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.

MaternityCare_2.0 ~ Mother-Baby-Father-Friendly Care for Normal Childbirth that all Americans can be proud of!

Today’s blog is the final installment about an ABC article reporting on the increase in maternal mortality in the US (published by ABC on March 4th, 2010, excerpts embedded in the March 8th of this blog (Normal-Birth.blogspot.com).

We know that what has been happening is the US is wrong - the false idea that Cesarean surgery makes birth safer. Now we need to figure out how to correct this problem -- how do we transform our maternity care system? And in particular, how do we end the mindless medicalization of normal birth - the overuse and misuse of induction of labor and elective Cesarean - in healthy women and replace it with evidence-based, cost-effective maternity care. This is the best way to (a) reduce preventable maternal mortality and (b) to provide an effective and efficient system that is highly rated by childbearing families as "satisfying" and highly rated by health care officials as affordable and accessable.

The science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.

Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.

MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0

Adopting evidence-based standards for normal childbirth will require legal and legislative changes that move us away from the mistaken idea that it is "substandard" for a physician to provide physiologic (i.e. non-medical) care, since childbirth is legally defined as a surgical procedure by the medical profession. We also need regulations to end the perverse incentives that pay for doing things *to* the mother (often risky, invasive or painful procedures) but don’t compensate a physician for spending time *with* the mother. Under the current surgical billing code for normal birth, medical providers are paid per procedure. This makes more interventions more profitable.

What we need is a new, non-surgical billing code for physiologically-managed childbirth that allows birth attendants to be protected from outmoded policies and inappropriate litigation, while at the same time being fairly compensated for their time and rewarded for preventing complications. This will also reduce long-term problems that burden the family and are expensive to the healthcare system.

Maternity Care 2.0 – a science-based model for the 21st Century:

For an essentially healthy population, the most efficacious form of maternity care 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.

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.

This is the right way, the only way to eliminate preventable maternal mortality and morbidity and eliminate unnecessary suffering of the children, fathers and families left behind.

Faith Gibson - former L&D nurse, California licensed professional midwife, ratifier of the Coalition for Improving Maternity Services (CIMS) “Mother Friendly Childbirth Initiative”

www.collegeofmidwives.org
www.normalbirth.org

The antidote to the routine medicalization of normal labor and overuse of induction of labor and elective Cesarean surgery

Today’s blog continues the commentary on the ABC article increasing maternal mortality (published March 4th, 2010, excerpts embedded in the March 8th Normal-Birth blog).

The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.

The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.

There is no getting around these very grim facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 2 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.

To access the research, go to: www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf

The only answer or antidote to routine medicalization, with its emphasis on elective procedures such as induction and scheduled Cesareans, is a return to the time-tested principles of physiological management. Medical dictionaries define “physiological” as: “…in accord with or characteristic of the normal functioning of a living organism”.

Physiologic care provides a reliable method for working with the normal process of biology and has long been used by those countries with the best maternal-infant outcomes. The scientific literature identifies physiological management for normal birth as the safest and most economical type of maternity care for a healthy woman with a normal pregnancy. It is the scientific or evidence-based standard of care.

Physiologic care during labor and birth is associated with the lowest rate of preventable maternal and perinatal mortality and is protective of the mother's pelvic floor. It has the best psychological outcomes and the highest rate of breastfed babies. Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative Cesarean complications and delayed or downstream complications of Cesareans in future pregnancies.

Physiological management takes into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this normal process move along without the need to use artificial hormones to speed up labor, but also diminishes the mother’s perception of pain, perhaps by stimulating endorphins.

Effective labor support always addresses the mother’s pain, her fears and privacy needs so that labor can progress spontaneously, reducing or eliminating the need for medical interventions such as artificial hormones (Pitocin) to speed up labor, pain medication, anesthesia and operative delivery.

Healthy, mentally-competent women have a natural right to have control over the manner and circumstance of normal labor and birth. Just as we acknowledge a woman’s right to choose obstetrical intervention, epidural or an elective Cesarean, so women have an even more compelling right to choose normal care based on the principles of physiological management and the healthcare system has a matching responsibility to provide access to physiologic care. It is society twin obligation to provide maternity care based on ‘best practices’ as determined by the scientific evidence, as well as seeing that women desiring or requiring obstetrical interventions do so with informed consent that also fully reflects the scientific literature.

What we need now is to reboot our maternity care system so that all categories of birth attendants (obstetricians, family physicians and midwives) are taught the body of knowledge and specific skills for effectively addressing the physical and biological needs and emotional stresses that healthy women typically face during labor. In addition, hospitals must become truly “mother-friendly” by providing evidenced-based care in a low-tech environment that is appropriate to normal childbirth.

This model of normal childbirth includes continuity of care, the full-time presence of the primary birth attendant though out active labor and the supportive presence of family members or other companions chosen by the laboring women. It acknowledges the mother’s on-going need for social and emotional support and physical privacy, which includes control over her environment and the people present. This means that laboring women are free to move about and choose their own positions and activities.

The strategies of physiologically-based care include patience with nature, the right use of gravity and proven methods to help mothers cope with the pain and stress of labor, such as one-on-one support, therapeutic touch, movement and access to hot showers or deepwater tubs.

Women who walk and move about at will and make use of traditional coping strategies to keep pain within manageable levels usually have greatly reduced rate of drugs and other interventions. However, mother-friendly care also provides ‘no-fault, no-blame’ use of pain medication or epidural analgesia when other methods don’t provide the needed relief.

Patience, maternal mobility and the right use of gravity are also critically important during the pushing stage. Even mothers who’ve had epidural analgesia benefit by pushing and delivering on their side, so they are not bearing weight on their sacrum (reducing blood supply to the placenta and O2 to the baby) or fighting against gravity as they try to push an 8# baby uphill and around the normal 60-degree angle of the pelvic outlet (the Curve of Carus).

This science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.

Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.

MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0

Come back tomorrow for the last installment of this 3-part series on the irrational enthusiasm of the “system” to unnecessarily medicalized and complicate normal birth and the deleterious consequences to maternal health and the economics of our national healthcare system.