as Proxy for Style of Intrarpartum Management
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 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 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 study of all maternal deaths occurring in one particular region of The Gambia is instructive.
It begins with the information that all but 2 of these maternity patients were in 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 location but quality of care that was the critical issue. 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 drugs, no banked blood, no gas to run the hospital generator for electric lights in the OR, no doctor on site who could perform a CS, etc) combined with unresponsive or inappropriate actions (or omissions) by the hospital staff.
As 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 instance in which it was evident (med-mal carrier settled out of court) that a baby died or was neurologically damaged by the elective use (physician preference) of medically unnecessary obstetrical intervention in a healthy mother who did not herself want the intervention (ex., induction or augmentation to speed things up) or the OB was not in the hospital and *did not come* when asked to by the nurses.
There were also a small number of OOH mfry cases with bad outcomes. These fell into two general categories. The first, and luckily the rarer category, was total disregard for well-established, evidence-based practices by either the parents or the midwife. In those instances, it was not location (home), but lack of common sense and good judgement by either one or both. This is also is not a "place of birth" issue. The answer to this problem is better education of the public, more responsive maternity care so that parents do not become pathologically fearful of medical services, and more effective preparation and regulation of midwives in the responsible practice of their profession, irrespective of location.
The more frequent, (but still statistically rare) situation was a genuinely unpredictable adverse event such as prolapsed cord with baby at a +1 station or placental abruption in a normotensive primipara. One certainly could argue that if the mother had been in the hospital 15 feet from a fully staffed OR in a tertiary care institution with 24-7 in-house surgical, anesthesia and perinatal services, the baby could have been rescued, maybe w/o suffering neurological damage, maybe not.
But 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 spent (waisted!) by nurses frantically paging "any doctor in house stat to L&D", while calling the OB at home, then paging him and finally 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 far too many places, PHB is the only circumstance where true physiological management can be legally and fully employed. This reflects 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 the 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 maximumly 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 this proxy state of affairs that appears to pit hospital against 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. Since we all know of preventable perinatal deaths and emergency hysterectomies subsequent to care in both places, the logical conclusion is that *both sides* are having 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 100 years, a consensus of scientific research 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 ideas 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 tress and do a superb job of debunking this idea by identifying (again) that the real issue is not place of birth. When we look across the board at M&M statistics (historical and contemporary) and records of malpractice litigation, its clear that none of the categories of birth attendants have a monopoly on poor judgement, 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 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 home birth. 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 and a meta-analysis of medically-managed hospital births 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 mfry care" in order to determine the innate riskiness of childbearing in an essentially healthy population, to determine if medical and mfry care make an over-all 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, but in this case, purposefully chose 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 ife-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 be approved for PHB under the care of a lay midwife. However, state laws did not authorized 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 -- its 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. 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. This group had no maternal deaths and 2.6 perinatal losses 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 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.
As measured by the outcome statistics of the four groups -- unattended, lay midwife-attended, professional midwife-attended and hospital-based, medically attended -- the most efficacious strategy for preventing maternal and perinatal mortality and morbidity consists of three simple aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth.
(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 hospital-based services for complications or if requested by the mother
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 and NNM rates comparable to professional midwives. This good outcome was 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 healthcare 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 intregrated 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 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.
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 :
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 PHB and hospital both seen as equally responsible choices in an integrated, cooperative and 'minimalist' model based on "best practices".
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