11 women midwives and 2 male midwives.

That ratio at band 5 isn't maintained as you move up the bandings - as you increase money and management responsibility. We see more men and fewer women, despite the very much larger pool of women to chose from.

Men in your case is 2 people, you can’t really use sample size to compare.

To be honest you’d have to be incredible to succeed as a male midwife as almost all expectant mothers will prefer a female midwife.

Hi Mr. "goes woof",

1. Yes, you can. His comparison works.

2. No, they usually don't have a choice.

In most countries you can ask for a different doctor/nurse/midwife.

"[study published] in the Proceedings of the National Academy of Sciences, women are no longer at a disadvantage when applying for tenure-track positions in university science departments. In fact, the bias has now flipped: Female candidates are now twice as likely to be chosen as equally qualified men."

And what do people usually reply? There is so few women in university science departments that the quality of women that manage to survive in such discriminate environment is higher than among men.

So lets copy paste the same for midwifery. The reason men get promoted faster is because the quality of men that manage to survive in such discriminate environment is higher than among women.

I will add that midwifery do stand out in gender segregation data. Using Swedish data it is the single worst segregated profession with around 99.7% and in higher education it was the only program last year where every single student (100%) was of the same gender. People who care about combating gender segregation do a great disservice in ignoring the worst offender.

Are you also opposed to efforts to get more female developers?

Depends on the region.

Some areas, specially consultancy agencies, do have a better M/F distribution than coding silos.

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