Originally posted Monday, June 28, 2010 ~ www.normalbirth.org
The Problem with Using Place of Birth as Proxy for Style of Intrapartum Management
faith gibson, LM, CPM
June 28, 2010
MANY MEDICAL AND MIDWIFERY PROFESSIONALS, as well as birth activists and consumers, confuse birth setting (hosp. vs. OOH) with intrapartum management style or may use these terms interchangeably, sometimes to mean an actual physical location, and other times to refer to a management style.
In this paradigm, ‘home’ has become a frequent proxy for non-medical or physiologically-managed care without use of, or access to comprehensive obstetrical services, while the hospital has become a proxy for medical management. We generally assume that the hospital-based medical model is universally safer, while planned home birth care is inevitably defined as more risky.
This makes two erroneous assumptions simultaneously — that PHB attendants routinely reject the appropriate and timely use of obstetrical services and that routine medicalization of healthy women is universally positive or at the very least, neutral.
I would never want to live in a place or an era without timely access to comprehensive medical and surgical services (which depend on hospital facilities), so I never see this as an ‘us vs. them‘ issue. I want hospitals to work and work well. But these proxy assumptions make it impossible to get our hands around the very real social and medical problems we face. Instead of stepping stones to progress, these notions become stumbling blocks that keep society from finding innovative solutions and making “best practices” more widely available to more people.
Even in places like Africa, we generally apply these same proxy assumptions. People frequently refer to the high maternal mortality rate in developing countries as a realistic measure of how dangerous childbearing is. However, an exhaustive, case-by-case study of all maternal deaths occurring in one particular region of The Gambia is instructive.
Normal Childbirth and Preventable Death in Third World Countries
An exhaustive study on maternal deaths in The Gambia provides a window into why childbearing women die in third world countries. The problems start with a lack of infrastructure to get to the hospital (no passable roads, no car, no gas, etc). For those lucky enough to arrange transportation, followed by an arduous 8 hour trip over unpaved roads, their problems are not solved simply by arriving at the hospital.
The medical version of “lack of infrastructure” are hospitals that did not have the essential element needed to provide the necessary care. Often there was no doctor on duty.
The most frequently preventable cause of unnecessary MM identified by the study was a tragic lack of simple economic resources — hospitals with no running water, no gas to run the hospital generator for electric lights in the OR, no doctor on site who could perform a Cesarean, no drugs to treat or prevent fatal infections, no banked blood to treat hemorrhage. These glaring deficiencies were often combined with unresponsive or inappropriate actions (or omissions) by the hospital staff.
In the Gambia study, all but 2 of these maternity patients were in the hospital at the time of their death, and one of those died of an infection after returning home after a Cesarean section performed in the hospital. The vast majority of these women either delivered in the hospital or were admitted early enough in the course of a potentially fatal complication to have been successfully treated by current medical standards. It was not the location but quality of care that was the critical issue.
Normal Childbirth and Preventable Death in the US
As a former administrator of a professional liability group from 1998 to 2000 for CNMs and licensed midwives in three states, I was privy to reports of malpractice cases against obstetricians and midwives in both hospital and OOH settings.
Unfortunately, there were a number of instances in which it was evident (med-mal carrier settled out of court) that a baby died or was neurologically damaged by the elective use of medically unnecessary obstetrical interventions in a healthy mother who did not herself want the intervention.
Just two sources of published literature (cited below) identified a long list of iatrogenic complications that resulted in serious morbidity or mortality and in some of these cases, malpractice litigation. These included:
- induction of labor for physician convenience
- augmentation to hurry things along due to obstetrician’s office hours
- use of fundal pressure that resulted in prolonged shoulder dystocia
- the OB was not in the hospital
- the OB refused to come when called by the nurse who reported a problem
[The Obstetrician’s Professional Liability: Awareness & Prevention, D. Rubsamen, MD, LLB, 1993; Nurses in the Courtroom: Cases and Commentary for Concern Professionals, B. Calfee, JD, LSW, 1993; How Doctors Think, J. Goopman, MD, 2007]
Childbirth and Preventable Deaths in Community-based Midwifery
There were also a small number of OOH midwifery cases with bad outcomes; these fell primarily into two general categories.
The first and thankfully rarest category was either a disregard for well-established, evidence-based practices by either parents or midwife, or a decision made by the parents after being fully informed in which they declined standard midwifery/ medical care such as prenatal lab work and genetic screening, ultrasound for congenital anomalies, or in a few cases, initially refused hospital transfer until it was too late.
In those instances, it was not the OOH location per se but a lack of common sense and/or good judgment by either the parents or the midwife or both.
Since these are not really a “place of birth” issues, the best answer to this problem is:
- better education of the public
- more responsive maternity care so parents do not become pathologically fearful of medical services
- effective preparation and regulation of midwives in the responsible practice of their profession, irrespective of location
The more frequent, but still statistically rare situations that result in a genuinely unpredictable adverse event. This includes a small number of cases in which serious morbidity results from longer transfer times; this primarily applies to babies that develop respiratory problems (such as meconium aspiration) and mothers with sever postpartum bleeding.
Mortality is thankfully rare and generally comparable to outcomes in planned hospitals births. These rare tragedies include prolapsed umbilical cord, placental abruption in a normotensive mother, fetal demise or stillbirth of a baby later determined to be the result of prenatal factors such as a maternal infection in early pregnancy. In at least one instance that i am familiar with, an amniotic fluid embolism resulted in a maternal death.
One certainly could argue that if these women had been laboring in a Level II hospital with a fully staffed OR just a few feet away, or in a tertiary care institution with 24-7 in-house surgical, anesthesia and perinatal services, the mother or baby could have been rescued.
However, these very same complications occur in hospitals, and in far too many instances (certainly as judged by the family who lost a loved one), even the most intensive of hospitalization was not able to prevent deaths and permanent neurological damage in most of these cases.
An Inconvenient Truth about First-World Hospitals
As a former L&D nurse who often worked in smaller or rural community hospitals, I also know of instances in which the mother was in the hospital but the doctor was at home.
Unfortunately, the same critical issues applied, with the same poor outcomes. Thirty-nine minutes from decision to incision can be far too long, no matter if it represents transport time from the parents’ home to an awaiting institution or time wasted by nurses frantically paging “any doctor in-house stat to L&D“, while calling the OB at home, paging him again and again and again, and then waiting for him to arrive while the nurses prepare the mother for a crash C-section that turned out to be too little too late.
In 1910 OOH became the Choice of Last-resort for families in the US seeking physiologically-manged labor & birth
In far too many places, OOH birth — particularly PHB — is the only circumstance where true physiological management can be legally and fully employed. This reflects two serious problems that could be but so far have not been addressed at the level of national maternity care policy.
The first are OB department policies and med-mal carrier protocols that require obstetricians to follow a strictly defined medical model of care. This frequently includes elective induction at 40-41 wks and preemptive use of IVs, continuous EFM, a medically-defined schedule for progress in labor, and liberal use of operative delivery for any number of minor variations.
Any obstetrician who fails to fully medicalize each and every patient risks a lawsuit in which plaintiff’s attorney’s will parade a line of “expert witnesses” happy to testify that physiological management is “substandard” in the context of professional care by an MD trained in the surgical specialty of obstetrics.
This artificially forces us into the current proxy state of affairs that appears to pit hospital against OOH-PHB. But in a rational evidence-based system, no healthy women should ever have to choose between a midwife and a physician or btw home and hospital in order to receive physiologically based care for a normal birth.
Statistically-speaking, the relative risks for planned place of birth in each location are approximately the same when midwifery care is provided by trained and experienced midwives with appropriate access to comprehensive medical services are needed.
Since we all know of preventable perinatal deaths and emergency hysterectomies subsequent to care in both planned places-of-birth, the logical conclusion is that *both sides* are having some level of bad outcomes that are preventable by today’s standards. While occurring for different reasons, the bad outcomes from each side are only canceling each other out and thus do not represent a true measure of relative risk.
That means we can stop arguing about place of birth and instead focus on improving all aspects of maternity care by all categories of birth attendants in all locations.
Over the last hundred years, a consensus of scientific research (over a hundred studies) has identified physiologically-based birth services, regardless of location, to be a relatively safe and therefore responsible choice when provided by trained midwives with access to and use of comprehensive obstetrical services to treat complications or if requested by the mother.
Every year one or more credible study on physiological management in non-medical settings is added to this growing body of research. However, five particular sources of research data do the best job of identifying the specific information needed to make science-based decisions relative to national maternity care policy for the United States.
The hottest controversy currently is an idea spawned by ACOG in 2008 that rejects all available research data because the studies are not randomized controlled trials. According to ACOG policy, the status quo — maximum medicalization of healthy childbearing under a strict obstetrical model — is the only ‘proven’ standard for safe and responsible maternity care and must be maintained until such time as randomized controlled trials can be done to address the question of safety. However, its obvious to everyone else that randomized trials under the terms insisted on by ACOG can never and will never be done
Fortunately for the rest of us, that is not the conclusion arrived at by Australian authors Bastia, Keirse, and Lancaster in a paper published in the BMJ in 1998 on perinatal death in PHB. They were able to distinguish the ‘forest from the trees’ and do a superb job of debunking this idea by identifying (again) that the real issue is not the planned place-of-birth.
When we look across the board at M&M statistics (historical and contemporary) and records of malpractice litigation, it’s clear that none of the categories of birth attendants have a monopoly on poor judgment, failure to use common sense and/or inappropriate use of resources.
The introduction to this Australian study hits all these high notes and gives us somewhere dependably solid to stand:
“Despite decades of political and academic debate, the relative merits of home-versus-hospital birth remain unproved. This is likely to remain so.
Although home and hospital offers different risks and benefits for birth, neither has standard care characteristics. In fact, the range from safe to unsafe may be wider within each location than it is between them.
Addressing what constitutes safe birth practice at home and in hospitals may be a more pivotal concern than attempting to quantify the theoretical differences attributable to planned place-of-birth.
… In the Netherlands, where 30% of birth are planned to be at home, there is a widely accepted list of criteria for homebirth. When home birth is uncommon, opinions and practices can vary more widely.”
These authors observed that when high-risk obstetrics is practiced in an OOH setting, the outcomes disfavor PHB (surprise, surprise!). However, when this high-risk group is removed from the calculations– a category the majority of midwives and physicians agree is generally best served by making physiological care available to them in a hospital setting — PHB is demonstrated as relatively safe for mothers and babies as compared with hospital-based medical management.
I have grouped the other 4 studies mentioned above together as a set. They include:
(1) unattended OOH
(2) lay midwife-attended OOH
(3) professional midwife-attended OOH
(4) a meta-analysis of hospital births attended by obstetricians, FP physicians, and certified nurse-midwives
This configuration of outcome data includes a “control group” of unattended births which allow us to compared ‘care’ vs ‘no care’ and then to compare the specific care of the 3 major groups of birth attendants to one another and to “no care”.
One must establish a baseline for “no medical or midwifery care” in order to determine the innate riskiness of childbearing in an essentially healthy population, to determine if medical and mfry care make an overall positive contribution (what economists refer to as “value added“) and finally to statistically calculate the manner and magnitude of medicine & midwifery’s ability improve maternal-infant outcomes in a cost-effective fashion.
Only in this way can we actually distinguish the qualities of maternity care that are essential (safety + cost-effectiveness) from those that represent traditional customs and preferences of professional providers, but do not directly contributed to improved maternal-infant outcomes via cost-effective “best practices”.
(1) The 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 economic access to all categories of maternity care providers and settings. Based on their unusual religious beliefs, a cohort of 344 women purposefully chose (or were required by their families) to have unattended births.
Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that all rejected 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 (a situation 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 birth (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.
(2) Planned Home Birth in an impoverished and medically-indigent population attended by experienced lay midwives. These maternity patients were risk-screened one time by a public health officer prior to being approved for PHB under the care of a lay midwife.
However, state laws did not authorize these non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears. These county-registered 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 3 perinatal losses per 1,000.
Note: This study also reported the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended, often because local hospitals turned away laboring women who did not have the prescribed ‘cash in hand’.
These unattended births had a dramatically increased perinatal mortality rate ranging from 30 to 120 stillbirth and neonatal deaths per 1,000, a perinatal mortality rate consistent with 3rd world countries and unattended births among the religious group in Indiana.
[Note again that the take-home message the same — it’s not the place of birth but the quality of care and the crucial preventive quality is physiologically-based services, not high-end obstetrics]
(3) Planned Home Birth in a general population attended by nationally-certified direct-entry (non-nurse) midwives. All clients were risked-screened and received prenatal care and those with medical or pregnancy complications were referred to medical services.
These professional midwives monitored maternal vital signs and fetal heart tones during labor and were authorized to carry emergency supplies such oxytocin (Pitocin + Methergine), IV fluids, oxygen, neonatal resuscitation equipment and 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 under 4% for PHB women hospitalized during labor; there were no maternal deaths this group and the neonatal mortality rate was 2.6 per 1,000.
(4) Planned Hospital Birth for low and moderate risk women — labor attended by a professional nursing staff, routine use of continuous electronic fetal monitoring, IVs and epidurals; 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. This group had no maternal deaths and a neonatal mortality rate of 1.3 per 1,000.
Studies of obstetrically-managed hospital birth in low-risk women give a range of NNM from a low of 0.79 to 4.1.
Note: The routine use of prenatal screening in the hospital population in conjunction with a termination of affected pregnancies during the pre-viable state results in an artificially lowered rate of PNM due to a reduced rate of babies carried to term with lethal anomalies.
Comparing Outcome of all four groups
Outcome statistics for (1) unattended, (2) lay midwife-attended, (3) professional midwife-attended and (4) hospital-based, medically attended provided very useful information the preventing maternal and perinatal mortality and morbidity. Based on this data, the most efficacious strategy consists of three simple aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth.
They are:
(1) Access to prenatal care, on-going risk-screening & referral to medical care for evaluation or treatment as indicated
(2) The presence of an experienced birth attendant during labor, birth and immediate postpartum-neonatal period
(3) Access to emergency services and comprehensive hospital-based care for complications or if requested by the mother or other family members
Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to unattended birth. Lay midwife outcomes for neonatal mortality rates were comparable to professional midwives.
These good outcomes were achieved by providing childbearing women with access to risk-screening during the prenatal period and referring those with serious medical or pregnancy complications to obstetrical services. The mother and unborn baby were monitored during active labor by capable midwives, who also arranged to transfer patients with complications to obstetrical services at the county hospital.
This simple access to prenatal care and physiological management during the intrapartum and postpartum-neonatal period reduced perinatal mortality by 20 to 40 times as compared to the mortality statistics for unattended women and at a small fraction of the expense was able to lower the maternal mortality rate to levels equal to that of hospital-based -obstetrical care.
Lay birth attendants are not an option within the structured health care systems of North American, which serve an educated population who rightfully expect 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.
However, lay midwives are an eager and reliable group that are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries.
When taken together, these five studies offer great certainty about what makes maternity care safe and effective and gives us a solid starting place. We know that childbearing is unnecessarily and unacceptably risky when women are denied (or refuse) the benefits of 20th-century biological science and modern healthcare.
We know that three simple, cost-effective steps reduce this high background rate to a level equivalent to most developed countries. National health policy must education the public to the very real dangers of ‘no care’ and then consistently provide circumstances that make such situations extremely rare by supporting this trilogy of skilled prenatal care that includes timely access to medical services during pregnancy, experienced birth attendance during labor, birth, the immediate PP & neonatal period and comprehensive obstetrical services whenever indicated for the treatment of health problems, complications and emergencies.
Again it must be noted that these are NOT place-of-birth dependent, but they do depend on integrating these three distinct categories of birth attendants (professional midwives, family practice physicians, and obstetricians) and both hospital and OOH birth settings.
In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the care provider(obstetrician, GP physician, or midwife) or the planned location of care. To do otherwise is illogical.
It is useful to take into account the enormous benefit that physiological management of labor and spontaneous birth in healthy women contributes to safe maternity care. This is the form of care routinely provided by general practice physicians and midwives in those countries with the best maternal-infant outcomes.
Simply put, the physiological principles of normal maternity care should be integrated with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies.
This integrated standard should apply universally to all categories of birth attendants when providing care to healthy women and be used in all birth settings, with comprehensive obstetric services reserved for those who develop a complication or if requested by the mother.
For essentially healthy women in an integrated system, physiologically-based childbirth services would be provided by family practice physicians and professionally-trained midwives, with appropriate access to the services of obstetricians, perinatologists and other specialists as necessary.
Only this articulated model of maternity care can bring evidenced-based maternity care into the mainstream of our healthcare system and consistently provide safe and cost-effective services to a healthy population of childbearing women and their unborn and newborn babies.
The most efficacious form of maternity care for an essentially healthy population is always the method that provides “maximal results with minimal interventions”. This is defined as a beneficial ratio of interventions to outcomes for each childbearing woman. It factors in mortality and morbidity rates for mothers and babies both, as well factoring in the immediate, delayed and downstream 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.
Creating such a rationally-based maternity care system would require a calm and fair-minded coalition of professional groups, willing to learn how to cooperate effectively with one another. The goal (already modeled by the Canadian system) would be a complimentary scope of practice and cooperative style of care among the different categories of birth attendants, a cost-effective model of care that is to the benefit of patients and professional alike.
Lessons for Evidence-based Maternity Care in the 21st Century :
As the planned place-of-birth, both OOH and hospitals are, statistically speaking, enjoy the same relative level of safety and suffer from a comparable number of failures. Substantial improvements are called for in both locations.
Having finally determined that neither places of birth is a superior choice, I can’t help but suggest we just stop talking (or in Amy Tuteur’s case screaming!) about “the dangers of home birth” and just focus our conversation and our research on how to improve the care provided in each setting, by all categories of birth attendants?
Let’s replace the vitriolic focus on ‘planned home birth (PHB) with a thoughtful public discourse on planned place-of-birth (PPB). As a part of this elevated debate lets clean-up our vocabulary so these distinctions make more sense and the risks and benefits of each become clearer and more useful to policy makers.
Here are my suggestion for a very useful “vocabulary re-set” to makes the important distinctions in training and customary practice between the discipline of midwifery and surgical specialty of obstetric and gynecology very clear:
The basic purpose of maternity care is to protect, promote and preserve the health of already healthy women during normal pregnancy, childbirth and new mother-baby phase of newborn care, breastfeeding, and developing parent craft skills.
The basic purpose of allopathic medical care is to diagnose and treat abnormal conditions, illness and injuries using drugs, medical methods and technologies, and surgical procedures.
As a professional discipline, maternity care is a concerned with promoting and maintaining the wellbeing of mother and baby across the whole spectrum of normal pregnancy and childbirth. This is accomplished by providing general health education about topics of concern to the mother-to-be and her family, such as nutrition and healthy lifestyle issues, initial.
Irrespective os where it is provided by a physician or a midwife, routine prenatal care includes on-going risk screening and obstetrical consultation or referral as indicated.
The good outcomes associated childbirth in essentially healthy women with normal pregnancies require the full-time presence of the primary birth attendant during active labor, birth, and the postpartum and neonatal period.
Primary birth attendants traditionally provide personal, hands-on support as well as continuously monitoring the wellbeing of the mother and her unborn/newborn baby. They are trained and equipped to detect potential problems, intervene if a complication develops and secure appropriate medical services as required or if requested by the mother.
As maternity care providers (ie. not providers of obstetrical management) they also facilitate the family in supporting the new mother-baby dyad, and helping her care for the baby. In the weeks following the birth, new mothers often need additional advice to help them to deal with older children and other family obligations.
The most basic definition of modern obstetrics is a surgical specialty focused on the compassionate treatment of medical complications and high-risk conditions of female reproductions, including infertility, tumors of the genital tract or pelvic organs and complications of pregnancy and childbirth.
As expected of obstetrics and gynecology as a combined medical-surgical discipline, its educational process, and clinical training focuses on the serious complications of childbearing and their treatments. This is as it should be. However, the current discipline of obstetrics and gynecology does NOT train its residents to physiological support the biology of normal labor and birth, nor does it define what the medical profession calls “labor sitting” as a part of the scope of practice. After graduation, practicing OB-GYN surgeons usually have either time nor interest in becoming health educators. Neither are they prepared by training or temperament to provide the physical and psychological support services consistently needed by childbearing women during their complex journey into motherhood.
After graduation, practicing OB-GYN surgeons usually have either time nor interest in either personally providing health educators as central part of their prenatal care. Neither are they prepared by training or temperament to be personally involved and present during the many long hours of normal labor as a provider of the physical and psychological support services consistently needed by childbearing women during their complex journey into motherhood.
Even if an individual obstetrician wanted to provide supportive maternity care, it would not possible for him or her to be economically compensated for what is technically non-obstetrical care. The billing codes for this specialty only apply to medical, surgical or diagnostic procedures.
Conclusion:
Under these far more ideal circumstances, planned place-of-birth would become what it was always suppose to be — the right choice for the particular situation for that specific mother & fetus — with PHB and hospital both seen as equally responsible choices in an integrated, cooperative and ‘minimalist’ model based on “best practices”.
References:
B-1 Maternal Mortality in the Gambia: PhD Thesis by Mamady Cham
B-2 Paper #1 Maternal Mortality in Bansang Hospital, The Gambia – Levels, Causes and Contributing Factors
B-3 Paper # 2 Maternal Mortality in Rural Gambia: What do we need to know to prevent It?
B-4 Q & A: What we can do to prevent maternal deaths
Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care — Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31
Study #2: “Home Delivery and Neonatal Mortality in North Carolina”, Burnett et al; JAMA, December 19, 1980, Vol. 244, No. 24, p. 2741-2745
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),
doi:10.1136/bmj.330.7505.1416
#4 Meta-analysis – Perinatal MR for planned hospital birth reflects a consensus of scientific literature, CDC birth registration stats and data on obstetrical intervention levels in general population from the “Listening To Mothers” survey, Childbirth Connection; 2002 and 2006
