A multi-part series originally posted on HealthCare_2.0 (to read entire document)
link back to part 2
Part 3 ~:~ 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 determinethe 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 range from safe to unsafe practice may be wider within each location that it is between them. Addressing what constitutes safe practice at home may be a more pivotal concern than attempting to quantify the theoretical differences attributable to place of birth.”
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.
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