Topic link 2 ~ Identifying the essential qualities of maternity Care for healthy women; Evidenced policies & a plan for action
Part I: 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 that is able to 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 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.
Maternity care as a continuum of provider characteristics
Using place-of-birth as proxy also fails to acknowledge a most central fact about maternity care – that it is a continuum of practices from pure physiologic care at one end, to the pre-emptive use of medical interventions at the other. Within the scope of their specific discipline, each practitioner also has a wide range of practices (or preferences) that span the most extreme ‘hands-off’ to the most aggressive use of intervention. In the middle of this spectrum there is a great deal of overlap, which means that both categories of birth attendants in both locations use the same management practices most of the time on most patients.
Another confounding factor in the safety equation is the level of competency by each individual within his or her own professional category, as well as a host of unpredictable elements such as budget cuts, extreme weather, chronic understaffing, an exceptionally high census that coincides with low staffing or lack of other resources, and occasional major or prolonged disruption, such as power outages following a natural disaster like a hurricane.
This profound divergence within the ‘standard of care’ means that the proxy use of place-of-birth cannot determine the qualities essential to maternity care in the 21st century. The hospital-OOH controversy asks the wrong question, one that goes unanswered because the underlying premise is flawed. Over the last century many earnest researchers have tried their best to use place-of-birth statistics as an opportunity to neatly cleave apart the core issue of childbirth safety – something hospitals were assume to have and OOH setting were assumed to lack. They hoped the statistical process would reveal a bright line between safe circumstances and responsible care, compared to unsafe care and irresponsible circumstances, which was assumed by the medical profession to be synonymous with the OOH settings.
Unfortunately, these assumptions became the basis for a national maternity care policy in the US aimed at promoting one and eliminating the other, turning OOH childbirth – in particular PHB — into a controversial topic with hard feelings and vitriolic rhetoric at every turn. Every few years a new peer-reviewed study that either confirms or disputes the safety of OOH is added to an already extensive body of scientific literature. Then the tension suddenly pops up on the public radar as opposing groups hurl invectives at one another in the media.
Most regrettably, this puts the media — instead of the science — into the role of arbitrator, as if the merits of this important issue could be decided by popularity contest. For example, the Internet edition of a world-class newspaper recently published an argumentative article about OOH birth that included an online survey asking readers to vote on the question: “Is Home Birth Safe? – Yes or No”. [UK Daily Mail-Aug 17, 2010] It’s absurd to think that the safety of particular childbirth practices could be established by the opinion of the public, rather than a thoughtful and unbiased evaluation of the scientific evidence. This reflects an unfortunate politicizing of maternity care in the very places that most need to be decided on substance – the evidence and the merits of the case.
Instead of optimizing a national model of maternity care, we have had a century-long turf war over place-of-birth. Sadly missing are policies or systemic efforts to integrate the excellent contributions of obstetrics as a surgical discipline with the time-tested principles of physiologically-based management of normal childbirth. Instead of a spirit of cooperation contributing to mutual advancement of evidence-based practice, the professions of obstetrics, family practice medicine and midwifery has spent the last hundred years arguing over the theoretical question of whether or not hospital childbirth is safer or PHB is dangerous.
But for all this heat (and no light), the nature of place-of-birth is and will remain hopelessly confounding: hospitals and OOH settings of every size and technical capacity, birth attendants of all types, abilities, temperaments and levels of competency provide care to patients spread across a spectrum from the healthy, highly educated, well-fed, well-housed, and compliant who receive state-of-the art prenatal care to those who had no prenatal care, are homeless, undernourished, chronically ill or medically non-compliant due substance abuse, mental illness or other unhealthy lifestyles. Using place-of-birth as a proxy for safety is like trying to ‘prove’ that restaurant meals are safer than food cooked at home – to which the answer will always be: “yes & no”, depending on which restaurant you are comparing to which household.
Hiding in plain sight – a simple solution to a perplexing problem
On close examination, using place-of-birth as a proxy for place-of-safety turns out to be a ‘distinction without a difference’. Unfortunately, it’s also a distraction that has keeps us from recognizing those distinctions that make the biggest difference — an entrenched collection of non-standard characteristics in both settings (hospital plus OOH) and all three professional categories (obstetricians, family practice physician & midwives of various backgrounds).
Since the early1900s, the medical profession in the US has related to questions of safety in childbirth practices as if there was only one basic variable that mattered — hospital vs. OOH. The nature of that care — who and how it was provided within that supposed ‘safe zone’ (i.e., hospital) – was assumed to be a constant and to produce consistently good results. Actually, all three categorical elements are all variables: place, professional category and personal preference of practitioner. In addition, the enormous variability of the crucial fourth element must be taken into account: the childbearing woman and her pregnancy, birth and baby-related needs, including her personal and religious beliefs, her economic and other resources, her relationship to her family and its status in the broader community (including immigration status)
The best advice about this controversy comes from Australian researchers H Bastian et al in the paper “Perinatal deaths associated with PHB in Australia”, published in the BMJ in1998. After noting that both settings lacked ‘standard care’ characteristics, its authors concluded that home and hospital offer different benefits for birth and that:
“the range from safe to unsafe practice may be wider within each location that it is between them. Addressing what constitutes safe practice at home may be a more pivotal concern than attempting to quantify the theoretical differences attributable to place of birth.”
The multiplicity of variables and confounding factors between places-of-birth can never be responsibly relied upon to define the elements of safe and cost-effective maternity care.
Nonetheless, safe and unsafe practices can and should be addressed. This becomes a straight-forward and useful activity when it is done in matched pairs – hospitals of a certain size compared to other with equal capacities, practitioners of the same background and practice characteristics providing care to an internally consistent cohort of childbearing women.
Part II:
