Identifying the Essential Qualities of Maternity Care: part 2 of Evidence-based policies & a plan for action

by faithgibson on April 19, 2013

in Contemporary Childbirth Politics

A multi-part series originally posted on HealthCare_2.0

Link to #1 – Intro ~ Background and Overview

The Optimal Purpose of Maternity Care

Part 2: 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 devoted to preserving health and effectively preventing or successfully treating 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.  

(a) Antenatal care with risk-screening & referral for medical evaluation or treatment as indicated
(b) Birth attendant (s) skilled and experienced in physiological management who remain present or immediately available at the mother’s discretion during active labor, and fully present during birth and postpartum-neonatal period
(c) Access and appropriate use of hospital-based obstetrical services for complications or if medical care is requested by the mother

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.   

Read more –> part 3 ~:~ Maternity care as a continuum of provider characteristics

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