Obstetrics Or Midwifery, Gynecology Or Well Woman Care

October 31, 2011

Whenever I think about women's health delivery I am struck with apparent confusion of roles that currently exists among the various providers. To understand this problem a review of the dramatic events in women's health in the 20th century is necessary.

Whenever I think about women's health delivery I am struck with apparent confusion of roles that currently exists among the various providers. To understand this problem a review of the dramatic events in women's health in the 20th century is necessary.


In 1900 the life expectancy of women 40-45 and the leading cause of death was childbirth. Cancer of the cervix was the commonest cancer in women. Today both of these entities are infrequent causes of mortality for American women. In fact, maternal mortality and cervix cancer do not even make the top ten causes of death. Life expectancy for women is now well into the 80's. The events that have contributed to these advances have resulted in the evolution of two sets of very different providers, physicians and midlevel practitioners.

Through most of the 20th century every effort has been made to move childbirth from the home into the hospital. With this change came the development of the specialty of obstetrics and gynecology. Until recently, this specialty was considered a consultative specialty, i.e. one that provided consultation and treatment for complex problems. As the specialty evolved, it came to dominate the area of reproductive health to the exclusion of all other practitioners. Residency programs in OB/GYN proliferated. By the 1970's, some began to raise concern that too many specialists were being trained. As a consequence of the large number of OB/GYN's it was increasingly difficult for the average practitioner to maintain competency in the management of the more complex problems for which the specialty had been created in the first place. In a move of monumental nearsighted shoot-yourself-in-the-foot-ism, the leadership chose not to curtail the growth of the specialty, a move that would have also shorn up the eroding quality of the specialty. Nooo! They chose to continue to train even more and address the problem of quality by creating a network of subspecialists who would be capable of doing the very things that the original specialist in obstetrics and gynecology had been created to do. So now what is referred to as the "general obstetrician gynecologist" performs routine screening exams of large numbers of mostly healthy women and provides prenatal care and delivery for, you guessed it, mostly normal pregnant women.

Midwifery and home birth were very common at the turn of the century; but, by the 1960's, it was fast becoming an anachronism. Women and their families, once the issues of survival of pregnancy and the labor process had become largely resolved, began to reexamine the birthing process as it was being conducted in hospitals by doctors and began to yearn for the more prosaic experience of traditional midwife managed home birth (how fickle of them!). Midwifery experienced a dramatic resurgence that was accompanied by a proliferation of other midlevel practitioners, nurse practitioners and physicians assistants. The stated mission of this non-physician group is to provide screening and primary reproductive health services for normal women both in and out side of pregnancy.

In this environment it is possible to define prenatal care and delivery of the normal pregnant woman as midwifery. And the routine examination and treatment of non-complex health problems as well woman care. But because we have an overabundance of OB/gyn's who are increasingly unable to take care of the complex problems for which they were originally trained they are reduced to practicing midwifery and well woman care. Of course this means they, the physicians, must compete with the midwives, nurse practitioners and physicians assistants for the same patient group. To add to this tragic comedy, the competition for patients and income has destroyed the possibility for any significant cooperation between these competing specialties. Thus ludicrous situations develop where midwives delay consultation of referral of high-risk pregnancy problems or demand reimbursement at the same rate as obstetricians. On the other side is the often pathetic public relations campaign waged by physicians against midlevel practitioners stating the "what if " concern. "What if you had a problem? Would the non-physician provider recognize it in time?" " What if the sky would fall…?" Mostly, I am embarrassed by these emotional assertions. I do believe that we as physicians have a unique service to offer but we don't need to invent reasons for our importance to society.

References:

Dr. Hutchin's office phone number is 610.667.4577 and his toll free number for book orders is 877-FIBROID