This question came in to my blog in response to my archived post on the use of Castor Oil. Since it is a subject I seem to deal with daily, I’ve answered it where everyone can join in the discussion. Gloria

QUESTION

Hi Gloria! I am a student midwife, and in my state, women must be transferred to an OB if they have not given birth by 42 weeks. The local midwives (my preceptors) use castor oil as a last resort induction method. They don’t like doing it, from what they tell me, but they feel that, if after nothing else works (walking, sex, black and blue cohosh), it would be better to try castor oil and breaking the woman’s water, than to have a perfectly healthy woman transferred to the hospital.

What is your opinion on this? If you were faced with a similar situation (I should mention that midwifery licensing is strict in Florida, and midwives may lose their license if they do not follow the “rules”), what would you recommend? I do not plan on practicing here in Florida when I graduate from midwifery school, but I’d like to pass along some information to the midwives that I work with. Florida Student

RESPONSE

I am faced with a similar situation in my province. We have registered, government paid midwives who have to play nice with the doctors in order to have hospital privileges, a government salary, and publicly funded malpractise insurance. They have the same complaint “We hate to induce naturally but it’s better than what they are going to get in hospital. . . .” We also have the same mess here in B.C. as the rest of North America. Those membrane stripping, castor oil, acupuncture, herbal inductions don’t work because the woman isn’t ready to have the baby and, then, she gets on the prostaglandin/pitocin intervention-cascade train and the midwife feels so bad. . . but, hey, what could she do?

Canadian midwife with client

Every day, I thank my lucky stars that they used me as an example to the government of what a “renegade” midwife was. Midwives in my province could only become a professional body if they proved there was a “danger to the public” by NOT having a profession. I got to be the designated “danger” because I had proven for years that I would not lie down with the doctors and side with them against my clients. Obviously, the midwives organization would never have given me a license, even if I applied, so I didn’t have to bother applying. A few of my friends did and they were bankrupted and humiliated by the “professional” body. As soon as the government registrations were issued, we saw these inductions start. So many women in my community have been fooled by this cruel trick.

When the local midwives first obtained registration, there was a lot of righteous conversation about “evidence based” midwifery. The large multi centre trial about 41 week inductions conducted by Mary Hannah of Toronto (1) was pointed to by midwives to frighten women into being induced at 41 weeks. We had never seen this in our province prior to regulation. We had twenty years of experience as lay midwives with many post dates women and had not seen any problems but that experience was set aside in favour of the “evidence base”. Even though the midwifery empirical knowledge did not support Ms Hannah’s conclusions and even though the midwives were extremely conflicted and frustrated by the results of their labour inductions, they still obeyed the medical “evidence”. Then, the “evidence” was shown to be without merit. In 2002, Hall and Menticoglou published a paper in the British Journal of Obstetrics and Gynecology proving that Hannah’s study was wrong (2). Has that meant that midwives in my province are now encouraging women to relax up to and past 42 weeks gestation? Oh no, because now the doctors have kept on with their aggressive policies of inducing everyone at 41 weeks and, evidence- be- damned, they’ll make the midwives do the same thing. Science is trumped by community “standard of care” which basically means “we’ll all follow like sheep and hope the wolf doesn’t catch us”. Now, I don’t hear too much rhetoric about “evidence based practice” among local midwives. There is still a lot of lamenting about “how bad they feel” but the inductions continue unabated. Of course, the midwives don’t feel even 1/100th as bad as the woman who has had major abdominal surgery thanks to their aggressive policies.

I’ll post a link here to the B.C. Government Vital Statistics chart (click on Item 11) which shows that, prior to regulating midwives in 1998, there was an up and down pattern to cesarean rates and the rates remained below 25%. For the last reported year (2011) the rate was over 30%. This means that, since midwifery regulated on January 1, 1998 the cesarean rate has risen and the pattern has been a steadily upward climb. The cesarean rate is the score card of what is happening in obstetrics in any given jurisdiction. We’re obviously not doing so well here in B.C. When the registered midwives were soliciting the government for a professional designation, one of the cornerstones of their bid was that they would save the government money by preventing cesareans.

Cesarean Rates in British Columbia Before and After Midwifery Regulation

So, in answer to your questions: a)What is your opinion on this? I think it is disgusting that midwives are so cowardly and turn perfectly healthy pregnant women into wounded mothers. And (2) If you were faced with a similar situation (I should mention that midwifery licensing is strict in Florida, and midwives may lose their license if they do not follow the “rules”), what would you recommend? I will not be faced with a similar situation because I would not join an organization where I was made to go against my conscience, my common sense and my promise to my clients. If I was in such an organization and realized that I could not do my work with integrity, I would not be complaining about these ridiculous “protocols” I’d be changing them or resigning in protest.

(1) Hannah ME et al. Postterm pregnancy: putting the merits of a policy of induction of labor into perspective. Birth 1996;23(1):13-9.
(2) Menticoglou SM and Hall PF. Routine induction of labour at 41 weeks gestation:
nonsensus consensus. BJOG 2002;109:485-91.

related post: Castor Oil Inductions
This post was updated on Sept 5, 2014 to reflect B.C. Vital Statistics to 2011
Updated Dec 30, 2014 to include link to “Nonsensus Consensus”