Over the centuries, midwives have worked hard to promote and maintain the normalcy of childbirth. With the advent of new specialists—the obstetricians—and the discovery of asepsis, childbirth was removed from the home to hospitals, and obstetric care changed dramatically.
Midwives continued to work with nurses and childbirth educators to reintroduce the concept of “natural childbirth,” and eventually it became a medically acceptable alternative. Then we began to include other natural options: delivery without shaving, enema, or intravenous, bed deliveries, and other deliveries without all the paraphernalia that medical science devised to fight “germs” and maternal infection.
By the 1960s many women had normal “natural” births. In the 1970s birthing centers began to flourish. Normalcy once again seemed to prevail. Now, once again, modern technology has changed the outlook for midwifery care.
In the 1980s, we are screening every patient for almost every disease; and new ones keep cropping up. We screen for diabetes, tuberculosis, and hepatitis, for herpes, chlamydia, gonorrhea, and syphilis. We check rubella status and offer alpha feta protein testing, sonars, and amniocenteses. We know how to deal with these diseases—and their presence or absence does not significantly alter the care we give or our relationship with our clients. Nurse-midwives are known as caring professionals who put the patients' needs first.
Now we are living in the AIDS generation. The American public is terrified of the disease. Screening for AIDS is becoming more readily available. This raises many ethical concerns. Should we offer it to all our clients? Should testing be mandatory for all pregnant women? What about those attending family-planning or venereal disease clinics?
And what will we do with the test results? Should we record the test results in the chart for all to see? How will these patients be treated if every doctor, nurse, or lab technician knows they are HIV positive?
An argument is raging at the institution where I work. Most of the staff feel that they have a right to know about positive cases so they can take extra precautions. The doctor in charge has declared, “You should take extra precautions with every patient. The ones you don't know about are just as infectious.” He's concerned about the patients' rights—including their right to good and humane care. We will soon be offering AIDS screening to all our patients, but we must still decide what to do with the results. In the mean-time, both diagnosed and undiagnosed patients attend our clinics.
How will this knowledge affect the care we give? Many of us work with inner-city patients, among whom drug use is high. Others feel safer, working in areas where intravenous drug abuse is low, and homosexuality is invisible.
I have heard rumors of certified nurse-midwives and doctors who refuse to deliver a patient in an emergency unless they have gloves on. We now are urged to wear extra heavy gowns, double gloves, masks, and goggles when performing a delivery or assisting at surgery. How can a woman feel that birth is a normal event when her midwife is dressed for outer space?
I cannot count the number of times I have been soaked with amniotic fluid, delivered a “precip” barehanded, gotten holes in my gloves, or blood splashed on my leg. How can I protect myself? And how much do I really have to worry? If the risk of AIDS infection is significantly lower than the risk of catching hepatitis, then perhaps some of us are overreacting.
We must all think about this issue realistically and base our decisions on medical facts, not on sensationalist news reports. As medical professionals, we have an obligation to our clients to provide accurate information, sound advice, and safe care. We cannot continue to prescribe oral contraceptives to single women without explaining the use of condoms to prevent the spread of AIDS.
Nurse-midwives must become knowledgeable about this new disease. We cannot support any refusal to care for certain patients or the use of inappropriate technology or precautions. Neither can we deny our heritage and philosophy based on the belief that normal healthy women should deliver their babies in a simple fashion. The importance of a woman feeling comfortable and unafraid at the time of birth will remain unchanged.
Nurse-midwives should support the widespread offering of AIDS testing, especially for women in high risk groups, because we have always supported the availability of informed choices for women. We should support the use of condoms because that is a wise health decision. And we should use appropriate protection for ourselves when dealing with high risk clients because we have always supported the use of new technology when medically indicated.
Birth for low risk women will then be able to retain its normalcy, and midwifery care will remain unchanged.