Word count 1600
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Wrap up of Mayday series:
Introducing a *new vocabulary*
Final Word & Action Plan
** The Bigger Picture and new vocabulary for the kind of maternity care that best serves the needs of healthy childbearing women and their families and is most cost-effective
Maternity care and obstetrical services are two different things!
I am making a vocabulary distinction in between the system of maternity care for healthy women with normal pregnancies and the system of comprehensive obstetrical care for women with high-risk pregnancies.
By being more precise with our vocabulary, we can easily make the important distinction between these two systems.
The term “maternity care” to describe the kind of care and the type of caregivers who serve essentially healthy women with normal pregnancies.
Likewise, the term “obstetrical care” identifies a medical-surgical discipline that provides services to childbearing women who have a high-risk pregnancy or develop a serious complication that benefits from the high-tech diagnostics, medical interventions, and surgical procedures.
No question that we need and benefit from both systems and that both systems need to respect and cooperate with each other.
When evaluating the two systems, efficacy of policies, and the risk-benefit and economic costs of diagnostics devices, medical treatments, and surgical procedures, all aspect of reproductive mortality and morbidity over the course of a woman’s entire reproductive life must be taken into account.
This determination of risk vs. benefit to the childbearing family and the economic cost to society must include delayed and downstream problems, complications in subsequent pregnancies, future fetal or neonatal loss and the overall cost of care to individuals and society.
All Maternity Care is Judged by its Results
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.
However, there is also no question that the population of healthy women with normal low-risk pregnancies far outnumbers the women who face highly risky circumstances. Over 70% of childbearing women in the US are healthy, have normal pregnancies and give birth to healthy babies.
The Basic Purpose of Maternity care for Healthy Women with Normal Pregnancies
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 adequately serve the needs of a healthy childbearing population and effectively prevent or successfully treat complications during pregnancy and childbirth.
Mastery in Normal Childbirth Services for Healthy Women With Normal Pregnancies
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.
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.
Physiologically-based Care for Spontaneous Labor and Normal Birth
For the vast majority of healthy women, the model of care that meet these goals is a non-interventive and supportive approach to described as “physiologically-based care” for spontaneous labor and normal birth.
Stedman’s Medical Dictionary defines “physiological” as “…in accord with or characteristic of the normal functioning of a living organism” (1995). Childbirth practices based on the physiologic model – principles such as an upright and mobile mother during labor and the ‘right use of gravity’ — contributes greatly to safe and cost-effective maternity care.
We enjoy a high standard of living in North America and the great majority of pregnant women have access both to routine maternity care and comprehensive obstetrical services to effectively treat complications. As a result, healthy childbearing women can expect a good outcome for themselves and their babies.
But to meet these needs requires 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 issue is the quality of care, irrespective of the type of birth attendant (MD or midwife) or the birth setting, that reliably and safely meets the needs of the childbearing women and their babies.
To paraphrase a popular religious text:
“Who among you if his child should ask for bread, would give instead a stone?”
We must make sure our system for providing care to healthy childbearing women with normal pregnancies does not unintentionally offer a “stone” in the place of the kindly extended and safe helping hand of a maternity care provider.
My Final Words:
The goal of this website and the raison d’etre of this MAYDAY series is a commitment to a wise blending of the art and science of modern maternity care. To put this into action in the real world would require developing a model of maternity care that uses emotionally intelligent ‘best practices‘ to serve pregnant and laboring women during the reproductive life-cycle of the childbearing family.
A wise midwife friend of mine describes this as:
“supporting the process of relocating power and solutions within the communities they are intended to serve” 1.
Couldn’t have said it better myself!
- Quote from the website of Maeve Sunstrom, LM, CPM.
And Now the Action Plan!
So far political activities have been unable to correct the inappropriate obstetrical standard of care used in the US for healthy low-risk women, but I believe there is a successful strategy that will actually work.
It is simple and straightforward, will not increase the cost of maternity care but will dramatically reduce the C-section rate and its associated complications. This will, in turn, reduce the costs for health insurance companies and the federal Medicaid program.
The goal is to rehabilitate the provision of maternity care in America so that c-EFM is no longer the universal standard of care and healthy women with normal low-risk pregnancies are not treated as if they were high-risk.
This will require a public information campaign (like this Mayday series) that will lead to both legal and legislative action.
I believe these 3 proposals would end the inappropriate use of EFM and would restore the ethical foundation of American obstetrics and return obstetrical medicine to its noble place in the pantheon of modern medical science.
1. Fully-informed Consent
1. The legal requirement of patient consent so configured that healthy low-risk women with healthy pregnancies can make fact-based choices about the kind of maternity care that best suits them.
This naturally would include specific information about auscultation of fetal wellbeing and c-EFM and other obstetrical policies, protocols, and procedures that might be recommended to them during their pregnancy or labor.
Information for childbearing families must acknowledge the inability of c-EFM to improved perinatal outcomes in low-risk pregnancies, as well as identifying the increased risk to the childbearing women directly associated with the statistically-significant increase in Cesareans (and their inevitable complications) relative to the routine use of c-EFM on healthy low-risk women.
It also must acknowledge additional increased risk when hospitals use central monitoring systems.
2. Embarking on public information campaign that includes investigative journalism from an organization such as ProPublica, PBS, and NRP
3. Requiring manufacturers and distributors of continuous EFM devices to acknowledge their legal “Duty to Warn“. This must include a product disclaimer printed in the technical manual shipped with each electronic fetal monitor machine that reports the published findings of scientific studies over the last 49 years.
The consensus of the scientific literature has unambiguously established c-EFM as ineffective at reducing the incidence of cerebral palsy and similar neonatal encephalopathies (i.e. neurological problems).
In addition, the routine use of c-EFM is medical inappropriate during the labors of healthy low-risk laboring women, as it increases the cost of care, the rate of Cesarean surgeries (with its associated increase in risks and complications) without any correlating benefit to the mother or baby.
Duty To Warn:
~ Manufactures of EFM Equipment, Hospital Obstetrical Department & Providers
Last but not least, is an additional “Duty to Warn” by the manufacturers of central EFM systems (CMS). Developers and manufacturers of the CMS must also acknowledge the scientifically-established fact that central EFM systems currently being used in hospital L&D units have an even higher C-section rate than the hospital’s standard use of c-EFM in which an L&D nurse is personally responsible for ‘monitoring’ the fetal monitor strip in real-time.
This Duty to Warn must include the many intra-operative, post-operative, delayed and downstream complication associated with Cesarean surgery which includes but are not limited to:
- Intra-operative and immediate complications: drug or anesthesia reactions, hemorrhage, shock, peripartum emergency hysterectomy (13 Xs higher rate following CS than vaginal birth) that requires days or weeks in the ICU
- Post-op complication requiring a post-Cesarean mother to be treated for an infection following her surgery
- Inability to establish or maintain breastfeeding when new mothers have to be re-admitted to the hospital with a drug-resistant infection the requires a week or more of IV antibiotics
- Delayed complications in previous-Cesarean mothers who develop a placenta accreta or increta in a subsequent pregnancy that is so extensive a Cesarean-hysterectomy is required
- Downstream complications in which previous-Cesarean mothers find themselves to be one of the unlucky 7 to 10% of placenta percreta patients that, in spite of being care for in one of the best hospitals with the best doctors, blood banking and best of modern medical and technological equipment, dies from a massive and uncontrollable hemorrhage
- Rare long-term complication a post-Cesarean mother dies months later from post-op complications such as a necrotic bowel caused by adhesions that develop due to her Cesarean surgery
- Secondary infertility when post-Cesarean women find they are no longer able to get pregnant due to a post-Cesarean surgery infection that scared their fallopian tubes
- Maternal death due to an intra-operative, post-operative, delayed or downstream complication of an often medically-unnecessary C-section
- Impact on Spouse and other family members — maternal death makes her husband or partner into a widower and leaves their children without a mother.
An Aside:
Technical Definition of the terms Efficacious vs. Effective when used in publications of scientific research
“… the clinical and translational science literature selectively uses the words efficacious/efficacy and effective/effectiveness consistent with their medical definitions to differentiate between an intervention (such as a drug) that can work in a controlled patient population during a randomized controlled trial and one that works in the real world in day-to-day practice, respectively.6“
Studies on the ability of c-EFM to reduce the incidence of cerebral palsy and other neurological problems affecting newborns usually employ the term “efficacious”, which describes ideal conditions of the study.
Even with this narrow definition, c-EFM is NOT any more effective than auscultation and continues to be associated with an increased rate of operative vaginal deliveries and C-sections.
