Safety & the maternity-care continuum
in an essentially 21st century healthy population:
Surely that is one of the most boring titles that’s ever been my misfortune to write and yours to read.
But what I have to say is certainly not boring. Turns out that the realistic risks associated with childbirth in the 21st century in developed countries with functional healthcare systems is not what it is assumed to be.
The problem starts with the way people think about childbirth. The lay public and the medical profession both generally see it as universally synonymous with ‘danger’ — the idea that the biology of childbearing is fundamentally flawed and like germs, needs to be eliminated. But it turns out that the realistic risks associated with childbirth in healthy women who live in developed countries simply are not at all what people have supposed them to be.
Fear-based definitions do not make useful distinctions btw childbirth 1st and 3rd world countries, or btw healthy women with normal pregnancies and those where mother or baby have medical complications. Based on the perception of danger, everyone assumes that the pre-emptive use of medical and surgical interventions makes childbearing women and their unborn or newborn babies safer. Unfortunately, that is not the case.
The actual danger for healthy childbearing women and their normal unborn or newborn babies is either a lack of access modern maternity care and/or refusal to use such services (no prenatal care and/or an unattended labor and birth. Lack of prenatal care and/or lack of emergency medical services when a complication occurs does indeed make childbirth in modern times as dangers as it was 100 years ago, or as it still is in places such as Afghanistan and countries in sub-Sahara Africa such as Ethiopia and the Congo.
Plain Facts about Normal Childbirth . . . .
What is there was a simple, easily understood, scientifically demonstrable idea that could dramatically change our ideas about childbirth? What if this information could be used to develop a model of maternity care that would improve the safety of normal birth in healthy women, drastically cut the cost of childbirth services AND make a lot of people — especially childbearing families and businesses that pay for employee health insurance — very happy?
Sounds like a pipe dream I know, but it’s true. All you have to do is read on while I identify the kind of thinking that has blocked us from seeing and using this elegant solution for more than a century. Then I will ‘connect up the dots‘ so you can see for yourself. I promise that every minute you spend learning about this brave new world of safe childbirth practices is well worth it.
The problem with looking in the wrong place for solutions is that it doesn’t work and so is eventually people just stop looking altogether. Society has either been asking the wrong questions or ignoring the topic altogether. However, asking the right question is amazing: What
The Way-back Machine — Where it all started and how we can get to a better place
For the last 100 years, organized medicine in the US has promoted two intertwined ideas.
- That normal childbirth, even for the healthiest of women with the most normal of pregnancies, is stunningly over-the-moon dangerous
- That it’s impossible to tell ahead of time what might go wrong for any one laboring woman or unborn baby, therefore, there the ONLY policy-level solution to prevent these tragedies is to preemptively medicalize normal childbirth
The reason for these negative assumptions was a mixed bag of motives. In the pre-modern medicine, pre-antibiotic era, mortality for childbearing women was indeed very high, so these ideas represented a noble purpose — the genuine desire to eliminate preventable tragedies. But they represented an assumption that class status, part economic :
It’s true that things can go seriously wrong before, during of after childbirth, and these problems can be unexpected. Its a fact that new mothers and babies can and do suffer and can even die if quick access to the right kind of medical services is not available. While these ideas are true, they don’t represent the whole story.
Nonetheless, it is a fact that things can go seriously wrong during childbirth, and such problems can be very unexpected. New mothers and babies can and do suffer and can even die if quick access to the right kind of medical services is not available. While these ideas are true, they don’t represent the whole story.
However, was nonetheless assumed by everybody that the twin ideas of danger + total unpredictability meant that nothing can be done at a policy level — that the danger of childbirth is immutable. With that as the guiding principle, the only national policy that seemed to address the issue was to unlimited amounts of money in an effort to maximize the medical treatment of each pregnancy woman and pregnancy woman and every woman.
So far the mainstream medical world has only identified only one area of maternity care policy that seems to help. Very early in the 20th century, public health official noticed a weakly positive relationship between early prenatal care and reduced complications. However, further research done many decades later discovered that it wasn’t the medical care received but the economic circumstances of the woman — with better financial resources, women can easily afford to start seeing a doctor as soon as they suspect their are pregnant. But it turns out the beneficial effect not in professional attention but the higher standard of living, with its better diet, more favorable working conditions and the likelihood that the spacing and number of children would be less because the mother-to-be had access to effective contraception.
The list of possible reasons for the depressing record was long but misguided — it was squed toward finding who to blame –a basic defect in the biology of female reproduction? bad genes in individuals? poverty? diet? lifestyle? lack of access to top-quality obstetrical care during labor and delivery? Not enough well-equipped hospitals? A more helpful inquiry is finding out where the real danger lies and what turns back that tide and then what building on what works, even if it doesn’t match one preconceived ideas.
In our own time, the explanation s for why we have such bad maternal-infant statistics compared to other developed countries tends to focus on blame. The preferred answer always seems to come back to an unfavorable, unflattering characterization of childbearing women, who are pejoratively identified as older, fatter, in poorer health, suffering from fertility problems due to delayed childbearing and then suffering the complication that come with A.R.T., such as in-vitro fertilization — multiple eggs often means multiple gestations (twins, triplets, etc) and all the complications that introduces, such as increased prematurity, the need induction or surgical delivery.
To the obstetrical profession, maternity care for healthy women equates to the routine or ‘pre-emptive’ use of medical interventions and invasive or surgical procedures in the vast majority of all childbirths. While 70% or more of all childbearing women are healthy and have normal pregnancies, the current model manages to impose no less than 7 major and minor intervention on over 90% of all births.
So far policies by groups, governments, insurance payors, etc have all been totally ineffective in turning this around. Even the sharp increase in maternal mortality has had little effect at a policy level — it seems that on an official level, we still believe that “the doctor knows best”.
Two kinds of data are required to intelligently determine if the maternity care provided by both obstetrical and midwifery practitioners is making the kind of cost-effective contribution that economists refer to as ‘value added’. But before we can identify “value-added”, we must first identify the innate riskiness of normal childbearing in modern times — that is, developed countries such as the US, with a functional health care systems and general access hospital-based comprehensive perinatal services. Only after we have those facts can we directly quantify the relative benefits of each category of maternity care.
All important comparison category of “No Care”
This requires baseline data for essentially healthy women who by choice received “no maternity care” (either prenatal care or profession birth services), 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.
1. 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:
(1) a contemporary study of purposefully unattended births & rejection of necessary emergent care (2) a retrospective study of lay midwife-attended OOH w/ access to comprehensive medical service
(2) a retrospective study of lay midwife-attended OOH w/ access to comprehensive medical service
(3) a prospective study of professional midwife-attended OOH w/ access to comprehensive medical services
(4) a prospective Canadian study that contrasted outcomes for a select groups of low-risk women that gave birth under three different circumstances (a) OOH setting under the care of direct-entry midwives, (b) in hospital under the same category of midwives and (c) in hospital by MDs
(5) a configuration of hospital-based obstetrical studies of medically-managed hospital births in low and moderate risk women by obstetricians, FP physicians and certified nurse- midwives.
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 for any reason, including economic hardship, 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.
2. 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 access to all categories of maternity care providers and settings, but purposefully choose unattended births based on religious beliefs.
Data on this group of unattended 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. This situation is 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 county-registered lay midwife. However, state laws did not authorized these non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears but as regulated group these lay 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 rate of neonatal loss of 4 per 1,000 (including 2 fatal birth defects).
Note: This study also noted the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended. This included women/families that rejected care, as well as women of color who turned away by local hospitals because laboring woman who did not have the prescribed ‘cash in hand’. These unattended births had a dramatically increased perinatal mortality rate of 30 to 120 deaths per 1,000. This rate was consistent with the dramatically increased rate of stillbirths and neonatal mortality in 3rd world countries and unattended births among the religious group in Indiana. It also highlights the preventive value of physiologically-based pregnancy and childbirth services and the importance of access to medicalized maternity care during pregnancy as indicated and use of 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 this form of midwifery care were a drug or medical device, it would be illegal for the healthcare system not to offer such care to childbearing woman.
Study #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 June 2005)
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 and 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 prospective study published in 2009 compared the outcomes of PHB in British Columbia (Canada) 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. This study found the risk of perinatal death associated with PHB attended by midwives did not differ significantly from the low rate noted for 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.
3. 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, the incidence of neonatal mortality would have reduced (but not eliminated) by greater use of prenatal diagnostics and planned hospital care. However, this is a patient choice and 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 prenatal diagnosis and termination of affected pregnancies does reduce neonatal mortality rate, but obviously does not reduce over all perinatal mortality.
There is nothing that birth attendants can do or not do that can reliably, and with economically sustainability, create a condition of zero risk for both mother and baby 100% of the time.
4. 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: Most people assume that the care of lay midwives would be little better than unattended births, but this is a mistaken conclusion. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives and provided to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality 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 midwives who were obviously capable of recognizing medical problems and arranging timely transfer of patients with complications to hospital-based obstetrical service.
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 reduced 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 the professional midwives in study #3, and lower maternal mortality rate equivalent to hospital-based-obstetrical care.
Expansion of services by lay birth attendants would not be a viable option for the structured healthcare systems of North American and their reimbursement scheme by governments and insurance carriers. 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 for any reason are excluded from, or exempt themselves 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 lethal birth defects). This was 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. 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 statistics do not account for all OOH births attended by Canadian direct-entry midwives during this five-year period. The study was restricted to the very lowest of low-risk women, which is merely sub-set of all childbearing women who choose midwifery care. The study population had good access to and use of prenatal screening, which eliminated all identifiable risks and all diagnosed congenital anomalies from all three cohorts.
The Principle of Autonomy in democratic societies
While we all aspire to the ideal circumstances used in this study, such perfection cannot be replicated 100% of the time by 100% of the childbearing population. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare. With the rarest of exceptions, this principle applies to all 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 accept the increase risk of a specific pregnancy situation or intrapartum circumstance that puts her into a moderate risk category — a small fibroid, a large baby, prolonged rupture of membranes, meconium, a post-dates baby with reactive NST or a vaginal birth after a Cesarean. It is necessary for the maternity care system to acknowledge the ethical and constitutional rights of adult women to continue receiving birth-related services even when they are not perfectly ideal candidates for OOH care.
Denying access to professional OOH care for women who are less than perfect candidates traps such women between the Devil and Deep Blue Sea. As a matter of policy, it unwisely forces them to choose between a level of medicalization they do not want, (and may not benefit from) or the very real risks unattended childbirth. The other problematic possibility is that many women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives this subset of women access to adequately trained attendants and medical back-up arrangements, but 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 right to 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.
PLANNED, 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 increased Cesarean section rate of 32% and drastically increased cost of care. However, this escalating CS rate has also been associated with the upward trend in maternal mortality (MM).
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.
5. 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.
