Several years ago, the distinguished Dutch obstetrician-gynecologist, Professor Gerrit-Jan Kloosterman was invited to London to give a lecture to an international association of obstetricians and gynecologists. Kloosterman, Chair of Obstetrics at the University of Amsterdam, was well respected and well known for his support of the maternity care system in the Netherlands, a system that relies heavily on midwifeassisted births at home. He was in the middle of his lecture—an analysis of the Dutch system that showed the continued use of midwife-attended home birth posed no danger to mothers and babies—when a strange thing happened. While he was talking, several members of the audience got up and left the room, noisily, in an obvious display of displeasure with his presentation.
After he finished the lecture, Kloosterman and the president of the association discussed the small “protest.” They asked themselves, “Why doesn’t this happen in other specialties?”They agreed it would be unheard of for physicians to walk out in the middle of a lecture about cardiology, even if they thought the data were suspect. Protocol in the science of medicine dictates that disagreements about data are hashed out in collegial exchanges: One does not “protest” against data; one challenges the data on the basis of methodology or analytic technique. Kloosterman and the president concluded that obstetrics does not really belong in the field of medicine. Perhaps, they conjectured, obstetrics is better located in the field of physiology. After all, it is the only discipline in medicine where something happens by itself, and, in most cases, with no intervention, everything ends well. Thinking about this incident, Kloosterman concluded: “Obstetrics is wider and broader than pure medicine. It has to do with the whole of life, the way you look at life, making objective discussion difficult. You are almost unable to split the problem off into pure science; always your outlook on life is involved.” 1
Kloosterman has it right. One need not look too far into the world of maternity care to find the wide gap between scientific evidence and clinical practice. For example, consider this: In May 1998 the U.S. National Center for Health Statistics released a report on the comparative infant mortality rates for midwives and physicians in the United States (NCHS, 1998). The study included all single vaginal births in the United States in 1991