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Essential Qualities of Maternity Care
Faith Gibson, LM, CPM
August 31, 2010
Overview, Background & Goals
Part I: The Optimal Purpose of Maternity Care
Safety & the Maternity-Care Continuum in an
Part III: Developing "Standard Characteristics" for OOH Studies
Part IV: Conclusions
Overview, Background & Goals
Whatever one’s individual opinion about the nature of childbirth, professionals and consumers both agree that the current maternity care system in the US is far from ideal -- we spend too much and get too little. We keep being brought back to the fundamental question of why – what are the forces that have shaped the century-long development of our highly medicalized system of obstetrical care for healthy women?
Eldest grandson 01-06-1994
What are the essential qualities of a maternity care system designed to provide cost-effective care to healthy women with normal pregnancies? How do we identify the characteristics of success when it comes to safety? What professions, places and policies make for the best maternal-infant outcomes? When it comes to the 70% of American women who are healthy and have normal pregnancies, there is the question of whether governments, other 3rd party payers and those who must pay out-of-pocket are getting an appropriate ‘bang for their buck’. Is the current configuration of medical and midwifery care making the kind of cost-effective contribution that economists refer to as ‘value added’?
Relative to the price paid, 'value-added' describes the positive contributions of a service that is suppose to make something "better" that it would be without that particular set of services. To identify that quality in maternity care, we must first be able to determine the innate risky-ness of normal childbearing and then track the same outcome criteria for all categories of birth attendants and all birth settings. As a result, the relative benefits of each category of maternity care can be directly quantified without falling back on place-of-birth as a proxy for anything else. This is the most direct way to establish the manner and magnitude of medicine and midwifery's ability improve maternal-infant outcomes in a safe and cost-effective fashion.
The passage of health insurance reform legislation in the US makes it even more crucial to determine if what we are doing – the theories, policies and practices developed early in the 20th century – is the best configuration for maternity care in the 21st century.
Minding the Gap: In an effort to address those questions, this commentary takes a fresh look at our aging 20th century maternity care system and the 21st century debate about its reform. At the heart of this controversy are two pivotal issues: 'place-of-birth' as proxy for the efficacy of intrapartum management and the lack of ‘standard care’ characteristics among birth attendants and birth settings.
Our current configuration of childbirth services is a smorgasbord of non-standard care characteristics as provided by midwives, family practice physicians and obstetricians in a variety of small, medium and large hospitals and in OOH settings that include independent birth centers and planned home birth (PHB). When combined with the economic and political complexities of modern healthcare, this unsystematic system creates a large gap between what is known about ‘best practices’ and what is consistently being provided to childbearing women and paid for by us all.
Of these two issues, the controversy over place-of-birth has made the most mischief and continues to direct our attention to a set of questions that, as currently formulated, cannot be answered. A hundred years after this brouhaha started, it continues to distract us from the questions about childbirth safety that can be answered.
Evaluating ‘quality of care’ & ‘standard’ vs. ‘non-standard’ care characteristics of practitioners & facilities:
An abundant source of data is already available, including studies provided in this commentary. This type of information can and should be used to rationally evaluate quality of care issues and standard care characteristics by distinguishing effective forms of care from customary practices that are not directly associated with better outcomes for mothers, babies and those who pay the bill.
The necessary precursor to safe and cost-effective maternity care in North America lies is distinguishing between safe and unsafe practices in each setting and for each type of birth attendant. This allows the essential qualities of maternity care to be determined and standard characteristics of practice be developed for all places and persons provide maternity care to health women.
To do that, evidence-based policies and a consensus for action must be developed among all stakeholders – childbearing parents and consumer activists, birth attendants, other maternity care professionals, hospitals, 3rd party payers and public health officials. The goal is nothing less than an integrated, cooperative and 'minimalist' model based on “best practices”.
To paraphrase from a popular religious text: “Who among you if his child should ask for bread, would give instead a stone?” We must make sure the maternity care system does not unintentionally offer a stone in place of kindly extended helping hand.
Part I: The Optimal Purpose of Maternity Care
The most basic purpose of maternity care is to protect and preserve the health of already healthy women. The basic goal is a cost-effective model that is able to preserve health and effectively prevent or successfully treat complications during pregnancy and childbirth. Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.
This factors in the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life, including delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and over-all cost of care to individuals and society. Ultimately, all maternity care is judged by its results -- the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.
The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system. Because we enjoy a high standard of living in North America and generally have access to routine maternity care and comprehensive obstetrical services for complications, healthy childbearing women can expect a good outcome for themselves and their babies. In the US, over 70% of childbearing women are healthy, have normal pregnancies and give birth to healthy babies.
Physiologically-based care for spontaneous labor and normal birth contributes greatly to safe and cost-effective maternity care. According to Stedman’s Medical Dictionary “physiological” means “…in accord with or characteristic of the normal functioning of a living organism” (1995).
In many parts of the world, including the five countries with the best maternal-infant outcomes, this supportive model is routinely provided by family practice physicians and midwives. All birth attendants know that complications, while infrequent, can occur in any pregnancy or labor, no matter how healthy the mother or normal the pregnancy. For this reason, access to and appropriate use of obstetrical interventions is an integral part of physiologically-based care, to be called on when needed to treat complications or if requested by the mother.
In contrast to this physiologic model, the standard obstetrical care in America currently treats labor as a medical event and birth as a surgical procedure. Despite this strict model of obstetrics, with its many policies and protocols designed to make childbirth safer, despite spending more on maternity care than any country in world, the US has always ranked near the bottom of the developed world in the most important quality measures: [30th] in maternal mortality and [14th] in neonatal outcomes. When it comes to rates of operative delivery, we also have a poor showing -- a 32% Cesarean section rate, which is among the highest in the world.
According to a review of the scientific literature, the best outcomes for healthy mothers and babies are consistently associated with three healthcare-related circumstances. In combination, these three basic elements are equally advantageous to industrialized countries as well as developing countries.
This integrated system presupposes two things: (1) universal access to a functional healthcare system based on modern biological science (2) that provides affordable medical services -- both routine and emergent -- to women and children over the course of their lifetime. No form of maternity care or obstetrical intervention can provide the characteristics of health to women who suffer from chronic disease or begin pregnancy with a serious illness that could have been prevented by timely access to appropriate medical treatment.
Essential Qualities of Maternity Care & Place-of-Birth Issues:
The goal of maternity care for healthy women is always a sustainable model of high-quality, cost-effective maternity care that works equally well for all stakeholders -- professional care providers and hospital staff, as well as childbearing families. The most important maternity care issue is not place of birth, but the essential qualities of care -- irrespective of birth setting -- that safely meets the needs of the childbearing women and their babies.
In US, the concept of birth setting is regrettably used as a proxy for management style. Hospitals are assumed to provide a uniform standard of medical care, while the providers of OOH care are assumed to be lacking in critical medical skills and access to higher-level services. Actually, neither assumption is accurate. The range of variables between and within each model means that neither hospitals nor OOH settings have ‘standard care’ characteristics, which makes direct comparison of the two locations irrelevant for determining safety based on place-of-birth.
For a great variety of reasons, hospitals do not universally medicalize all maternity patients. In a hospital, normal childbirth in a healthy woman can be physiologically-managed by midwives or family practice physicians. In other instances a high-risk labor patient in urgent need of medical intervention may deliver precipitously on a stretcher as she arrives in the ER or she may give birth all alone in the bathroom on the L&D unit while the nurses are busy elsewhere. On the other hand, laboring women can be closely monitored in an OOH setting using IA (intermittent auscultation) or the newer generations of small, battery-operated EFMs, while her skilled professional attendants are able to provide immediate access to IVs, oxytocin, O2, resuscitative technologies, etc -- the same common medical interventions for the same common problems that maternity patients receive in hospital settings.
Transfer Time – Not the issue it seems: Within the place-of-birth controversy, much is made of the transfer time between OOH locations and the hospital. In an emergency, the obvious concern is that additional travel time will delay critically-needed care. This presupposes that emergency care is instantly available in all hospitals and that merely being a hospital labor patient equates to having an obstetrician, anesthesiologist and OR staff on stand-by, with an operating room held ready and waiting every minute. Unfortunately this television model as portrayed on “Gray’s Anatomy” only applies to large tertiary care hospitals that do not happen to be overly busy at that precise moment, and for whom the needed staff also happens to be available. Real life is not a TV soap opera.
In the US, most babies are born in small and medium-sized community hospitals that do not have 24-7-365 emergency coverage. While the laboring mother is in the hospital, the doctor is often in his or her office, doing surgery at another hospital across town or at home. This also causes a delay between the recognition of an emergency and the ability to instantly intervene, a quality no different than what occurs in an OOH setting. After recognizing the urgent problem, the nursing staff must telephone all off-site physicians (OB, anesthesiologist and perinatologist) and the operating room technicians, who must dress and drive to the hospital and then change into scrubs. At their very best, this still means a gap of approximately 30 minutes between the decision to surgically intervene and the incision into the uterus.
When the same kind of emergent event occurs in an OOH setting, the birth attendant or EMTs contact L&D nurses at the receiving hospital. While the patient is in route by ambulance, the nursing staff initiates same notification process, which often means that the OOH patient and the off-site physician arrives at the door of the operating room at same time. In non-teaching, non-level III hospitals, the typical decision-to-incision time is at least 30 minutes, whether the patient labors in house or off-site.
The Eternal Conundrum ~ Risk vs. Benefit, Time vs. Money
No delay, whether due to on-site or off-site issues, is ever good from the standpoint of mothers and babies and in a perfect world, everything and everyone would be in place every time. But we must come to terms with the economic realities of childbirth services, which are not all that different from the general risk-benefit ratios that apply to other health care situations. At this point in history, no society would ever be able to pay for a 100% perfect circumstance for 100% of its population 100% of the time. As an ER nurse, our department did not send every person with a headache for an MRI or hospitalize them for 72 hours observation to rule-out a brain tumor.
When it comes to maternity care, the only alternative to the current mix of small, medium and large hospitals and birth centers is to close down all facilities that deliver less than 500 babies a year and send laboring women to very large regional centers. A joint committee of the American College of Obstetricians and Gynecologists’ and the American Association of Obstetrical Anesthesiologists proposed this very idea just a few years ago, as a way to make epidural anesthesia available 24-7 to all maternity patients. Apparently, the enthusiasm of organized medicine for eliminating all but the largest hospital maternity services was not shared by the administrators of small and medium-sized community hospitals.
But the practical side of this so-called ‘solution’ would create a host of other expensive and daunting problems, such as transportation for those without a car, driving times (especially in bad weather) and the significant number of women who would give birth unattended in their car before arriving at the region center. To visit new mothers or premature and sick babies (who might be hospitalized for weeks), there would be expensive hundred-mile round trips, childcare problems and extensive time off work. And in spite of everyone’s best efforts, such a tertiary care system would still not be able to get everyone in the right place at the right time, and can’t guarantee that mothers and babies will always get exactly the care they need.
Annual spending on health care in the US is currently 17% of our Gross Domestic Product, which was as calculated by the World Bank’s Development Indicators in 2008 to total $14.59 Trillion . That means we spend $2.43 trillion every year on healthcare. One quarter of that princely sum pays for maternity care, with about 70% of this impressively huge number going to pay for medicalized maternity care for health women with normal pregnancies. Even if it were economically feasible, throwing more money at the problem will not be the answer.
In regard to healthcare of all sorts, it’s always a bad idea to spend 99% of economic resources to meet the rare 1% need, while trying to stretch the remaining 1% of the money to cover the predictable needs of the majority. The promise that simply spending enough healthcare dollars will guarantee a perfect record every time is a hoax – the number of adverse events for the human condition never has and never will be zero. The far better choice is a practical and cost-effective approach that could meet 99% of the needs for 99% of the people using 99% of the available resource. This practical plan should apply to all aspects of health care, not just childbirth or maternity care.
Maternity care as a continuum of provider characteristics
Using place-of-birth as proxy also fails to acknowledge a most central fact about maternity care – that it is a continuum of practices from pure physiologic care at one end, to the pre-emptive use of medical interventions at the other. Within the scope of their specific discipline, each practitioner also has a wide range of practices (or preferences) that span the most extreme ‘hands-off’ to the most aggressive use of intervention. In the middle of this spectrum there is a great deal of overlap, which means that both categories of birth attendants in both locations use the same management practices most of the time on most patients.
Another confounding factor in the safety equation is the level of competency by each individual within his or her own professional category, as well as a host of unpredictable elements such as budget cuts, extreme weather, chronic understaffing, an exceptionally high census that coincides with low staffing or lack of other resources, and occasional major or prolonged disruption, such as power outages following a natural disaster like a hurricane.
This profound divergence within the ‘standard of care’ means that the proxy use of place-of-birth cannot determine the qualities essential to maternity care in the 21st century. The hospital-OOH controversy asks the wrong question, one that goes unanswered because the underlying premise is flawed. Over the last century many earnest researchers have tried their best to use place-of-birth statistics as an opportunity to neatly cleave apart the core issue of childbirth safety – something hospitals were assume to have and OOH setting were assumed to lack. They hoped the statistical process would reveal a bright line between safe circumstances and responsible care, compared to unsafe care and irresponsible circumstances, which was assumed by the medical profession to be synonymous with the OOH settings.
Unfortunately, these assumptions became the basis for a national maternity care policy in the US aimed at promoting one and eliminating the other, turning OOH childbirth – in particular PHB -- into a controversial topic with hard feelings and vitriolic rhetoric at every turn. Every few years a new peer-reviewed study that either confirms or disputes the safety of OOH is added to an already extensive body of scientific literature. Then the tension suddenly pops up on the public radar as opposing groups hurl invectives at one another in the media.
Most regrettably, this puts the media -- instead of the science -- into the role of arbitrator, as if the merits of this important issue could be decided by popularity contest. For example, the Internet edition of a world-class newspaper recently published an argumentative article about OOH birth that included an online survey asking readers to vote on the question: “Is Home Birth Safe? – Yes or No”. [UK Daily Mail-Aug 17, 2010] It’s absurd to think that the safety of particular childbirth practices could be established by the opinion of the public, rather than a thoughtful and unbiased evaluation of the scientific evidence. This reflects an unfortunate politicizing of maternity care in the very places that most need to be decided on substance – the evidence and the merits of the case.
Instead of optimizing a national model of maternity care, we have had a century-long turf war over place-of-birth. Sadly missing are policies or systemic efforts to integrate the excellent contributions of obstetrics as a surgical discipline with the time-tested principles of physiologically-based management of normal childbirth. Instead of a spirit of cooperation contributing to mutual advancement of evidence-based practice, the professions of obstetrics, family practice medicine and midwifery has spent the last hundred years arguing over the theoretical question of whether or not hospital childbirth is safer or PHB is dangerous.
But for all this heat (and no light), the nature of place-of-birth is and will remain hopelessly confounding: hospitals and OOH settings of every size and technical capacity, birth attendants of all types, abilities, temperaments and levels of competency provide care to patients spread across a spectrum from the healthy, highly educated, well-fed, well-housed, and compliant who receive state-of-the art prenatal care to those who had no prenatal care, are homeless, undernourished, chronically ill or medically non-compliant due substance abuse, mental illness or other unhealthy lifestyles. Using place-of-birth as a proxy for safety is like trying to ‘prove’ that restaurant meals are safer than food cooked at home – to which the answer will always be: “yes & no”, depending on which restaurant you are comparing to which household.
Hiding in plain sight – a simple solution to a perplexing problem
On close examination, using place-of-birth as a proxy for place-of-safety turns out to be a ‘distinction without a difference’. Unfortunately, it’s also a distraction that has keeps us from recognizing those distinctions that make the biggest difference -- an entrenched collection of non-standard characteristics in both settings (hospital plus OOH) and all three professional categories (obstetricians, family practice physician & midwives of various backgrounds).
Since the early1900s, the medical profession in the US has related to questions of safety in childbirth practices as if there was only one basic variable that mattered -- hospital vs. OOH. The nature of that care -- who and how it was provided within that supposed ‘safe zone’ (i.e., hospital) – was assumed to be a constant and to produce consistently good results. Actually, all three categorical elements are all variables: place, professional category and personal preference of practitioner. In addition, the enormous variability of the crucial fourth element must be taken into account: the childbearing woman and her pregnancy, birth and baby-related needs, including her personal and religious beliefs, her economic and other resources, her relationship to her family and its status in the broader community (including immigration status)
The best advice about this controversy comes from Australian researchers H Bastian et al in the paper “Perinatal deaths associated with PHB in Australia”, published in the BMJ in1998. After noting that both settings lacked ‘standard care’ characteristics, its authors concluded that home and hospital offer different benefits for birth and that:
The multiplicity of variables and confounding factors between places-of-birth can never be responsibly relied upon to define the elements of safe and cost-effective maternity care.
Nonetheless, safe and unsafe practices can and should be addressed. This becomes a straight-forward and useful activity when it is done in matched pairs – hospitals of a certain size compared to other with equal capacities, practitioners of the same background and practice characteristics providing care to an internally consistent cohort of childbearing women.
Safety & the maternity-care
Two kinds of data are required to intelligently determine if the current configuration of medical and midwifery care is making the kind of cost-effective contribution that economists refer to as 'value added’. In order to identify “value-added”, we must first identify the innate riskiness of normal childbearing and directly quantify the relative benefits of each category of maternity care. This requires baseline data for “no care” in an essentially healthy US population, as well as outcome statistics for each type of birth attendant. Having done that, the essential qualities of maternity care can be distinguished from customary practices not directly associated with better outcomes for mothers and babies.
The ultimate goal is to test the validity of all current maternity care policies, protocols and practices in regard to safety, cost-effectiveness and patient satisfaction and to arrive at ‘standard care’ characteristics. This would integrate the principles of physiological management with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies, with obstetric interventions reserved for those with complications or if requested by the mother. Having scientifically identified ‘standard care’ characteristics, this model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.
Childbirth risks in healthy women & policies that reduce them
In searching for the essential qualities of safe and cost-effective maternity care, I have identified 5 useful sources - 4 published studies in combination with a consensus of the research literature for hospital-based maternity services in the US. These included:
CONTROL GROUP: The study of unattended birth functions as a ‘control group’ that allows comparison of ‘care’ versus ‘no care’. Then we can compare the 3 major groups of birth attendants to one another and to the ‘no care’ cohort.
Taken together these studies provide information on the biological background rate of maternal and perinatal mortality and morbidity when all the benefits of modern biological sciences are absent, inaccessible or rejected by a childbearing population due to cultural traditions or religious beliefs.
The poor outcomes for purposefully unattended birth in the US in an educated and essentially healthy population are consistent with available statistics for maternal-infant mortality in the late 19th and early 20th century in the US, and the current high maternal mortality rates in developing countries such as Afghanistan, Ethiopia and the Gambia. The major cause of MM in this first-world cohort was hemorrhage and infection and establishes a background rate of biological risk that is independent from poverty, malnutrition and other factors specific to deprivation.
CONVENTIONAL OBSTETRICS: At the other end of the scientific continuum, this collection of studies also helps us to distinguish between maternity care policies and practices that benefit healthy women and those non-productive traditions, customs and provider preferences that increase the economic cost, but do not directly contribute to improved maternal-infant outcomes.
Five Models, Five Perspectives, Five Insights
Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care - Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:
This control group consists of women with the same general health and demographic characteristics that are seen in the CDC birth registration data. This is predominately healthy, white, middle-class women who had economic access to all categories of maternity care providers and settings, but in this case, purposefully choose unattended births. Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that rejected all forms of medical care under all circumstances – no prior diagnosis or treatment of chronic medical problems, no risk-screening of mothers during pregnancy, no prenatal care, no trained attendant during childbirth and no emergency transfer of mother or baby with life-threatening complications to a medical facility – a situation similar to rural parts of the developing world.
Out of 344 births, the unattended group had 6 maternal deaths and 21 perinatal losses. The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live births (92 times higher than Indiana’s MMR for the same period) and one perinatal loss for every 16 births or PNM rate of approximately 45 per 1,000.
Study #2: "Home Delivery & Neonatal Mortality in North Carolina", Claude Burnett, Judith Rooks; JAMA, Dec 19, 1980, Vol. 244, No. 24, p. 2741-2745:
Planned home birth (PHB) in an impoverished and medically-indigent minority population attended by experienced lay midwives. These demographically high-risk maternity patients were risk-screened one time by a public health officer prior to being approved for PHB under the care of a lay midwife. However, state laws did not authorized non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears. These county-registered midwives were required to transfer patients with complications to a local hospital in an appropriate and timely manner. The lay midwife-attended group had no maternal deaths and 4 neonatal losses per 1,000 (including 2 fatal birth defects).
Note: This study also reported the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended, often because local hospitals turned away laboring women who did not have the prescribed ‘cash in hand’. These unattended births had a dramatically increased perinatal mortality rate ranging from 30 to 120 stillbirth and neonatal deaths per 1,000, a perinatal mortality rate consistent with 3rd world countries and unattended births among the religious group in Indian.
This highlights the preventive value of physiologically-based pregnancy and childbirth services and the equally important access to medicalized maternity care during pregnancy as indicated and the ability to call on comprehensive medical services during the intrapartum and immediate postpartum-neonatal period whenever necessary. Compared to the combined mortality statistics for the control group, the care of these lay midwives saved the lives of 14 mothers and 58 babies. If their care were a drug or medical device, it would be illegal for every childbearing women not to have one of them.
#3: Outcomes of planned home births with certified
professional midwives: large prospective study in North America;
Kenneth C Johnson, senior epidemiologist; BMJ 2005;330:1416 (18
Planned home birth (PHB) in a generally healthy population as attended by nationally-certified direct-entry (non-nurse) midwives in the year 2000. All clients were risked-screened and received prenatal care and those with medical or pregnancy complications were referred to medical services. Professional midwives monitored maternal vital signs and fetal heart tones during labor and were authorized to carry emergency supplies such oxytocin (Pitocin + Methergine), IV fluids, oxygen, neonatal resuscitation equipment and also to suture perineal lacerations. Twelve percent of PHB patients were transferred to the hospital during labor or after birth, the majority of whom were first-time mothers. Cesarean rate was < 4% for PHB women hospitalized during labor. This group had no maternal deaths and 2.6 neonatal losses per 1,000 (including lethal birth defects).
Study #4: Outcomes of planned home birth with midwives versus planned hospital birth with midwife or physician; Janssen PA, Saxell L, Page LA, et al. CMAJ 2009;181:377-383:
A 5-year Canadian prospective study published in 2009 compared the outcomes of PHB in British Columbia attended by professional direct-entry midwives btw 2000 and 2004. It compared planned hospital births also attended by this same category of professional midwives and a matched low-risk cohort of physician-attended hospital births. They found that the risk of perinatal death associated with PHB attended by midwives did not differ significantly from the low rate associated with planned hospital birth. The study also found that women who planned a home birth had a reduced number of obstetric interventions and adverse maternal outcomes.
The neonatal death rates per 1,000 births were 0.35 for midwife-attended planned OOH birth, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births. Maternal mortality for all three groups was zero. Inclusion in the two hospital categories required the childbearing women to have the same low risk-based characteristics as those who were planning to labor at home. These finding echoed a Dutch study published in July that also found a planned home birth to be as safe as a planned hospital birth, provided that a well-trained midwife is available, transportation and medical referral system is in place, and the mother is at low risk of developing any complications.
The authors concluded: “… (the) study showed that planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and adverse maternal outcomes compared with planned hospital birth attended by a midwife or physician”.
#5 Neonatal mortality rates for planned hospital birth as reflected in a consensus of scientific literature, plus CDC birth registration stats for birth after 37 completed wks and data on obstetrical intervention levels in general population from the "Listening To Mothers" survey, Childbirth Connection; 2002 and 2006:
Planned hospital services for low and moderate risk women -- labor attended by a professional nursing staff, routine intrapartum use of continuous electronic fetal monitoring (93%), IVs (86%) and epidurals (63%); birth conducted as a surgical procedure by a physician or certified nurse midwife. Medical intervention rate for this group was 99%; aggregate surgical intervention rate was 70% (episiotomy, forceps, vacuum extraction and Cesarean section). The CS rate was approximately 25% in 2002 (now 32%). The scientific literature reported neonatal mortality for obstetrically-managed hospital birth for low-risk women to range from a low of 0.79 to 4.1, with an average NNM rate of 1.5 per 1,000.
The patient-choice issue of genetic testing & termination
The routine use of ultrasound and prenatal genetic screening in the hospital cohort, in conjunction with termination of affected pregnancies during the pre-viable state, slightly lowers the rate of perinatal and neonatal mortality when compared to the sub-set of families who choose OOH birth. This is due to a reduced number of babies in the hospital cohort with lethal anomalies who are carried to term.
Families that choose non-medical maternity care are statistically less likely to utilize prenatal genetic and ultrasound screening or to terminate affected pregnancies when indicated. One study in PHB in Washington State (1996) documented a disproportionate increase NNM due to congenital anomalies, not all of which were incompatible with life. Among this specific sub-set of non-testing parents, prenatal diagnosis and planned hospital care would have reduced (but not eliminated) the incidence of neonatal mortality. However, this is a patient choice and is not a provider or place-of-birth issue.
In regard to the great debate about safety, it is useful to realize that birth-related morbidity and mortality can be time-shifted, place-shifted and practitioner-shifted, but they cannot be eliminated. In other words, increasing rates of pregnancy termination reduces neonatal mortality rates but obviously does not reduce over all perinatal mortality. There is nothing that birth attendants can do or not do that reliably, and with economically sustainability, can create a condition of zero risk for both mother and baby 100% of the time.
The risk-benefit continuum among the 4 responses to normal childbirth and the 3 types of birth attendants:
Simple access to prenatal care, on-going risk-screening and physiological management of active labor, birth and immediate postpartum-neonatal period by experienced birth attendants of all categories improved outcomes by orders of magnitude. Here is the breakdown for each type of birth attendant and both in and out-of-hospital settings.
NO CARE: The most startling conclusion is the consequences of "no care". Lack of prenatal care, no skilled birth attendant present during labor and birth and not having or not using emergency care when indicated is unconscionably dangerous and represents a failure of society at some level. The total absence of medical and maternity services, whether by religious or personal choice, due to poverty or cultural beliefs, can turn the otherwise normal biology of pregnancy and childbirth into a lethal condition.
LAY MIDWIVES: Many people would have assumed that the care of lay midwives would have been little better than unattended births but they would have been very mistaken. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to the control group.
When it comes to 'value-added' above the background biological hazard, lay midwives added the most value of any category of birth attendant. These good outcomes were achieved by providing childbearing women with prenatal care, on-going risk-screening and referring those with serious medical or pregnancy complications to obstetrical services. Mothers and their unborn babies were monitored during active labor by capable midwives who recognized medical problems and arranged timely transfer of patients with complications to the obstetrical service at the county hospital.
This straight-forward access to prenatal care, risk screening, transfer as indicated and physiological management during labor, birth and postpartum-neonatal period as provide by lay midwives was able to reduce perinatal mortality by 20 to 40 times compared to the mortality statistics for control group. This substantial feat was accomplished at a small fraction of the expense and was able to lower neonatal mortality to a rate similar to that of professional midwives and a maternal mortality rate equivalent to hospital-based-obstetrical care.
Within the structured healthcare systems of North American and the formal reimbursement scheme by governments and insurance carriers, expansion of services by lay birth attendants would not be a viable option. Our educated population rightfully expects their healthcare providers to be professionally trained, regulated by the state, able to carry emergency drugs and equipment and to repair simply perineal lacerations as a part of their normal scope of practice.
Nonetheless, lay midwives are an eager and reliable group that should not be overlooked. They are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries and among groups that are for any reason excluded from the official healthcare system in developed countries. It is illogical and unwise to criminalize this group.
PROFESSIONAL MIDWIVES: In study #3 state-regulated direct-entry midwives had no maternal mortality and a neonatal mortality rate of 2.6 per 1,000 (including fatal birth defects), which was ever-so slightly better that the lay midwives and in the same general range as hospital-based obstetrical care for low and moderate-risk women. However, childbearing women cared for by professional midwives had 2 to 10 times less obstetrical intervention than medicalized hospital care and a 6-fold decrease in Cesarean section (under 4%). All of these good outcomes were achieved at a small fraction of the expense of orthodox obstetrical care.
In study #4, the Canadian direct-entry midwives were fortunate to be providing care in a providence that had an integrated model of care with generally cooperative and complimentary relationships between midwives and physicians. Midwives in several parts of Canada have hospital admitting and practice privileges, so healthy women have the option of a planning a midwife-attended hospital birth. This also allows for continuity of care for transfers from home to hospital when the mother-to-be does not require obstetrical management or operative delivery. When the services of an obstetrician are needed, this articulated system provides for a seamless transfer of care and 'no-fault' receptions.
Last but not least, these statistics are for a sub-set of childbearing women -- the lowest of low risk women. This is a patient population with good access to and use of prenatal screening and for whom all diagnosable congenital anomalies have been eliminated from this cohort. Neonatal deaths for midwife attended PHB in this population are the very lowest of all stats for normal birth in any setting -- NNM per 1,000 of 0.35 for births planned home births, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births.
These are ideal circumstances and while we all aspire to them, they cannot be replicated 100% of the time by 100% of the childbearing populations. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare.
With the rarest of exceptions, this general principle applies to healthy childbearing women. Assuming that the mother-to-be is fully informed by her birth attendants, she has the right to decline prophylactic medicalization and choose instead (or accept) the increase risk of a specific pregnancy or intrapartum circumstances that puts her into a moderate risk category -- for example, a small fibroid, a large baby, vaginal birth after a Cesarean, prolonged rupture of membranes, meconium, or a post-dates baby with reactive NST. It is necessary for the maternity care system to acknowledge the constitutional right of adult women to continue receiving birth-related services even when they are not totally 'ideal' candidates for OOH care.
The alternative is to put many women between the Devil and Deep Blue Sea by denying access to professional OOH care. This forces them to choose between medicalization they do not want, and in actual fact may not benefit from, or having unattended births (the risks of which have already been identified). The other problematic possibility is that women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives her of access to adequately trained attendants and medical back-up arrangements, but also creates another group of unregulated lay midwives, which is both unnecessary and unwise.
The better strategy is to acknowledge that moderate risk women have a constitutional right to have professional services for an OOH birth. The statistical record of a mixed-risk population (low plus moderate-risk women) consistently demonstrates a NNM rate between 1.5 and 2.6 per 1,000, irrespective of birth attendant or birth setting.
HOSPITAL-BASED CARE: Institutionally-based obstetrical care appeared to have improved neonatal mortality ever so slightly (approximately 1.5 per 1,000) as compared to the lay attended group (3:1,000) and professional midwives (2.6:1,000, but this small gain was offset by a dramatically increasedCesarean section rate of 32% and drastically increased cost of care. This escalating CS rate has been associated with the current upward trend in maternal mortality (MM) by other researchers.
In that regard, physiologically-based forms of care, which lower the incidence of Cesarean, also reduce rates of maternal mortality. While no family or birth attendant should ever be forced to choice between the life of the baby and that of the mother, we also must be sure that enthusiasm for the lowest possible neonatal mortality statistics does not increase the risk to the childbearing woman and result in avoidable maternal mortality.
High-tech, high-cost, highly interventionist obstetrical care for healthy women does not appear to improve combined mortality rates for mothers and unborn or newborn babies. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of surgical delivery.
Bottom Line: Hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.
As measured by the outcome statistics for the 3 categories of birth attendants: lay midwife-attended, professional midwife-attended and hospital-based, medically attended -- the most efficacious strategy for preventing maternal and perinatal mortality and morbidity consists of the three simple already identified aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth. This was associated with prenatal care, risk-screening, transfer to medical services as indicated, birth attendant skilled in physiologic care present during the intrapartum, postpartum-neonatal period and appropriate use of emergent and comprehensive medical services as necessary.
Evidence-based maternity care by birth attendants trained in physiological (non-interventive) management achieved “maximal results with minimal interventions” by a wide margin. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.
To paraphrase the popular African saying, it takes a village of skilled and knowledgeable people to support the safe passage of mother and baby thru pregnancy and birth.
OBSTETRICIANS IRRATIONALLY HANDICAPPED:
Unfortunately, the current legal ‘standard’ for the surgical specialty of obstetrics is a medical-surgical model of care. Physiologically-based principles of care have not been a legitimate part of obstetrical practice since being defined as medically inferior in 1910. At that time, Dr. J. Whitridge Williams gave voice to the low esteem that physiological care had in the scheme of obstetrical practice when he said; "That word 'physiological' has all along stood as a barrier in the way of progress." [Twilight Sleep: Simple Discoveries in Painless Childbirth, Dr. H. Smith Williams; 1914, p. 90] The theory and skills of physiologically-based care were never incorporated into the 20th century medical curriculum and are not taught in 21st century medical schools.
Practically speaking, this means the use of physiological management, which is primarily non-medical in nature, is legally a ‘substandard’ form of care when provided by an surgically-trained specialist such as an obstetrician. Currently, the principles and practices of physiological management are only taught in midwifery training programs. Until that changes, midwives will continue to be the sole providers of maternity care based on physiological principles.
In far too many places, PHB is the only situation where true physiological management is legally able to be employed. This artificially forces us into a proxy state of mind that appears to pit hospital against PHB. But in a rational evidence-based system, no healthy women should ever have to choose between a midwife and a physician or between home and hospital in order to receive physiologically-based care for a normal birth.
In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the birth attendant or the planned location of care.
Responsible Midwifery for the 21st Century
Responsible midwifery is an integrated model of care. It is able to meet its social obligation to serve and protect mothers and babies while simultaneously protecting the professional capacity of midwives and preserving the reputation of midwifery. In order to meet the biological, psychological, educational and social needs of childbearing families, excellent maternity care needs to be based on the highest level of art and the most comprehensive level of science. It must also be an ever-evolving discipline as new knowledge, new technologies and new thinking come to the healthcare field.
Physiological care as a 'subtle' system and independent form of 'expertise': Regardless of a midwife's formal education, responsible midwifery for healthy women rests on the incontrovertible principles of physiological management as the universal standard of care. This ‘whole cloth’ model is organized around pregnancy and birth as a healthy function of normal biology. Obviously, this designation includes 'first-responder' emergency skills and equipment, as well as timely access to comprehensive medical care as the back-up plan (Plan B), However, the foundation of physiologically-based, non-medical care --"Plan A", if you like -- is best understood as a 'subtle' system.
In regard to healthcare, the word 'subtle' describes a supportive structure of normal (non-medical) care. Subtle systems are at one end of the healthcare continuum, while the pathology-focused, macro-level of intervention that defines the practice of medicine are at the other end. In the middle of this caregiver spectrum are integrated types of care and different types of careproviders who creatively blend the best of both (the subtle and the interventive) to suit the circumstances.
The practice of medicine is organized around diagnosing pathology in physical or biological function and implementing a predetermined set of interventions. There is nothing 'subtle' about a patient who is unconsciousness, in a coma, hemorrhaging or having seizures. Nor is there anything subtle in the treatment of these dramatic physical symptoms and other evident pathologies, all of which requires the use of diagnostic procedures, medical treatments, drugs or surgery.
This is not to say that some level of subtly is not an aspect of the diagnostic process or provision of good medical care -- such subtly is often the mark of true expertise and makes one an "expert" in his or her field. Its just that subtle observations and subtle responses are not the core of the medical process. They are a minor part, or an expression of extraordinary fineness, but not the macro or basic unit of activity.
In direct contrast to the medical model of care, normal physiologic needs are typically detected and responded to via a subtle or 'micro' level of patient indicators and caregiver reactions. Physical and psychological needs are, for the most part, detected by subtle visual or auditory clues -- the fleeting look of anxiety, pain or surprise that momentarily passes over the mother's face, a faint hint of perspiration on her upper lip, her hands gripping the bedstead, a moan or low grunty sound that escapes her lips. Depending on the stage of labor, these subtle clues are likely to indicate the beginning of painful contractions in early active labor, the onset of transition labor accompanied by the mother's feeling of panic or the very first urge to push early in 2nd stage.
A word picture for the subtle nature of supportive care comes from the world of parenting. The mothers and fathers of infants and small children naturally develop the ability to detect the smallest tell-tale sign that a child is about the up-chuck. Since the beginning of time, parents (and nurses) all over the world over have instantly responded by quickly moving the child or turning the baby's head so it won't choke and the mess will be easier to clean up. Breastfeeding mothers also respond to a variety of subtle clues that their babies is are either hungry or ready to quit nursing because they are full.
It's this kind of watchfulness that is at the heart of physiological management as a subtle, non-medical system of care for an essentially healthy population of childbearing women and their newborns. As with parenting and the profession of nursing (as well as driving a car or piloting a plane), one must be present and paying attention in order to see and hear and respond to these subtle indicators -- hence the descriptive (as well as legal implications) in the word "birth attendant". Older medical and midwifery textbooks refer to this quality of waiting and watching as "patience with nature".
Birth attendants and other caregivers respond to the subtle physiological and psychological needs of the laboring woman by watching carefully, asking the mother about her sensations (what are you feeling now?) and how she feels about what is happening (her emotions). After assessing the situation to be within the normal range for the stage or phase of labor, caregivers provide practical, non-medical support (physical or psychological) as appropriate. Often this nothing more than an a hand laid reassuringly on her shoulder, a word or two of encouragement or explanation, a suggestion that she change positions, get up or move around. These subtle reactions communicate that she and her baby are OK, that she is making progress and it won't be too much longer before her baby is born.
The temperament required for this kind of 'patience with nature' is a large part of what makes a birth attendant good at providing normal care for normal childbirth. Unfortunately, these characteristics are the opposite of the personality traits associated with surgical specialties. Surgeons are trained and paid to make split-second decisions, take quick decisive action, finish up as efficiently as possible and move on to the next most urgent need. If surgery had an unofficial motto, it would be "lickity-split". In addition, surgery is such a highly specialized field that most of us do not even have a right to voice an opinion about how its practiced. As a result surgeons do not take kindly to having their understanding or judgment questioned.
For professionals who spent hundreds of thousands of dollars and 12-15 years training in the surgical specialty of obstetrics, the idea of sitting in the room with a laboring woman and just watching and waiting for hours and hours is met with the same enthusiasm as watching paint dry. For this reason, physiologic care will likely remain the purvey of non-obstetricians for the foreseeable future.
The role of the midwife is to provide a supportive structure for the physical, mental, emotional, and social needs that accompany this normal (but extremely intense) aspect of reproduction. The goal of this integrated model is to serve the full spectrum of practical needs experienced by childbearing women. This includes guidance and counseling, as well as one-on-one, hands-on support and encouragement and spans the most mundane issues of newborn behavior and breastfeeding at one end to the appropriate utilization of obstetrical or neonatal services as desired by the mother or required by baby.
It should be noted here that community midwifery has far more in common with general practitioners than the specialty of obstetrics. The midwife who provides care in non-institutional setting is generally responsible for the entire ante-, intra-, and postpartum period as well as the immediate and on-going care of the newborn baby and all the issues this entails such as breastfeeding, weight gain, colic and concerns about newborn behavior for the first 6 weeks.
Reproductive biology not perfect: For healthy women with normal pregnancies, absolutely no routine medical or surgical treatment, drug, protocol or procedure can make normal labor and birth better than the process already provided by the normal biology of human reproduction. But reproductive biology is no more perfect that any other aspect of our physical body, which means the risk of complication and emergencies must remain ever-present in the minds and plans of all birth attendants. The incontrovertible principle of responsible midwifery is right relationship between midwives, mothers and the biological sciences, with critical thinking skills at the heart of it all. The invaluable contributions of modern medicine in responding to complications must be enthusiastically acknowledged, which includes appreciation for the vital role of obstetricians, perinatologists and hospital-based care.
To achieve a high level of preparedness, midwifery educators need to intellectually prepare their students to be fully competent in both the art and the science of midwifery. This includes adequate clinical experience in manual dexterity skills, development of clinical judgment skills and the mental toughness to make right use of appropriate interventions or initiate a timely transfer of care when indicated. There is no shame or blame for either mother or midwife in necessary hospitalizations, but rather a recognition that each person involved in the situation has to deal, as best they can, with the cards dealt by Mother Nature. This is often the opposite of what the parents expected and the midwife hoped for. Nonetheless, a timely hospital transfer and use of comprehensive obstetrical services is not a “failed home birth” or failure of other aspects of the care-giving process. An appropriately timed hospital transfer is a marker of responsible midwifery, to be applauded and appreciated.
Since the birth attendants who provide normal care for normal birth are primarily midwives, the hundred-year history of prejudice by the medical community against physiological management is a burdensome legacy. Unfair as this hard-wired prejudice has been, non-nurse or direct-entry midwifery is sometimes endangered from within by a ‘soft prejudice’ of its own low expectations. This describes a well-meaning but inappropriately defined role of intrapartum management that is a combination of ‘do-nothing’ and ‘feel-good’ care that parrots platitudes and responds to everything that happens with comments like “that’s normal” and “it’s OK”. But childbirth is no place for magical thinking. This idea of ‘midwifery-lite’ completely misses the crucial role that midwives take on as primary caregivers for childbearing women and their newborns.
Regrettably, Mother Nature presents us with potentially life-threatening situations in 1 out of 10 pregnancies. This number includes the entire spectrum of childbearing women, even those who are healthy and have low- and moderate-risk pregnancies. Like the lifeguard at the pool, the mandate is eternal vigilance. A midwife is an educated observer with emergency response capacity. Watchfulness and well-timed access to intervention can make a huge difference for mothers or babies who need help. In the majority of cases, small well-timed actions will correct the problem and successfully circumvent the danger. That is not a place-of-birth issue, nor does it normally depend on high-end technology. But someone must be present and paying attention (hence the original of the phrase “birth attendant”).
In any labor, the midwife must be continually aware of the mother’s childbearing history, current pregnancy status, the size, position and gestational age of her baby, the psychological status of the parents, their religious beliefs, goals and values, as well as the real-time characteristics of her labor, the critical facts of the mother and baby’s immediate biological situation and any diminution of wellbeing for either mother or unborn baby. This is particularly an issue in planned home birth where transfer time must be factored in. This requires consideration of the geography, weather, traffic, distance, financial impact on the family and the level of cooperation (or lack thereof) that can be expected from the staff of the receiving hospital.
This sobering reality requires that all OOH birth attendants be smart and capable – smart to recognize situations which have the potential to develop into a complication and capable of dealing with unusual or abnormal circumstances in ways that dramatically reduces the likelihood that a low level problem will become a complication that escalates into life-threatening emergency.
Part III: Developing "Standard Characteristics" for OOH Studies of Intrapartum Care
Assumptions about OOH birth not fact-based on either side
Great confusion occurs when childbirth is extracted from the rest of life and looked at as outside the scheme of modern biological science. Women do not give birth in isolation from their culture, as if they were spinning around alone in outer space tethered to an oxygen tank. It is important to realistically evaluate the risks of childbirth in a healthy population in the context of both time and place.
It is no more appropriate to judge the safety of pregnancy and birth in isolation from modern science than any other aspect of our physical wellbeing, or stage of life – infancy, childhood, adolescence, a mature working person or old age. In the ‘bad old days’ before antibiotics and other marvels of modern medicine, just about every phase and every aspect of life could be dangerous, including but not exclusively childbirth. For example, in the early 1900s in the US, 1 out of five (20%) of children living in big city tenements died before reaching their fifth birthday. This is much larger number than the highest contemporary maternal mortality in the world, which is 1 out of 8 in Afghanistan. In our era of modern biological science, premature death has become rare in every aspect of life, including pregnancy, childbirth and early childhood. The safety net for is the same all people and places – appropriate use of preventative healthcare, modern medical treatment as needed and emergency services when indicated.
However, there are influential forces at both ends of this political spectrum that either deny or exaggerate the potential dangers associated with childbirth – both extremes lead to trouble and neither can be justified by the facts. The adverse effects and bad outcomes resulting from over treatment are not naturally better or worse than those from under treatment. Denying or seriously underestimating biological risk by some within the midwifery profession has already been addressed. The other end of this spectrum is exemplified by official policies and political actions of the American College of Obstetrics and Gynecologist over the last 3-plus decades.
The professional organization for obstetricians has publicly and formally rejected all peer-reviewed research to date on the relative safety of a professionally-attended OOH as a planned place of birth. ACOG continues to insist that the only way to satisfy their organization is randomized controlled trials (RCTs) conducted under the auspices of the obstetrical profession within the structure of a hospital review board. Between the vicarious liability for the institution and ethical and practical issue of randomizing place-of-birth, this idea can never be satisfactorily implemented.
Childbearing women are generally not willing to have the location of birth be randomly assigned. Only 11 of 77 women agreed to randomization in one attempt to conduct RCTs on place-of-birth. Even if there were a sufficient sample size it would be impossible to generalize from RCTs. Randomly assigning place-of-birth drastically changes the dynamics for the childbearing woman, since the most basic element of OOH birth is that the woman herself must voluntarily choose to have unmedicated labor and birth.
But in identifying RCTs as the only acceptable metric, ACOG seems to be choosing to perpetuate the historical controversy by locking out what we can know and identifying the impossible to obtain criteria (RCTs) as the only source of evidence that they will consider. ACOG position statements have also made it known that even if RCTs are conducted and support OOH care, they may well ignore the research and continue their exclusionary policies.
This position is remarkable in light of the historic relationship between obstetrical practice and evidence-based research, including RCTs. The current standard for normal childbirth in the US, which includes the "active management" of labor, is based on a strict obstetrical model that was originally adopted in 1910 and universally applied without first having conducted studies of any kind. In the intervening 10 decades, these unsupported assumptions having reevaluated.
Historical Context for Contemporary Obstetrical Policies
Most people assume that the way obstetrics is practiced today is the way it always was, but so-called 'modern' American obstetrics is a relatively resent invention. Through out the 19th century, obstetrics was always part of a non-specialty practice of medicine often referred to as 'man-midwifery'. By 1910, this classic view of obstetrics as a hybrid form of midwifery practiced by GPs (who used physiologic management plus drugs for pain, forceps for prolonged labor, etc) was replaced by the ‘new obstetrics’ as a newly minted surgical specialty.
The new obstetrics was a whole new ball game. Obstetricians saw this drastic reshaping of childbirth as exciting modern solution to the ancient problem of unexpected, unexplainable complications seen so frequently in a pre-antibiotic era. Pregnancy was officially referred to as a “nine-month disease requiring a surgical cure”. At that time in history, a third of all maternal deaths in hospitalized maternity patients were the result of deadly infections -- 'childbed fever' or puerperal sepsis -- in the days following a normal birth.
An important obstetric textbook of the period flatly rejected the idea of childbirth as a normal or healthy function of female reproduction. Its author, Dr. Joseph DeLee, was a skilled and compassionate obstetrician with many admirable personal traits. He owned a small private lying-in hospital in inner city Chicago that served an immigrant population. He was known to provide care to the poorest of these women without charge. In his 1913 textbook he states that labor and birth, if viewed properly, are pathologic processes that damage both mothers and babies “often and much.” In the first issue of the American Journal of Obstetrics and Gynecology, Dr DeLee proposed a sequence of interventions designed to save women from the “evils natural to labor.”
No less a historical figure than Dr J. Whitridge Williams, chief of obstetrics at Johns Hopkins from 1911-1923, likewise believed there was no place for physiologic care (non-medicalized man-midwifery) in the modern practice of obstetrics: He said, “That word ‘physiological’ has all along stood as a barrier in the way of progress.”
This perspective gave us a pathology-oriented model of childbirth in which healthy women with normal pregnancies became the patients of a surgical specialty. Labor was seen as a pending emergency to be managed as a medicalized event by professional nurses; normal childbirth was to be conducted as a surgical procedure by an obstetrically-trained surgeon. The focus of health care during childbirth changed from "responding to problems as they arose to preventing problems". [ref: Judith. Rooks] It was the obstetrician’s duty to control the course of labor and birth through the routine use of interventions, a policy that applied equally to those who were healthy and had normal pregnancies as it did to high-risk patients. These policies normalized the pre-emptive use of obstetrical intervention, made medicalized care the standard for labor and turned normal spontaneous birth into a surgical procedure.
This policy was directly responsible for the most profound change in childbirth practices in the history of the human species. It was implemented all across America without first having tested the fundamental hypothesis or its individual elements by conducting RCTs or any other form of scientific analysis that contrasted outcomes associated with strict obstetrical management in a healthy population to outcomes of physiologically-based model of care in a matching cohort.
No scientifically-conducted studies or statistical research was ever done that identified surgeons as the preferred choice for providing primary care for a healthy population or supported the routine use of obstetrical interventions and invasive procedures as a better model of maternity care. Nor was there any established scientific basis for re-assigning laboring women to a passive role, one that routinely rendered them unconscious under general anesthesia while the doctor delivered their baby, often assisted by episiotomy and forceps.
“In Johns Hopkins Hospital,” said Dr. Williams, “no patient is conscious when she is delivered of a child. She is oblivious under the influence of chloroform or ether. [Twilight Sleep: Simple Discoveries in Painless Childbirth, Dr. H. Smith Williams; 1914, p. 67]
It is just a fluke of history that a hundred years later we are still using the idea of normal birth as a surgical procedure, one that is still billed under a surgical code. This idea was originally introduced during a pre-antibiotic era (prior to 1937) in an effort to reduce the frequency of deadly childbirth-related infections, which were particularly risky for maternity patients giving birth in an institutional setting.
EVIDENCE-BASED MEDICINE -- EXCEPT FOR ACOG: In the 34 years since the controversial issue of experimental medicine came to light, both the medical profession and society has recognized the value and embraced the benefits of evidence-based medicine. In spite of this, ACOG has still not reevaluated the historical assumptions about childbirth practices made during a pre-antibiotic era, even though these outdated ideas were implemented without being established as safe and cost-effective and continue to underpin contemporary care during normal childbirth in the US.
Nor has ACOG put policies in place that require RCTs to be conducted on all new obstetrical interventions before they are allowed to become standard practice. This is particularly relevant to the introduction of continuous electric fetal monitoring (EFM) in the 1970s and the current high-level of elective use of induction (33%) and operative delivery, which underpins our current 32% Cesarean rate. This highly interventive form of maternity care for a healthy population is an unproductive expensive that entails immediate, delayed and downstream risks of complications that affect a woman’s contemporary health, future childbearing ability and her wellbeing as she ages.
As an “expert” system, obstetrics has failed in the very area it was supposed to have the most mastery and expertise -- preserving the health of already healthy mothers and babies.
Physicians Spokespersons for Medical Science
Physicians are the natural spokespersons for the scientific discipline of medicine. While that status bestows many privileges, it also comes with additional responsibilities. The very fact that Doctors of Medicine (MDs) are holders of a doctorate (equivalent of a PhD) in the science of medicine gives the public and the press every good reason to believe that formal statements made by physicians about matters of health, safety and medical care are unbiased, scientifically-based and factually correct.
This places a unique social burden of both candor and accuracy on doctors by virtue of their advanced education and license to practice medicine, with its legal power and elevated level of trust and respect. This results in a higher standard of ethical conduct for MDs than the mere recitation of personal preference or professional self-promotion. This high ethical standard would include a duty to communicate only scientifically valid information in a public forum unless such statements are identified as a personal, political or corporate opinion.
As amply demonstrated by the literature, many of those with a doctorate in medicine are not living up to their obligation to speak and act on the best scientific evidence. This has recently as been argued by state medical boards in regard to 'expert witness testimony' by MDs in disciplinary cases and other litigation that licensed physicians have a legal or "due diligence" obligation to provide "honest, complete, and impartial" information in their field of expertise. I suggest this would extent to the obstetrical profession in regard to press conferences and other public statements provided to the media.
Developing "Standard Characteristics" for OOH Studies
When it come to research on planned place-of-birth, RCTs are never going to be part of the picture, but that doesn't mean that researchers are not interested in collecting data. Unfortunately, a number of high-profile studies on place-of-birth have been designed by those with no direct experience or interest in OOH birth. Some researchers apparently started out with a strong prejudice against OOH settings or equally strong desire to definitively prove the greater safety of highly medicalized care. Most media reports of OOH research do not distinguish between well-done studies with useful information and those that were poorly done and arrived at mistaken or misleading conclusions.
For example, a large retrospective study of planned home birth published in 2002 chose to use state birth certificate data from a state that did not collect or record the "intended" or planned place of birth. As a result, the study's conclusion -- that planning an OOH birth doubled the risk of neonatal death (a statement widely circulated by the media) was based on this unreliable data. A number of other studies that claim to prove hospital birth is safer or OOH more dangerous) have missing data, used poor methodology or other technical errors. This meant the study's conclusions were not be supported by their own data.
Another example of this same problem is a recently published but much disputed OOH study -- the Wax et al meta-analysis available on-line on July 2, 2010. Out of 16,500 birth that (may or may not) have been planned to occur OOH, the Wax analysis recorded a total of 32 neonatal death." Twenty of these 32 deaths -- nearly two-thirds -- were taken from the 2002 study mention above that could not reliably determine whether an OOH birth was intended or not, or if the mother had been treated in the hospital for a considerable time during labor or if the baby was actually born in the hospital.
Even when planning status for OOH birth can be confirmed, the researcher still has the dilemma of what to do with appropriate transfers of women late in pregnancy for medical problems (breech baby, pre-term labor, PROM) or immediate transfer at the time of the initial labor evaluation to due to discovery of a high risk condition such as bleeding, fever, thick meconium, etc. Since some percentage of women (or their babies) who planned an OOH birth will eventually need, want or receive hospital-based medical care, so the question is how to fairly determine place-of-birth outcomes relative to the mother's choice of OOH.
If midwives transfer all the complications that occur in their OOH practices to the hospital, the stats for OOH (with all problems automatically eliminated) might unrealistically portray OOH birth as 100% safe, while hospital birth -- recipient of all those complicated OOH transfers -- would look (but not really be) more dangerous. In an attempt to circumvent this problem, outcomes have been assigned to the "intended" (planned) place of birth, no matter who actually provided care, or what type of care was actually provided or where the mother actually labored (in or out-of-hospital) or where the baby was actually born.
Studies that focus solely on the pregnant woman's plan to give birth OOH assign all subsequent data to the OOH-PHB cohort, even when a pregnancy risk factor or complication was identified by the birth attendant and a necessary transfer of care was initiated long before labor. Another aspect of this confounding factor is assigning neonatal outcomes to OOH care even when the mother was transferred to the hospital early in labor and 80% (or more) of the intrapartum care was standard obstetrical management -- IV, Pitocin, EFM, immediate access to Cesarean surgery, perinatology services at delivery, etc -- for many hours before the baby was born in the hospital.
Unfortunate, this attempt to make the statistical comparison more fair means the outcome of the care as it was actually received is not correctly identified. The initial "intention" or preference of the family for a situation that never materialized becomes more relevant than the actual situation and type of medical care received. Without knowing if the adverse events in question occurred at home with a professional (or experienced) attendant present (i.e., not a precipitous delivery before the midwife arrived) or happen in the hospital, or if the medical problem was avoidable vs. unavoidable, or if the parents declined prenatal testing or medically recommended treatments, there is no rational way to assess the impact of place-of-birth.
How the data for 'intended' place of birth is defined, collected and used makes a big difference. Done poorly, it merely trades one type of statistical dilemma for another, which means these particular OOH studies fail to answer the fundamental question of relative safety or provide us with "actionable" information in designing public policies, educational curriculums and identifying 'best practices'.
Newspaper reporters and media spokespersons naturally assume that each of these must touted studies was based on rock-solid data and impeccable methodology. This would includes a full forensically investigation of each of these deaths so that all facts were verified and a complete set of specific information was available for each bad outcome and that conclusions of the studies was internally consistent with the data. But that is not the case for the this small subset of studies aggressively promoted by ACOG. In fact, the opposite is true. Because these studies tells us so little about the proximal cause and circumstances surrounding each of these individual incidence of neonatal death, it keeps their authors and the rest of us from coming to meaningful conclusions. With such rare events and small numbers, each adverse event could and should be specifically confirmed and forensically evaluated.
OOH maternity care is an articulated model that purposefully includes policies and protocols for transfer of care as needed. This is no different than the triage process used by small and medium-sized community hospitals. Hospitals routinely assess labor patients on admission for complications that require a higher level of medical service and arrange for those with such complications to be transported to tertiary care facility.
Nowhere in the scientific literature does one see maternal-infant outcome statistics used to evaluate a form of maternity care based on the hospital where the mother initially planned or preferred to give birth, but in fact did not actually give birth, either because she delivered elsewhere or developed a complication that required her to be transported to another facility. The current convoluted methodology of OOH birth would not be tolerated in any other aspect of modern healthcare and it is also not appropriate for place-of-birth research.
While the consensus of the scientific literature supports planned and attended OOH labor and birth as a responsible choice for healthy women with normal pregnancies, the lack of "standard characteristics" for OOH studies does a great deal of mischief and causes no end of grief for the midwifery profession. Studies on place-of-birth need to use standard scientific criteria that reduce personal bias and hidden political agendas, and instead helps inform public health officials and others who make policy decisions.
The only statistics on safety that are relevant to planned OOH birth are those that reflect outcomes for a normal term pregnancy that confirms the OOH status after onset of spontaneous labor and initial evaluation by the birth attendant. Only after the mother-to-be and her fetus are both confirmed to be essentially healthy and labor is at that point is normal can this mother's labor and birth be documented as a planned OOH event. In addition, the actual place of birth, the timing of any transfer (how many hours before or after the birth) and the actual reasons for any labor or birth-related 'bad outcome' is crucial.
Finding Middle Ground in Science:
Currently the neonatal outcome statistics for each basic category of birth attendant (MDs and midwives) and the two settings is remarkably similar. According to a general consensus of the scientific literature, hospital and OOH is statistically equivalent as judged by the rate of neonatal deaths. However, both side have a handful of controversial studies that either show a slight increase in neonatal mortality in OOH birth or show a significant increase in obstetrical intervention and Cesarean sections rates in the hospital-based group.
Even though the numbers of are small – approximate 1 ‘excess’ neonatal death per a 1,000 -- every doctor and every midwife has personally seen avoidable bad outcomes. If they are honest, they will have to admit that isn’t just the “other” category of practitioner that makes mistakes or otherwise exercises poor clinical judgment or has deficient skills. The apparent parity of outcomes between hospitals and OOH birth and between midwives and physicians represents parity in preventable mortality and morbidity, as each side loses some very small, but equal number of babies under circumstances that could have been avoided and should be improved upon.
As good as current outcomes are when compared to historical times and current third world countries, they could still be better. Some but not all of these poor outcomes are the cost of a system that does not have standard care characteristics for either category practitioners or either location for birth services. Logically speaking, if both professions addressed these essential quality-of-care issues head-on, we would see improved outcomes for mothers and babies.
For obstetricians and family-practice physicians, this includes a solid foundation in the principles and skills of physiological management, which would dramatically reduced number of medical and surgical interventions and operative deliveries. For midwives and others who manage childbirth physiologically, it would include a greater degree of caution and less hesitancy to consult, collaborate, co-manage or transfer care.
When caring for healthy women with normal pregnancies, trusting the wisdom of Mother Nature is a sound strategy. However, this strategy is even better when it is combined with the ancient wisdom of the Middle East, which counsels us to: “Trust Allah but tether your camel”. Of course this includes a sturdy rope and good knot-tying skills.
Part IV: Conclusions
When taken together and evaluated from a holistic perspective, these five studies offer great certainty about what makes maternity care safe and effective and provide us with a solid starting place.
We know that childbearing is unnecessarily and unacceptably risky when women are denied (or they refuse) the benefits of biological science and modern healthcare. We know that three simple, cost-effective healthcare measures reduce this high background rate of mortality and morbidity to a level equivalent to most developed countries. When this safety net is absent for any reason, including being rejected by the woman, prohibited by her family or their religious beliefs or hampered by laws that block access to birth attendants trained in physiological management, unnecessary risk and dangers are introduced into otherwise normal childbirth. It’s like swimming without a lifeguard.
These insights allows us to identify a number of actions and changes in national pubic health policy that effectively meet the purpose and goal of maternity care -- protecting and preserving the health of already healthy women.
Public health officials must work diligently to educate the public about the very real dangers of 'no care', and unattended ‘do it yourself” (DIY) births. The remedy to that is affordable, accessible, women-centered, mother-baby friendly maternity care with seamless (and no-fault) access to comprehensive obstetrical services as medically indicated or as requested by the childbearing woman.
National policies and efforts by public health officials must produce a mother-baby-father-friendly form of care that encourages the widest possible use of prenatal care and makes DIY unattended childbirth extremely rare. These are NOT place-of-birth dependent, but they do depend on integrating the three distinct categories of professional birth attendants (midwives, family practice physicians, and obstetricians) and both hospital and OOH birth settings.
Rejecting the Preemptive Use of Intervention as a Matter of Public Policy
The highest level of scrutiny, skepticism, and scientific proof must be applied to the preemptive use of medical protocols that disrupt the normal biology of childbearing or interfere with other normal biological function. At a national policy level, we must also reject maternity department routines that apply a protocol or medical treatment to the majority of its mothers or babies based on a minor risk factor or theoretical advantage, including a perceived advantage to the institution to protect itself against litigation or increase the profitability of its services.
PIT-TO-DISTRESS: An example of these dubious practices can be seen in a protocol known as “Pit-to-distress”. In this instance, the patient’s physician has ordered the L&D nursing staff to administer the drug “Pitocin” intravenous to induce or augment the woman’s labor. Then the nurse in charge of the patient is directed by the patient’s doctor or required by obstetrical unit's protocols to incrementally increase the rate of the IV Pitocin until the mother either delivers vaginally, her uterus ruptures or the unborn baby goes into fetal distress and has to be delivered by emergency C-section. This Pit-to-distress protocol is applied without the fully informed consent of the mother or other family members. Whatever perceived benefits to maternity departments or individual obstetricians are irrelevant -- 'Pit-to-distress' is not and never could be an ethical practice.
In 2006 the Wall Street Journal reported on these questionable practices and other "common practices in the delivery room ... endangering both mothers and infants". The article described efforts by some hospitals to reduce the liability-insurance premiums for their obstetrics units. These attempts were meant to curtail the excessive use of Pitocin and other labor inducing drugs to start or speed up contractions because they "can lead to ruptures of the uterus, fetal distress and even death of the infant". An assistant vice president of one institution described the problem by saying: "Pitocin is used like candy in the OB world, and that's one of the reasons for medical and legal risk ... in many hospitals it is common practice to "pit to distress".
Of the top six contributors to obstetrical litigation, the number one reason is the "inappropriate use of labor-inducing drug". In addition to the human cost, the WSJ's review of medical-malpractice claims showed that the use of Pitocin was involved in more than 50 percent of situations leading to birth trauma. After the Intermountain Healthcare instituted a program to reduce elective inductions and prohibit practices such as 'Pit to distress', they reported a sharp drop in birth complications that cut costs by $500,000 annually. [New practices reduce childbirth risk; Wall Street Journal July 12, 2006; Laura Landro]
INAPPROPRIATE UNTIL PROVEN OTHERWISE: More than 70% of all childbearing women are healthy and their full-term pregnancies are normal, a statistic that should be inversely related to the ratio of interventions. This is not rocket science. In fact, the math is simple – only a small proportion of mothers and babies are high risk or have complications, therefore, only a small number of maternity patients should be subjected to interventions and in all cases, a clear indication should be demonstrated. Any institutional policy that applies ‘special circumstance’ protocols to a high percentage of mothers or babies is inappropriate until proven otherwise.
This is best done by supporting the trilogy of skilled prenatal care that includes timely access to medical services during pregnancy and experienced birth attendants who are present through out labor, birth, the immediate PP & neonatal period. As always, this is tightly articulated with comprehensive obstetrical services whenever indicated for the treatment of health problems, complications or emergencies.
In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the care provider (obstetrician, family practice physician, or midwife) or the planned location of care. To do otherwise is illogical and irrational.
In conclusion, we come back to the basic principles: Mastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. Taken together these 5 sources of scientific information allow us to develop mastery in the normal by identifying the qualities essential to maternity care in the 21st century.
In summary, the three essential elements of safe and cost-effective maternity care are:
(a) Prenatal care with
risk-screening & referral to medical care for evaluation or
treatment as indicated
In an integrated system, physiologically-based childbirth services for essentially healthy women would be provided primarily by family practice physicians and professionally-trained midwives, with appropriate access to the services of obstetricians, perinatologists and other specialists as necessary.
Only this articulated model of maternity care can bringing evidenced-based maternity care into the mainstream of our healthcare system and consistently provide safe and cost-effective services to a healthy population of childbearing women and their unborn and newborn babies. Our energies must be used to transform our national maternity care policies and to reconfigure the system at its most basic and practical level, so that it promotes:
Lessons for Evidence-based Maternity Care in the 21st Century:
THE BELL THAT CAN'T BE UNRUNG: Physiological management – normal care for normal birth -- is the bell that can’t be un-rung. But to create a rationally-based maternity care system we must include all stakeholders and all professional providers, hospitals and other facilities. This would obviously require a calm and fair-minded coalition of professional groups, willing to learn how to cooperate effectively with one another. While this is an ambitious goal, it’s not impossible and it won’t break the bank cost-wise. It does however provide a firm foundation for all people of good will to come together. Working cooperatively, we can transform the policies and practices of maternity care in the US into a safe, cost-effective 21st century model that every American (even ACOG fellows) can be proud of.
There already are a number of vibrant and thoughtful consumer and professional organizations engaged in this question who have been doing a phenomenal job and have make had made a stellar contribution to advancing the public discourse and bringing about needed policy changes -- the Coalition for Improving Maternity Care (CIMS), the International Cesarean Awareness Network (ICAN), Childbirth Connection, Lamaze International, Midwives Alliance of North America, (MANA), the American College of Nurse Midwives (ACNM), the American College of Community Midwives (ACCM) and many many others. What we need is for ACOG to reach across the isle and work in equal partnership with this energized base.
While the discipline of midwifery is not a practice of medicine, it is a form of primary healthcare that incorporates the same body of knowledge about the basic characteristics of health and wellbeing. This requires the same skills to discern normal from abnormal and make appropriate referrals. In order for midwives to do their ‘half’ in healing the schism between medicine and midwifery, midwives of all educational backgrounds must utilize a high level of professional abilities in every arena of their practice. The other half of the equation is for state and federal governments to uniformly recognize the professional services of non-physician primary practitioners and first-responders and fairly compensated them for providing care in a wide variety of situations associated with pregnancy, birth, motherhood and newborns.
With the rarest of exceptions, the invaluable contributions of modern medicine enthusiastically acknowledged by midwives of all backgrounds, including the vital role of obstetricians, perinatologists and hospitals in responding to complications. This complimentary relationship between medicine and midwifery must replace the historical prejudice against physiological care and the obstetrical hubris against midwives left over from the 19th and 20th centuries. For midwives, burying the historical hatchet means gracefully walking away from a rather long list of grievances. For a very small group of midwives, it may require rethinking their own relationship with modern medicine. Irrespective of the starting point, the destination is nothing less than an inclusive, complimentary and mutually respectful model of cooperation.
The goal (already modeled by some Canadian provinces) would be in three crucial areas.
The form of care recommended by W.H.O. for a healthy population integrates the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This standard should apply to all categories of birth attendants and in all settings and include the use of conventional obstetrical interventions to treat complications or if requested by the mother.
This integrated model would transform the narrow focus of our interventionist obstetrical system into a broad based maternity care model able to respond to the practical needs a healthy population. Regardless of which system one is referring to, the crucial words are 'not disturbing the spontaneous biology of normal labor and birth unless necessarily', ‘access’ to the fruits of modern medical science and ‘appropriate use’ of medical services as indicated.
In a balanced system, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home in order to receive physiological management for normal childbirth. No matter who provides maternity care, they can be confident of receiving the best obstetrical services if or when they desire or require them and receiving appropriate, physiologically-based care for a normal labor and spontaneous birth.
Under those circumstance, place-of-birth would become what it was always suppose to be -- the right choice for the particular situation for that specific mother & fetus -- with hospital and OOH both seen as equally responsible choices in an integrated, cooperative and 'minimalist' model based on ‘best practices’.
Ultimately, all maternity care is judged by its results -- the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.
Quotes from Dr. Williams' Book ~ Twilight Sleep -
Simple Discoveries in Painless Childbirth
Baby Girl Brooks Thomas, born @ home June 12, 1991
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