Part 3 (of 3)
The Silent Third Partner:
Parental Decision-Making and how the ethical and legal rights of parents to make medically unpopular or unwise choices may result in preventable neonatal mortality and how that aspect is routinely ignored in studies conducted on the relative safety of OOH birth services.
In regard to safety vs. danger in normal childbirth, we so far have focused on whether the mother-to-be had routine prenatal care vs. “no care“, an attended birth vs. unattended, whether the birth attendant was a MD or midwife, and whether the planned place-of-birth was in- or out-of-hospital.
Unacknowledged research bias on OHH Mfry Care
Of these four binary “yes/no” circumstances, two of them reflect choices made by parents — for example, to have or not have prenatal care; to have an attended vs. purposefully-unattended OOH birth — while the last two are practitioner-centric.
From the standpoint of research on OOH setting, the choice of place-of-birth is usually (though illogically) seen as a practitioner issue. The unspoken assumption is that birth attendants decide the choice of setting since each category of practitioner generally refuses to provide care to childbearing families who do not plan to give birth in the setting preferred by that birth attendant. The medical profession is firmly convinced that the whole issue of relative safety would go away in an instant if midwives would just get hospital privileges and thereafter refuse to attend home births.
That however begs the point, which is our current obstetrical-centric system as applied to healthy childbearing women. In the US, our hospital-based system steadfastly declines to provide the quality of care that families choosing OOH birth services are seeking and have an ethical right to receive — a science-based, cost-effective model specifically configured to meet the full spectrum of physical and practical needs of healthy childbearing women with normal pregnancies who do not want, need or benefit from medicalized services.
Safety research on OOH birth leaves parental decision-making out of the equation
Of the three categories of decision-makers noted above (parents, midwives & doctors), the studies on PHB/OOH only focus on the last two by only contrasting MD care vs MF care, and/or hospital vs. OOH/PHB. Regrettably, this makes relative safety into a win-loose contest: Hospital-based obstetricians versus Midwives providing care in OOH settings.
In general, midwives don’t get full credit when the outcome is good (just “lucky”), nor are they adequately credited for reducing the medical interventions 2-to-10-fold; they are however fully blamed for any possible professional inadequacy along with problems associated with an OOH environment (transfer time that delays emergency treatment).
On the other hand, the obstetrical profession is credited with all good outcomes but not held responsible for problems associated with the hospital environment and associated problems such as a high Pitocin-augmentation and C-section rate, medication mistakes, antibiotic-resistant infections and other nosocomial complications.
In both instances, parental decision-making is left out of the equation entirely, as is an equal focus on the risks and benefits of each environment — hospital as well as OOH settings. Personally, I think that is the wrong way to look at this issue, but realistically the identified ‘responsible party’ in studies on this topic is still obstetricians and midwives.
In theses instances, it’s assumed that the outcomes of midwife-attended, planned OOH births had little or nothing to do with lawful decisions make by the parents that resulted in acts or omissions that may have affected outcomes.
During prenatal care, this includes their decision to decline routine labs, pregnancy-dating and level II ultrasounds, genetic testing & termination (or refusal to terminate) a pregnancy affected by potentially lethal birth defects. During the intrapartum period, they may not tell the midwife when the water breaks before labor, or decline prophylactic antibiotic treatment when the mother is GBS+. So far as i know, only the Snowden study on PHB/OOH birth in Oregon has directly acknowledged that parental decision-making often plays a substantial role in adverse events and bad outcomes.
However, this focus on the birth attendants reduces parents to mere by-standers in someone else’s drama, and exempting them of any responsibility — good or bad — for the outcome.
In this last section, we will examine the impact of parental choice that run counter to the wishes or recommendation of their care providers or standard medical advise and in some cases, may have resulted in what appeared to be a preventable stillbirth or neonatal death.
Slient Partners: The unacknowledge role of Parental decision-making in childbirth outcomes
FACTS: The routine use of ultrasound and prenatal genetic screening in the hospital cohort, in conjunction with the termination of affected pregnancies during the pre-viable state, slightly lowers the rate of perinatal and neonatal mortality when compared to the subset of families who choose OOH birth. This is due to a reduced number of babies in the hospital cohort with lethal anomalies who are carried to term.
Families that choose non-medical maternity care are statistically less likely to utilize prenatal genetic and ultrasound screening or to terminate affected pregnancies when indicated. One study in PHB in Washington State (1996) documented a disproportionate increase NNM due to congenital anomalies, not all of which were incompatible with life. Among this specific sub-set of non-testing parents, prenatal diagnosis and planned hospital care would have reduced (but not eliminated) the incidence of neonatal mortality. However, this is a patient choice and is not a provider or place-of-birth issue.
In regard to the great debate about safety, it is useful to realize that birth-related morbidity and mortality can be time-shifted, place-shifted and practitioner-shifted, but they cannot be eliminated. In other words, increasing rates of pregnancy termination reduces neonatal mortality rates but obviously does not reduce overall perinatal mortality. There is nothing that birth attendants can do or not do that reliably, and with economically sustainability, can create a condition of zero risk for both mother and baby 100% of the time.
The risk-benefit continuum among the 4 responses to normal childbirth and the 3 types of birth attendants:
Simple access to prenatal care, on-going risk-screening and physiological management of active labor, birth and immediate postpartum-neonatal period by experienced birth attendants of all categories improved outcomes by orders of magnitude. Here is the breakdown for each type of birth attendant and both in and out-of-hospital settings.
The most startling conclusion is the consequences of “no care”. Lack of prenatal care, no skilled birth attendant present during labor and birth and not having or not using emergency care when indicated is unconscionably dangerous and represents a failure of society at some level. The total absence of medical and maternity services, whether by religious or personal choice, due to poverty or cultural beliefs, can turn the otherwise normal biology of pregnancy and childbirth into a lethal condition.
Many people would have assumed that the care of lay midwives would have been little better than unattended births but they would have been very mistaken. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to the control group.
When it comes to ‘value-added’ above the background biological hazard, lay midwives added the most value of any category of birth attendant. These good outcomes were achieved by providing childbearing women with prenatal care, on-going risk-screening and referring those with serious medical or pregnancy complications to obstetrical services. Mothers and their unborn babies were monitored during active labor by capable midwives who recognized medical problems and arranged timely transfer of patients with complications to the obstetrical service at the county hospital.
This straight-forward access to prenatal care, risk screening, transfer as indicated and physiological management during labor, birth and postpartum-neonatal period as provide by lay midwives was able to reduce perinatal mortality by 20 to 40 times compared to the mortality statistics for control group. This substantial feat was accomplished at a small fraction of the expense and was able to lower neonatal mortality to a rate similar to that of professional midwives and a maternal mortality rate equivalent to hospital-based-obstetrical care.
Within the structured healthcare systems of North American and the formal reimbursement scheme by governments and insurance carriers, expansion of services by lay birth attendants would not be a viable option. Our educated population rightfully expects 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.
Nonetheless, lay midwives are an eager and reliable group that should not be overlooked. They are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries and among groups that are for any reason excluded from the official health care system in developed countries. It is illogical and unwise to criminalize this group.
In study #3 state-regulated direct-entry midwives had no maternal mortality and a neonatal mortality rate of 2.6 per 1,000 (including fatal birth defects), which was ever-so-slightly better that the lay midwives and in the same general range as hospital-based obstetrical care for low and moderate-risk women. However, childbearing women cared for by professional midwives had 2 to 10 times less obstetrical intervention than medicalized hospital care and a 6-fold decrease in Cesarean section (under 4%). All of these good outcomes were achieved at a small fraction of the expense of orthodox obstetrical care.
In study #4, the Canadian direct-entry midwives were fortunate to be providing care in a providence that had an integrated model of care with generally cooperative and complimentary relationships between midwives and physicians. Midwives in several parts of Canada have hospital admitting and practice privileges, so healthy women have the option of a planning a midwife-attended hospital birth. This also allows for continuity of care for transfers from home to hospital when the mother-to-be does not require obstetrical management or operative delivery. When the services of an obstetrician are needed, this articulated system provides for a seamless transfer of care and ‘no-fault’ receptions.
Last but not least, these statistics are for a subset of childbearing women — the lowest of low-risk women. This is a patient population with good access to and use of prenatal screening and for whom all diagnosable congenital anomalies have been eliminated from this cohort. Neonatal deaths for midwife attended PHB in this population are the very lowest of all stats for normal birth in any setting — NNM per 1,000 of 0.35 for births planned home births, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births.
These are ideal circumstances and while we all aspire to them, they cannot be replicated 100% of the time by 100% of the childbearing populations. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare.
With the rarest of exceptions, this general principle applies to healthy childbearing women. Assuming that the mother-to-be is fully informed by her birth attendants, she has the right to decline prophylactic medicalization and choose instead (or accept) the increase risk of a specific pregnancy or intrapartum circumstances that puts her into a moderate risk category — for example, a small fibroid, a large baby, vaginal birth after a Cesarean, prolonged rupture of membranes, meconium, or a post-dates baby with reactive NST. It is necessary for the maternity care system to acknowledge the constitutional right of adult women to continue receiving birth-related services even when they are not totally ‘ideal’ candidates for OOH care.
The alternative is to put many women between the Devil and Deep Blue Sea by denying access to professional OOH care. This forces them to choose between medicalization they do not want, and in actual fact may not benefit from, or having unattended births (the risks of which have already been identified). The other problematic possibility is that women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives her of access to adequately trained attendants and medical back-up arrangements but also creates another group of unregulated lay midwives, which is both unnecessary and unwise.
The better strategy is to acknowledge that moderate risk women have a constitutional right to have professional services for an OOH birth. The statistical record of a mixed-risk population (low plus moderate-risk women) consistently demonstrates a NNM rate between 1.5 and 2.6 per 1,000, irrespective of birth attendant or birth setting.
Institutionally-based obstetrical care appeared to have improved neonatal mortality ever so slightly (approximately 1.5 per 1,000) as compared to the lay attended group (3:1,000) and professional midwives (2.6:1,000, but this small gain was offset by a dramatically increasedCesarean section rate of 32% and drastically increased cost of care. This escalating CS rate has been associated with the current upward trend in maternal mortality (MM) by other researchers.
In that regard, physiologically-based forms of care, which lower the incidence of Cesarean, also reduce rates of maternal mortality. While no family or birth attendant should ever be forced to choice between the life of the baby and that of the mother, we also must be sure that enthusiasm for the lowest possible neonatal mortality statistics does not increase the risk to the childbearing woman and result in avoidable maternal mortality.
High-tech, high-cost, highly interventionist obstetrical care for healthy women does not appear to improve combined mortality rates for mothers and unborn or newborn babies. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of surgical delivery.
Bottom Line: Hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.
As measured by the outcome statistics for the 3 categories of birth attendants: 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 the three simple already identified aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth. This was associated with prenatal care, risk-screening, transfer to medical services as indicated, birth attendant skilled in physiologic care present during the intrapartum, postpartum-neonatal period and appropriate use of emergent and comprehensive medical services as necessary.
Evidence-based maternity care by birth attendants trained in physiological (non-interventive) management achieved “maximal results with minimal interventions” by a wide margin. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.
To paraphrase the popular African saying, it takes a village of skilled and knowledgeable people to support the safe passage of mother and baby thru pregnancy and birth.