Topic link #5 ? Essentical Qualities of Maternity Care for Healthy Women ~ +?+?+
Part IV: Conclusions
When taken together and evaluated from a holistic perspective, these five studies offer great certainty about what makes maternity care safe and effective and provide us with a solid starting place.
We know that childbearing is unnecessarily and unacceptably risky when women are denied (or they refuse) the benefits of biological science and modern healthcare. We know that three simple, cost-effective healthcare measures reduce this high background rate of mortality and morbidity to a level equivalent to most developed countries. When this safety net is absent for any reason, including being rejected by the woman, prohibited by her family or their religious beliefs or hampered by laws that block access to birth attendants trained in physiological management, unnecessary risk and dangers are introduced into otherwise normal childbirth. It’s like swimming without a lifeguard.
These insights allows us to identify a number of actions and changes in national pubic health policy that effectively meet the purpose and goal of maternity care — protecting and preserving the health of already healthy women.
Public health officials must work diligently to educate the public about the very real dangers of ‘no care’, and unattended ‘do it yourself” (DIY) births. The remedy to that is affordable, accessible, women-centered, mother-baby friendly maternity care with seamless (and no-fault) access to comprehensive obstetrical services as medically indicated or as requested by the childbearing woman.
National policies and efforts by public health officials must produce a mother-baby-father-friendly form of care that encourages the widest possible use of prenatal care and makes DIY unattended childbirth extremely rare. These are NOT place-of-birth dependent, but they do depend on integrating the three distinct categories of professional birth attendants (midwives, family practice physicians, and obstetricians) and both hospital and OOH birth settings.
Rejecting the Preemptive Use of Intervention as a Matter of Public Policy
The highest level of scrutiny, skepticism, and scientific proof must be applied to the preemptive use of medical protocols that disrupt the normal biology of childbearing or interfere with other normal biological function. At a national policy level, we must also reject maternity department routines that apply a protocol or medical treatment to the majority of its mothers or babies based on a minor risk factor or theoretical advantage, including a perceived advantage to the institution to protect itself against litigation or increase the profitability of its services.
PIT-TO-DISTRESS: An example of these dubious practices can be seen in a protocol known as “Pit-to-distress”. In this instance, the patient’s physician has ordered the L&D nursing staff to administer the drug “Pitocin” intravenous to induce or augment the woman’s labor. Then the nurse in charge of the patient is directed by the patient’s doctor or required by obstetrical unit’s protocols to incrementally increase the rate of the IV Pitocin until the mother either delivers vaginally, her uterus ruptures or the unborn baby goes into fetal distress and has to be delivered by emergency C-section. This Pit-to-distress protocol is applied without the fully informed consent of the mother or other family members. Whatever perceived benefits to maternity departments or individual obstetricians are irrelevant — ‘Pit-to-distress’ is not and never could be an ethical practice.
In 2006 the Wall Street Journal reported on these questionable practices and other “common practices in the delivery room … endangering both mothers and infants”. The article described efforts by some hospitals to reduce the liability-insurance premiums for their obstetrics units. These attempts were meant to curtail the excessive use of Pitocin and other labor inducing drugs to start or speed up contractions because they “can lead to ruptures of the uterus, fetal distress and even death of the infant”. An assistant vice president of one institution described the problem by saying: “Pitocin is used like candy in the OB world, and that’s one of the reasons for medical and legal risk … in many hospitals it is common practice to “pit to distress”.
Of the top six contributors to obstetrical litigation, the number one reason is the “inappropriate use of labor-inducing drug“. In addition to the human cost, the WSJ’s review of medical-malpractice claims showed that the use of Pitocin was involved in more than 50 percent of situations leading to birth trauma. After the Intermountain Healthcare instituted a program to reduce elective inductions and prohibit practices such as ‘Pit to distress’, they reported a sharp drop in birth complications that cut costs by $500,000 annually. [New practices reduce childbirth risk; Wall Street Journal July 12, 2006; Laura Landro]
INAPPROPRIATE UNTIL PROVEN OTHERWISE: More than 70% of all childbearing women are healthy and their full-term pregnancies are normal, a statistic that should be inversely related to the ratio of interventions. This is not rocket science. In fact, the math is simple – only a small proportion of mothers and babies are high risk or have complications, therefore, only a small number of maternity patients should be subjected to interventions and in all cases, a clear indication should be demonstrated. Any institutional policy that applies ‘special circumstance’ protocols to a high percentage of mothers or babies is inappropriate until proven otherwise.
This is best done by supporting the trilogy of skilled prenatal care that includes timely access to medical services during pregnancy and experienced birth attendants who are present through out labor, birth, the immediate PP & neonatal period. As always, this is tightly articulated with comprehensive obstetrical services whenever indicated for the treatment of health problems, complications or emergencies.
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, family practice physician, or midwife) or the planned location of care. To do otherwise is illogical and irrational.
In conclusion, we come back to the basic principles: 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. Taken together these 5 sources of scientific information allow us to develop mastery in the normal by identifying the qualities essential to maternity care in the 21st century.
In summary, the three essential elements of safe and cost-effective maternity care are:
(a) Prenatal care with risk-screening & referral to medical care for evaluation or treatment as indicated
(b) Birth attendant(s) skilled and experienced in physiologically-based care who are present or immediately available at the mother’s discretion during active labor, 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
In an integrated system, physiologically-based childbirth services for essentially healthy women would be provided primarily 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 bringing 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. Our energies must be used to transform our national maternity care policies and to reconfigure the system at its most basic and practical level, so that it promotes:
- Maximal results with minimal interventions
- Skillful use of physiological management
- Adroit use of medical interventions as necessary
- Fewest number of medical-surgical procedures
- Least expense
- Best outcome to for mothers and babies
Lessons for Evidence-based Maternity Care in the 21st Century:
photo –>Hohlman Family ~ PHBs
THE BELL THAT CAN’T BE UNRUNG: Physiological management – normal care for normal birth — is the bell that can’t be un-rung. But to create a rationally-based maternity care system we must include all stakeholders and all professional providers, hospitals and other facilities. This would obviously require a calm and fair-minded coalition of professional groups, willing to learn how to cooperate effectively with one another.
While this is an ambitious goal, it’s not impossible and it won’t break the bank cost-wise. It does however provide a firm foundation for all people of good will to come together. Working cooperatively, we can transform the policies and practices of maternity care in the US into a safe, cost-effective 21st century model that every American (even ACOG fellows) can be proud of.
There already are a number of vibrant and thoughtful consumer and professional organizations engaged in this question who have been doing a phenomenal job and have make had made a stellar contribution to advancing the public discourse and bringing about needed policy changes — the Coalition for Improving Maternity Care (CIMS), the International Cesarean Awareness Network (ICAN), Childbirth Connection, Lamaze International, Midwives Alliance of North America, (MANA), the American College of Nurse Midwives (ACNM), the American College of Community Midwives (ACCM) and many many others. What we need is for ACOG to reach across the isle and work in equal partnership with this energized base.
While the discipline of midwifery is not a practice of medicine, it is a form of primary healthcare that incorporates the same body of knowledge about the basic characteristics of health and wellbeing. This requires the same skills to discern normal from abnormal and make appropriate referrals. In order for midwives to do their ‘half’ in healing the schism between medicine and midwifery, midwives of all educational backgrounds must utilize a high level of professional abilities in every arena of their practice.
The other half of the equation is for state and federal governments to uniformly recognize the professional services of non-physician primary practitioners and first-responders and fairly compensated them for providing care in a wide variety of situations associated with pregnancy, birth, motherhood and newborns.
With the rarest of exceptions, the invaluable contributions of modern medicine enthusiastically acknowledged by midwives of all backgrounds, including the vital role of obstetricians, perinatologists and hospitals in responding to complications. This complimentary relationship between medicine and midwifery must replace the historical prejudice against physiological care and the obstetrical hubris against midwives left over from the 19th and 20th centuries.
For midwives, burying the historical hatchet means gracefully walking away from a rather long list of grievances. For a very small group of midwives, it may require rethinking their own relationship with modern medicine. Irrespective of the starting point, the destination is nothing less than an inclusive, complimentary and mutually respectful model of cooperation.
The goal (already modeled by some Canadian provinces) would be in three crucial areas.
- The first is to develop of standard care characteristics based on the health status of the mother (i.e., not the professional status of the birth attendant) and standard criteria when conducting research on OOH birth settings and practices
- The second is a complimentary scope of practice between the medical and the midwifery profession, as well as a cooperative style of care among the different categories of birth attendants and a non-surgical billing code that recognizes and legitimizes the use of physiological management by all categories of birth attendants.
- The third is a cost-effective model of health care that is to the benefit of patients and professional alike, economically sustainable and ‘green’ in regard to it use of carbon-based energy and other finite resources.
The form of care recommended by W.H.O. for a healthy population integrates the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This standard should apply to all categories of birth attendants and in all settings and include the use of conventional obstetrical interventions to treat complications or if requested by the mother.
This integrated model would transform the narrow focus of our interventionist obstetrical system into a broad based maternity care model able to respond to the practical needs a healthy population. Regardless of which system one is referring to, the crucial words are ‘not disturbing the spontaneous biology of normal labor and birth unless necessarily’, ‘access’ to the fruits of modern medical science and ‘appropriate use’ of medical services as indicated.
In a balanced system, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home in order to receive physiological management for normal childbirth. No matter who provides maternity care, they can be confident of receiving the best obstetrical services if or when they desire or require them and receiving appropriate, physiologically-based care for a normal labor and spontaneous birth.
Under those circumstance, 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 hospital and OOH both seen as equally responsible choices in an integrated, cooperative and ‘minimalist’ model based on ‘best practices’.
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.
Synopsis of Dr J. Whitridge Williams’ Plan
for a national system of Lying-in hospitals as described in
“Twilight Sleep — Simple Discoveries in Painless Childbirth
Quotes from Dr. Williams’ Book ~ Twilight Sleep –
Simple Discoveries in Painless Childbirth
Photo ~ Baby Girl Brooks Thomas, born @ home June 12, 1991
End of this series
