Your Childbirth Models of Care Options

There are two approaches to maternity care: The medical model of care and the physiological model of care, also known as the midwifery model of care. Knowing the different maternity care models and which your provider practices can help you know what to expect during your pregnancy and birth and what your options are within that care model.

The Medical Model of Care

"Pregnancy in western society, in fact, straddles the boundary between illness and health" - Comaroff 1977: 116

The medical model of care (also known as the technocratic model of care or medical management) is a specific approach to maternity care that both doctors and midwives can subscribe to. If your care provider states that they follow the medical model of care, it's important to know what exactly that means.

"Medical management practitioners start from the premise that pregnancy and birth are intrinsically difficult and potentially dangerous process that, when left to occur naturally, frequently result in poor outcomes." - Optimal Care in Childbirth by Henci Goer

For care providers that practice the medical model of care pregnancy is a condition that depends upon treatment for a positive outcome. Interventions are necessary and superior to the natural/normal birth process.

Some key characteristics of the medical model of care:

• Provider centered
• Birth normal in retrospect
• Female reproductive system dysfunctional
• Mind and body are separate
• Birth is a mechanical process
• Intervention dependent
• Routine care
• Safety of baby pitted against mother's emotional needs
• Adherence to labor time charts
• Objective: Live mother and baby in reasonably good condition at discharge.

The basic premise is that birth is a mechanical process that depends only on "the powers, passage, and passenger" or the strength of contractions, the size of the pelvis, and the size of the baby. No other factors are considered such as the emotional state of the mother, her laboring position, or whether routine interventions are interfering with the labor process.

The theory presents that any problem in labor is mechanical and the provider as the mechanic can correct the situation with a procedure or medication. All unwanted effects of interventions are treated with more interventions:

"...when high-dose oxytocin infusion leads to nonreassuring fetal heart rate, the medical management model calls for IV fluid boluses, internal fetal monitoring, and, ultimately, cesarean surgery." Optimal Care in Childbirth by Henci Goer

This is opposed to lowering the oxytocin dose or avoiding its use in the first place.

It is important to emphasize that there is not much space for wiggle room in the medical model. Many providers do try to accommodate women's wishes, but it is a system that is not easily adjusted. For example, a woman who wants the freedom of movement in labor and then chooses a birth place where continuous monitoring is the norm may be thinking, "well, how hard is it to just not hook me up to a monitor?" Very. That monitor is apart of their staff. It reports to the nurses station so that one nurse can be assigned to several mothers. That nurse may not be able to effectively do her job without the monitor. Also, your care provider may be able to access the monitor readings from home or the office, which is a convenience that would be hard to give up. The monitor is also essential to the provider who believes birth is a runaway train ready to fly off the tracks at any moment. Without the monitor, how can a woman labor safely? Those taught under this theory literally may know of no other option. The monitor also reinforces the belief that the baby is a separate patient from the mother needing protection should the mother pursue her desire for a birth experience over the safety of her baby. Refusing an intervention in the medical model of care is not like asking for your burger with no pickles, it's a complicated system and an entire birth philosophy held dearly by its followers.

The medical model calls for less time spent assessing the mother as an individual, making this approach convenient for providers. Most routine tests will pick up possible problems in the pregnancy, but at the cost of providing individualized preventative care.

For example, instead of looking at a mother's risk factors, family history, and talking to her about nutrition and exercise in early pregnancy, a provider will routinely screen all women for gestational diabetes late late in pregnancy and then treat the women who develop the condition. Treatment may be hard on mom and prevention may have yielded better outcomes, but individualized care is unrealistic in busy practices that see lots of moms.

If you are very comfortable with your care provider making decisions for you and you don't mind medical procedures being done even if they may not be necessary, then choosing a provider that follows the medical model will likely not conflict with your personal feelings about birth. If you would like to be apart of making decisions about your care, would prefer a low intervention birth, or believe that pregnancy and birth are a normal part of a woman's life, you will encounter more conflict in this model of care.

The Physiological Model of Care

“Remember this, for it is as true as true gets: Your body is not a lemon. You are not a machine. The Creator is not a careless mechanic. Human female bodies have the same potential to give birth well as aardvarks, lions, rhinoceri, elephants, moose, and water buffalo.” - Ina May Gaskin, Ina May's Guide to Childbirth

The physiological model of care is more commonly referred to as the midwifery model of care, and sometimes woman-centered care. Physiological refers to a characteristic of an organism's healthy or normal functioning (Merriam-Webster Online). The belief held by followers of the physiological model of care is that birth is fundamentally healthy and normal and birth is safest when practices facilitate normal birth. The physiological model of care is a holistic approach that addresses a woman's physical, psychological and social well-being:

"The midwifery model of care makes the woman and her life the central focus of prenatal care. A large part of the midwife’s attention focuses on the pregnant woman as a unique person, in the context of her family and her life. The midwife is interested in the woman’s expectations and experience of her pregnancy—her perceptions and beliefs; her knowledge and opinions; her questions and worries; her satisfactions and dissatisfactions; her comforts and discomforts; her desires, decisions, and actions; and the effect of all these on her pregnancy, fetus, labor, delivery, breastfeeding, postpartum recovery, and development as a mother." - Our Bodies Ourselves

Some key characteristics of the physiological model of care:

• Woman centered
• Birth is a normal life event
• Female reproductive system healthy
• Birth is holistic
• Observation dependent
• Individualized care
• Safety of baby and mother's emotional needs not mutually exclusive
• Mother and baby are an inextricable unit
• Time charts irrelevant
• Objective: Live, healthy mother and baby, positive birth experience.

Women who transfer from a provider practicing the medical model of care to one practicing the physiological model of care are often shocked by the differences. Appointments are longer and much more in depth. The provider following the physiological model of care will usually ask the mother what her wishes are in birth as apposed to a women having to ask if a provider will "let her" fulfill whatever her wishes are. Women are an active participant in their prenatal care.

The physiological model of care supports autonomy between the provider and mother. In the medical model of care supports class distinctions where the provider holds I higher class standing than the patient. The physiological model of care recognizes that the couple is able to take responsibility for their birth and take part in the decisions that will affect it. Couples are often encouraged to research and care options are thoroughly explained. The woman is not caught in a system where the provider/institution may be biased towards a higher intervention birth which would yield more income for the provider/institution.

Holding the perspective that birth is normal does not mean fewer precautions are taken in ensuring a healthy and happy mother and baby. While tests and procedures are not used indiscriminately, all of the tools (like doppler to listen to baby's heart beat, checking blood pressure, ordering blood tests and ultrasounds) employed by those practicing the medical model of care are still used in prenatal visits, but care is taken to ensure all tests are appropriate.

The physiological model of care is most often adopted by midwives. While doctors are trained in seeking out complications and intervening in labor, with little or no training in normal birth, midwives receive extensive training in how to facilitate normal birth in addition to being able to identify complications so that mothers who need an obstetrician can receive that care.

Middle Ground Model of Care

Yes I made that up.

Is there a place in maternity care for two models that appear to be so different?

A 1999 study distributed a questionnaire to pregnant women regarding their provider style preferences. It found that women preferred elements of both midwifery and medical styles of care." Concluding that:

"Broadening access to obstetric care will involve moving from our own preconceived notions of appropriate packaging into a patient-based and multi-option setting for delivery of these services."

As women become more informed about our options and the differences between the medical model and physiological model of care many may switch from providers and hospitals that only offer the medical model for providers. This is a positive change for women, and hopefully a wake-up call to those individuals and institutions not practicing woman-centered, evidence-based care. However, hope is not lost for medicine!

With cooperation from those who practice the medical model but want to give women options, there is room for both models in maternity care:

"Midwifery and medical obstetrics are separate but complementary professions with different philosophies and overlapping but distinct purposes and bodies of knowledge. Physicians are experts in pathology and should have primary responsibility for the care of pregnant women who have recognized diseases or serious complications. Midwives are experts in normal pregnancy and in meeting the other needs of pregnant women— the needs that are not related to pathology. In most countries, midwives have primary responsibility for the care of women with uncomplicated pregnancies."  - Our Bodies Ourselves

In most of the rest of the developed world in countries like the United Kingdom, Australia, and Japan, low risk women see midwives while women who are determined to need an obstetrician transfer care to one. The result? These countries have much lower rates of maternal and infant deaths... in fact, we are rated 47th. It is safer to give birth in Singapore (3 deaths per 1000 births), Iceland (5/1000), and Qatar (7/1000) than it is to birth here (21/1000). Medicine plays an essential and irreplaceable role in our society, but the medical management model of care alone is an unbalanced system leaving few options for low risk women who hope to have an uncomplicated, normal birth.

As an expecting couple you are the consumers. You have a choice in what kind of care you receive. More than just your birth experience rides on that decision.