Link to: Twenty-first century maternity care as a cooperative adventure btw medicine and midwifery
We need to learn to love our maternity care system, dysfunctional as it seems to us.
We need to own it, to think of it as ours, to believe that it can again be based on rational logic and returned to balance by meeting the needs of all stakeholders – mothers, babies, all categories of birth attendants and healthcare institutions including hospitals.
We need to use our energies to transform our national maternity care policies and reconfigure the system at its most basic and practical level. We need to promote ideas like:
- Maximal results with minimal interventions
- Skillful use of physiological management
- Adroit use of medical interventions as necessary
- Fewest number of medical/surgical procedures
- Least expense
- Best outcome for mothers and babies
- Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and others members of the family
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 standard obstetrical interventions to treat complications or if requested by the mother.
When that is done, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home. No matter who provides maternity care, they can be confident of receiving appropriate, physiologically-based care for a normal labor and spontaneous birth and having appropriate access to the best obstetrical services if or when they desire or require them.
Mind the Gap!
We rabble rousers believe that physiologically-based care should be the universal standard for healthy women with normal pregnancies unless the mother herself requests medicalized care.
Many of us have worked our entire adult life to transform the narrow focus of our interventionist obstetrical system into a broad based maternity care model, one that is able to respond to the practical needs a healthy population. The Coalition for Improving Maternity Services (CIMS) calls this “mother-baby-father friendly maternity care”.
But for all our idealism, enthusiasm and sustained effort, we remain locked out of the system by factors that are political rather than scientific. In the current configuration, mothers and midwives have to lose in order for ‘them’ (the obstetrical system) to win. The resurgence of independent midwifery and PHB was the result of our collective inability to make a positive impact on our hyper-medicalized system.
As non-nurse midwives, we specifically wanted to fill in the ‘gap‘ by meeting the needs of childbearing women that the obstetrical profession couldn’t or wouldn’t address or acknowledge.
None of us ever expected (or wanted) to create a parallel system of midwifery education and practice that remained permanently separate and outside the health care system. Apartheid is never a satisfactory situation. Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the fray.
Even more than our frustration as activists, we continue to be personally affected by the painful schism between our values and our on-going experience of interventive obstetrics as applied to healthy women. Speaking as someone who has been doing this since the 1960s, when twilight sleep, episiotomy and forceps deliveries were both mandatory and universal, our activism has not been a happy or totally successful endeavor.
Yes, we have won a few battles and I am grateful for that, but in many instances it was an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that manages to change but never actually fix the problem. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.
The routine use of narcotics, scopolamine and general anesthesia in the 1960s (over 80%) has simply been replaced by an epidural rate in most hospitals of (you guessed it!) 80%. The liberal use of Cesarean replaced the routine use of forceps and leaves us with a C-secton rate that is as high as 70% in some hospitals.
Childbirth is still conducted and billed as a surgical procedure. Our monolithic obstetrical model is characterized by routine interference in normal biology (such as routine inductions). This type of unnecessary intervention is either mandated by medical liability issues or they represent “physician preference”.
But the bottom line is this: The risk of childbirth-related morbidity and mortality can be time-shifted, place-shifted and person-shifted, but no matter how much risk and cost-shifting is done, bad outcomes will never be totally eliminated.
There is nothing in modern medicine that can be done or purposefully left undone that will reliably, ethically, and with economically sustainability, reduce risk to zero for both mother and baby 100% of the time.
Increased rates of pregnancy termination via prenatal testing, and at term through the use of scheduled inductions and Cesarean delivery may very slightly reduce perinatal morbidity & mortality rates. Obstetricians claim hospital care reduces NNM by 1 baby per 1,000 live birth, but this cannot be done without the obvious cost of increased maternal morbidity and mortality, especially as related to surgical delivery.
Painful, invasive or humiliating procedures that we neither need or want continue to performed on our clients, our loved ones or on ourselves. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled induction and elective Cesarean as the way to make ‘better babies’. Apparently no all obstetricians are equally invested in making things better and safer for childbirth women.
Whether one is ‘merely’ a pregnant women or a midwife, we have been losing the intervention war for the last 100 years.
As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. It’s hard to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will perpetuate instead of fix this out-of-balance system.
What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems.
Contemporary obstetricians inherited a difficult situation that was not of their own making. They were schooled by a system that taught female biology was destiny when it came to reproductive. Childbearing is seen as an undependable patho-physiology that uses women up the way salmon are sacrificed during spawning. It must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed were rule. In places like sub-Sahara Africa and Afghanistan, women dying relative to pregnancy childbirth claim one out of every eight such mothers-to-be.
- World health organizations identify a ‘natural’ level of approximately 1,100 maternal deaths per 100,000 pregnancies in areas without access to comprehensive obstetrical services. In the late 19th and early 20th century, when our interventionist model of American obstetrics was first developed, physicians were facing the same problems that developing countries grapple with today.
- In 1900, the average married woman in the US had 17 pregnancies, 12 live births, but only 9 living children. Women expected to lose a tooth with every pregnancy. Poverty and high birth rate were associated with problem pregnancies, especially in very rural farming areas and for immigrants and ethnic minorities living in crowded urban tenements.
- Racial discrimination and economic inequities resulted in chronic ill-health, which made childbearing women vulnerable to childbirth serious complications that obstetricians could not predict, prevent or treat. In the poorer sections of town, one new mother died for every 100 births and one of 10 infants did not live to see their first birthday.
- Many of these life-threatening complications childbearing required surgical solutions and these became the heart and soul of the ‘new’ obstetrics for the 20th century as a surgical specialty – desperately needed ways to rescue mothers and babies that would otherwise die or be permanent damaged.
These well-intentioned obstetricians were responding to this grave situation in the many decades that preceded the discovery of antibiotics, when one-third of all maternal deaths were the result of puerperal sepsis – the infection known as ‘childbed fever’. The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis in hospitalized maternity patients.
Labor began to be managed as a medically emergency. For the first time ever, normal vaginal birth was defined as a surgical procedure. As a surgical procedure, the ‘delivery’ was to occur in a restricted, sterile environment, routinely conducted as an operation by a surgically-trained physician. Due to the difficulty of maintaining strict surgical sterility, it was necessary to anesthetize labor patients. Once anesthetized, the delivery need to be surgical included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the episiotomy or other perineal wounds.
This represented the most profound change in childbirth practices in the history of the human species. This advancement in maternal-fetal medicine It was nothing shot of a miracle when applied to women suffered from pre-existing diseases and those who developed life-threatening complications during pregnancy or labor.
Unfortunately, the pre-emptive use of these aggressive and invasive techniques was routinely applied to healthy women without any problems or complications. This was the consequence of an unexamined premise — that childbirth was only normal in retrospect meant and that the preemptive use of intervention was the proper standard of care for all pregnant women, irrespective of their risk-status.
However, when such extreme measures are used on women who don’t have any life-threatening problems, these life-threating medical treatments themselves can become life-threatening.
We now know that interventionist obstetrics as the standard for healthy women was based on an erroneous assumption – that the pre-emptive use of such highly invasive and medically risky procedures would eliminate all the risks of childbirth.
For the first decade of this “new obstetrics” regime (1910-1920) the maternal mortality rate actually rose by 15% a year, and birth injuries for newborns by 44% over the same decade. Thankfully, the most egregious of these practices – were abandoned by the obstetrical profession decades ago as the dangers they introduced became obvious to all.
Beginning with Grantly Dick Reed’s book “Childbirth Without Fear” and the classic “Thank You Dr. Lamaze in the late 1960s, there was an awakening of interest in normalizing childbirth by childbearing women, childbirth educators, and L&D nurses. Organization such as the ICEA, ASPO and Bradley Methods were the natural conclusion of this consumer-based interest in changing hospitals policies and obstetrical practices.
This was much more difficult and slow that most people expected and in many ways achieved only cosmetic results – friendly architecture, colorful bedspreads, wallpaper and curtains and policies that permitted husbands and other family members to be present during the labor and birth. However, changes in obstetrical policies and practices continued under the radar to go in the wrong direction.
Continuous electronic fetal monitoring and IVs during labor keep women tethered to the bed during labor. Twilight Sleep drugs (scopolamine and narcotics) and general anesthesia was replaced by epidural, which also meant IVs, automatic blood pressure cuff and a Foley catheter. Liberal use of Cesarean replaced the use of forceps to hasten birth or terminate the labor for any reason. As the first Listening to Mothers’ survey identified, the average CB woman had seven significant medical and surgical interventions.
The failure of the obstetrical profession in the US to listen to mothers and other consumer activists eventually lead to a major resurgence of interest in independent midwifery and planned home birth. But home birth is not really the issue – in fact, it’s a distraction. The real deal is that no health childbearing woman ever be forced to choose between a midwife and a physician, or btw home and hospital in order to have a physiologically-managed normal childbirth.
As mothers and midwives, our real goals have never changed. We need a 21st century maternity care system that works in and out of hospitals, works for doctors and hospitals as well as mothers and midwives.
We want a maternity care system that fulfills its basic purpose — protecting and preserving the health of already healthy women. That describes a cost-effective model able to simultaneously 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 definition must factor in the full spectrum of reproductive mortality and morbidity throughout a woman’s entire reproductive life. That includes complications at the time of the birth as well as any delayed and downstream problems in subsequent pregnancies, such as future fetal or neonatal loss. Mastery-level care also factors in both the economic and the human cost.
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.
That means a maternity care system in which the physiological management of normal childbirth is the science-based standard of care for all healthy childbearing women. Such a system would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women, and used by all birth attendants regardless of their educational background (MD, OB, CNM or LM) or the planned place-of-birth (home, hospital, or free-standing birth center).
In this system, the nature of care provided would logically determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife).
This will reduce our Cesarean rate by 50% and bring our MMR back down to earth, while making for happier mothers and healthier babies and freeing up an additional 10% of the health care budget to spend on people who are genuinely ill or injured.
As an “expert” system, 20th century obstetrics often failed in the very area it is supposed to have the most mastery and expertise — preserving the health of already healthy mothers and babies. When corrective information was provided, the obstetrical profession was willing, for the most part, to take the appropriate corrective action. That is maddening and frustrating, but in the long run anger and blame won’t help. Doctors and midwives both need to leave this 20th century baggage behind, and create via mutually respectful dialogue, a willingness to work through the problems to a win-win solution.
An integrated 2st century system would utilize obstetricians for what they are actually trained to do – treat women who are suffering from the diseases and dysfunctions of fertility and childbearing. The idea of spending 12 years in medical school to become an obstetrically trained surgeon (w/ $150,000 in student loans), and then spending your days mostly providing supportive non-medical to healthy women has always been a crazy.
What if we decided instead to have obstetricians practice obstetrics and midwives practiced midwifery?
So we are back to beginning – learning to love our maternity care system, warts and all. We need to own it, to think of it as ‘ours’, to believe that it can again be based on rational logic and returned to balance by meeting the needs of all stakeholders – mothers, babies and all categories of birth attendants.
We need to use our energies to transform our national maternity care policies and reconfigure the system at its most basic and practical level. We need to promote ideas like:
- Maximal results with minimal interventions
- Skillful use of physiological management
- Adroit use of medical interventions as necessary
- Fewest number of medical/surgical procedures
- Least expense
- Best outcome for mothers and babies
- Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and others members of the family
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.
That’s a win-win for everyone. ^O^ ^O^ ^O^
Link to: Twenty-first century maternity care as a cooperative adventure btw medicine and midwifery
