A commentary about the Wax et al meta-analysis (the newest controversial study published by the obstetrical profession), the Joint Commission on hospital accreditation's new 'perinatal core measures', which are justifiable critical of our highly and unnecessarily medicalized system of obstetrically-based care for healthy women and the use of peer-reviewed studies by the American College of Obstetricians & Gynecologists to derail public attention, manipulate the media, and unduly influence public opinion:

In my opinion, the media hype generated by ACOG over the Wax et el (1) place-of-birth analysis is a red-herring. This controversy is not about midwifery vs. obstetrics, or choice of hospital vs. out-of-hospital (OOH) birth setting. Instead, this badly flawed study is being used to distract the public and the press from the real story – the need to normalize childbirth practices and adopt cost-effective maternity care for healthy childbearing women.

On April 1, 2010, the Joint Commission on hospital accreditation issued a directive the obstetrical profession to lower its intervention rates, particularly targeting the run-away use of elective induction, early labor hospital admission and Cesarean in healthy first-time mothers who had a single baby in a vertex or head-down position.

It is helpful to remember that the basic purpose of maternity care is to preserve and protect the health of already healthy women. 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.

Unfortunately, our 20^th century system of ‘pre-emptive’ intervention has not been able to live up to this promise.

We currently have a hundred-year old system based on the routine medicalization of normal birth and many other obstetrical practices that don’t serve healthy mother and babies, but do introduce artificial and unnecessary risks for both. A historical decision made by the obstetrical profession in 1910 declared that obstetrics, as a surgical specialty, was to be the standard of care for everyone, including healthy women.

However, there was never any scientific basis for a maternity care model that identified surgeons as primary care providers for a healthy population or systematically used obstetrical interventions and invasive procedures on all laboring women. It is a fluke of history that a hundred years later we are still conducting normal birth as a surgical procedure.

Prior to the discovery of antibiotic in the 1930s, normal birth as a surgical procedure was part of a strategy to reduce fatal infections in maternity patients. This included dividing childbirth between two different professions and separating labor from birth. Nurses were to provide medical management for the first stage of labor, a process that included keeping women in bed and administering repeated injection of drugs for pain. The nurses were expected watch carefully and notify the patient's doctor when the mother started pushing. Birth as a surgical procedure is called 'the delivery' and was to be perform by surgically-trained specialist. Typically the mother was put to sleep with general anesthesia and delivering the baby included episiotomy, forceps, manual removal of the placenta and putting in stitches afterwards.

The types of intervention and rationales for their use have changed several times since 1910. By 2010 forceps had long ago been replaced by Cesareans and epidural had taken the place of general anesthesia. These newer forms of intervention are far safer, but the overall number of medical and surgical procedures has gone up with each and every decade. This is completely inexplicable, as childbearing women are many times healthier now that they were in 1910 and have far fewer pregnancies due to effective contraception. Modern medicine has access to antibiotics and many other wonderful new drugs, as well as ultrasound technology and other prenatal testing to discovery serious problems before labor even starts. Despite great advances in public health and medical ability, the operative rate has risen from 10% in 1910 to 70% in 2010.

The ‘Listening To Mothers’ Survey' in 2002 and 2006 identified the medical intervention rate to be 99%, with an average of 7 medical interventions for every woman in labor. The aggregate rate for surgical procedures during childbirth was approximately 70% -- episiotomy, forceps, vacuum extraction or Cesarean section and suturing the perineal or abdominal incision. These procedures not really different than the ones used in a century ago.

For the last 30 years, this newer version of 1910 preemptive intervention policies has come to been known as "active management". Unfortunately, there is still no scientifically evidence that the new version is any safer or more cost-effective for healthy childbearing women than physiologically-based care. However, there considerable evidence that active management and other current policies routinely introduce unnecessary risk and are associated with iatrogenic complications. As an “expert” system, obstetrics has failed in the very area it was supposed to have the most mastery and expertise -- preserving the health of already healthy mothers and babies.

Nonetheless, it seems that ACOG hopes to justify this highly medicalized status quo in the face of strongly-worded criticism of these very practices by the Joint Commission on hospital accreditation. To qualify for government reimbursement hospitals must be evaluated and approved by the Joint Commission [3], so the Commission's opinions are really important to hospital administrators. You can’t appreciate the historical politics behind Dr. Wax’s hospital vs. OOH study without reading the new “core measures” for hospital-based birth care published by the Commission on April 1, 2010. These guidelines can be accessed on-line @:

http://manual.jointcommission.org/releases/TJC2010A/PerinatalCare.htm.

Readers may be surprised to hear that the Joint Commission is critical of the excessively-medicalized, unproductively expensive, and unsafe childbirth practices for healthy women that have become the norm in the US. Whatever the original intentions of Dr. Wax and the other authors, ACOG is now using the study’s assertions to support its own preferences -- the continuing medicalization of normal childbirth -- despite a direct challenge to these policies by the Joint Commission.

Based on impeccable scientific evidence, the Commission’s directive includes instructions for reversing “the Cesarean epidemic” and the escalating rates of elective induction and hospital admissions early in labor. None of these common practices have improved outcomes for babies, but they do result in increased complications for mothers and are implicated in a rising maternal mortality rate.

The Joint Commission’s guidelines could not be clearer. They start out by saying:

“The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes. (Gould et al; 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.” [emphasis added]

No wonder some women try to avoid an unnecessary C-section by planning an OOH birth under the care of a midwife or family-practice physician. The wisest strategy for ACOG would be take the Commission’s report to heart and come up with innovative plans to implement these recommendations. Such a strategy would incorporate the principles of physiological management of normal birth in a healthy population in place of the current policy of 'active' obstetrical management. It would also end it's hundred year war against the midwifery profession.

But instead of 21st century progress, ACOG is sticking to its usual fear-based PR campaign that aggressively promotes the same old “more is better” notion, despite all evidence to the contrary. ACOG has chosen to use its considerable resources to re-direct the public’s attention to the self-generated controversy about OOH (less than 1% of all births), in an effort to distract us from the poor obstetrical practices being used in the other 99% of hospital births. [Listening to Mothers Survey, Childbirth Connections; 2002 + 2006]

Elective induction and early admissions in labor have become so routine they are almost the standard for obstetrical care, but the Joint Commission identifies both of these interventions with a significant increase in a hospital’s rate of operative delivery, prematurity and neonatal complications. Scientific evidence cited in Joint Commission’s core perinatal measures include instructions for dramatically reducing induction, early admission and elective Cesarean surgeries.

According to the Joint Commissions: “… almost 1/3 of all babies delivered in the United States are electively delivered, with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/American Academy of Pediatrics’ guidelines. Most of these are for convenience, and result in significant short-term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) [Clark et al; 2009].

“… compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay [Glantz, 2005]” … “[Dr] Main et al (2006) found that over 60% of the variation [in C-section rate] among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer”

“The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns [Tita et al., 2009].”

Another statement in the Commission’s new Core Measures acknowledges what many childbearing families, midwives and every L&D nurse in America has known for decades – that the use of obstetrical intervention is far more about the physician’s personal preference than scientific evidence. According to the Joint Commission:

“Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses, are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003).”

While the Joint Commission never uses the word “physiological management” or directly recommends replacing this excessively-medicalized model of care with physiologically-based practices, that is the only available method to lower the rates of invasive procedures and reduce the harm (and cost) associated with run-away medicalization. A consensus of the scientific literature shows physiological management of normal childbirth by professional birth attendants to be the evidence-based care for healthy women with normal pregnancies. This cost-effective model is used worldwide by those countries that get far better outcomes for much less money.

By every measure of excellence for maternity care (except the unconfirmed issue of neonatal mortality), even the Wax analysis concluded that the non-medicalized approach results in dramatically improved outcomes. The “RESULTS” section of the study’s abstract states:

“Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery.

These women were less likely to experience lacerations, hemorrhage, and infections.

Neonatal outcomes of planned home births revealed less frequent prematurity, low birth weight, and assisted newborn ventilation. … planned home and hospital births exhibited similar perinatal mortality rates ...”

Nonetheless, ACOG’s strategic use of the Wax analysis of OOH birth was effective in derailing effective public discourse on the aforementioned obstetrical excesses. There has been absolutely NO coverage of the real media bombshell – the Joint Commission the April 1, 2010 publication of these new perinatal core measures designed to reduce elective and operative interventions. ABC's Good Morning America Health did a segment on 'at-home birth', provocatively titled "Home Birth vs. Baby-At-Risk". They did NOT cover or even mention the Joint Commission's new core measures for excellence in perinatal care or discuss the 'Cesarean epidemic' as the public health and economic problem that it is.

Conclusions:

Whether in hospital or out-of-hospital, normal care for normal birth, in combination with the appropriate use of medicalization as needed (or as requested by the mother), is the safest and most cost-effective model for a healthy population. Regardless of which system one is referring to, the crucial words are the same: 'not disturbing the spontaneous biology of normal labor and birth unless necessarily', 'timely access’ to the fruits of modern medical science when indicated and ‘appropriate use’ of medical services as required.

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 and well-trained obstetricians, so I never see this as 'us versus them' issue. I want hospitals to work and work well. I want physicians of all kinds to be skilled and seamlessly available. I also expect them to be knowledgeable about physiologically-based practices and cooperative with mothers and midwives. We actually are all on the same team -- the one that wants to use the best practices all the time for everyone.

Unfortunately, ACOG's favorite assumption -- that more aggressive medicalization automatically improves normal childbirth -- is incorrect and out-dated. As long as this mistaken idea is enthusiastically embraced by leaders of the obstetrical profession, it will be impossible to get our hands around the very real social, medical and economic problems we face. As a country, we cannot hope to compete successfully in a global economy against other countries and parts of the world that depend on normal care for normal childbirth at a 1/10th of the cost of our bloated and dysfunctional system.

Instead of stepping stones to progress, ACOG's 19th century notions have become stumbling blocks that keep keep physicians and midwives from cooperating with one another. They stymie efforts by ACOG fellows to participate in a system of seamless care to women cared for by midwives. What is really needed is a cooperative approach by all stakeholders - childbearing women, all categories of birth attendants and hospitals - that seeks out innovative solutions and finds ways to make "best practices" more widely available to more people.

According to a review of the scientific literature, the best and most cost-effective outcomes for healthy mothers and babies are consistently associated with three healthcare-related circumstances (2). In combination, these three basic elements are equally advantageous to industrialized countries as well as developing ones. In a perfect world, these safe motherhood measures and mother-baby-father and family-friendly practices would provide a foundation for a cooperative and complimentary relationship between all categories of birth attendants and be perfectly in alignment with the 'Perinatal Core Measures' of the Joint Commission:

(a) Antenatal care with risk-screening & referral for medical evaluation or treatment as indicated
(b) Experienced birth attendant(s) skilled in physiological management who are present or immediately available at the mother's discretion through out 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 a balanced and cooperative system healthy women would not 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 provided maternity care, women would have access to the best obstetrical services if they desire or require them, while being confident of 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.

References:

1. Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis; Joseph R. Wax, MD, F. Lee Lucas, PhD, Maryanne Lamont, MLS, Michael G. Pinette, MD, Angelina Cartin, Jacquelyn Blackstone, DO; published online 02 July 2010.

Presented at the 30th Annual Meeting of the Society for Maternal-Fetal Medicine, Chicago, IL, Feb. 1-6, 2010.

2. Identifying the Essential Qualities of Maternity Care -- Evidence-based policies and a plan for action -- an annotated essay by Faith Gibson

3. About The Joint Commission -- An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 18,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Our Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Read more.

Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings. Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

The Joint Commission evaluates and accredits more than 18,000 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years.

The Joint Commission is governed by a 29-member Board of Commissioners that includes physicians, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate and educators. The Board of Commissioners brings to The Joint Commission diverse experience in health care, business and public policy. The Joint Commission’s corporate members are the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association, and the American Medical Association.

The Joint Commission employs approximately 1,000 people in its surveyor force, at its central office in Oakbrook Terrace, Illinois, and at a satellite office in Washington, D.C. The Washington office is The Joint Commission’s primary interface with government agencies and with Congress, seeking and maintaining partnerships with the government that will improve the quality of health care for all Americans, and working with Congress on legislation involving the quality and safety of health care.