Common Sense Care
for Childbearing
Bringing
Back the Hippocratic Oath to 21st Century Obstetrics
The Childbirth
Declaration of the
Independence
from the Unscientific and Harmful Forms of Maternity Care
as Provided to Healthy Childbearing Women in the U.S:
We
hold these truths to be self-evident
-- that every normal healthy woman has the right to preserve the
biological and psychological integrity of her person and her unborn
baby from all forms of maternity care that fail
the test of common sense.
Common
Sense Maternity Care is science-based. Common sense maternity care
is organized around preserving the health of the already healthy
mothers. Common sense maternity care is based on the principle of
physiological management, which is in accord with and supportive of the normal biology. Common sense
maternity care is careful
not to disturb the normal biological process. Common sense maternity
care is fundamentally “efficacious” – that is, safe,
cost-effective, accessible, affordable, acceptable and mother-baby,
father, and family-friendly.
The
Universal Standard of Care:
Physiological
management is the evidence-based model of maternity care. Unfortunately,
our the dominate 20th
century model of interventionist obstetrics for healthy women is not
scientifically-based. This is a problem that needs to be
remedied.
A
true scientific standard of
care would integrate the classic principles of physiological
management with the best
advances in obstetrical medicine to create a
single,
evidence-based standard for all healthy women be used
in all birth settings and by all
maternity care providers -- family practice physicians,
obstetricians, and professional midwives.
Healthy
Childbearing Women have a right to:
v
Preserve the Integrity
of
Normal
Birth
v
Unfettered Access to
Scientifically-based Maternity Care
v
Control the Manner and
Circumstances of
Normal
Childbirth
Problem: The uncritical acceptance in the US
of an unscientific premise for normal maternity care – an untested experimental system of
surgical obstetrics for healthy women with normal pregnancies -- is
a serious problem. The obstetrical system defines normal childbirth as a surgical procedure to be
performed by an obstetrical surgeon. However, interventionist
obstetrics for healthy women is a risky and expensive model that
fails to account for or address the ecology of normal birth. It
routinely introduces unnecessary and unnatural risks and results in
iatrogenic or nosocomial harm in a significant proportion of cases. About
20% of our health care budget is spent on maternity care, so a
problem of this nature dramatically increase the cost of that care
without improving outcomes and in many instances, creating
additional costs in both in economic and in humanitarian terms.
Solution:
A science-based maternity care system that uses physiological
management is safe, cost-effective and
mother-baby-father friendly. The physiological model of care reserves medical and surgical
interventions for the treatment of complications and at the request
of the childbearing woman.
The
Science: The scientific basis for physiological management of
pregnancy and normal childbirth is supported by a consensus of the
scientific literature both in contemporary times and historically.
Physiological management is actually protective for both mothers and
babies, reducing the episiotomy & operative delivery rate (and
associated complications), from approximately 72% to approximately
5% [Listening to Mothers, Oct
2002] with an identical, or even slightly improved perinatal mortality
rate. It is efficacious -- that is, both safe and cost effective.
How
come we don’t already have science-based maternity care?
Americans
are accustomed to believing that we have the very best of everything,
especially the best health care system. However obstetrics, as
currently provided to healthy women with normal pregnancies, does not
live up to this expectation. The reason is that childbearing in a
healthy population does not routinely benefit from surgical skills or
routine medicalization. Worse yet, spontaneous labor and birth does
suffer when the normal
physiology of childbirth is disturbed. Serious problems can occur (a
category known as iatrogenic and nosocomial complications) as a result
of unnecessary medical interventions.
The
"modern" obstetrical system fails to live up to its
potential because it rejected the physiological model of childbirth
early in the 20th century, believing that the routine use
of medical and surgical interventions made birth safer for healthy
women. To understand why obstetricians came to that unusual
conclusion, we have to examine the history of obstetrical medicine.
Obstetrical medicine as we know it today got its start in the medical
schools of
Europe
during the 17th, 18th and 19th
centuries. This is where the teaching and practice of obstetrics
was first institutionalized. It was this institutionalized model of
maternity care that was adopted as the form of obstetrics still used
in the
US in modern times.
Nineteenth Century hospitals as places for obstetrical education
BACKGROUND:
In
Europe
during the Middle Ages there
was a large population of pregnant women who were both indigent and
homeless. Usually they were unmarried, widowed, immigrants, friendless
or otherwise without resources -- the equivalent of what we now call
“street people”. During the last weeks of their pregnancies they
sought shelter in charity hospitals run by Catholic nuns. The
‘hospitality’ extended by these nuns is the origin of the modern
word ‘hospital’ and idea of hospitals as places of caring.
Eventually
these early centers of hospitality became linked to medical schools
and evolved into places to conduct clinical research and teach
clinical medicine. The most efficient way for medical students to
learn about normal birth and to diagnosis and treat complications was
to use the large number of hospitalized patients as teaching cases. This
in-patient population provided medical students with opportunities to
learn and practice their clinical skills.
Unfortunately,
being a patient in these early hospitals also exposed childbearing
women to extreme crowding and unhygienic circumstances – no running
water, no sanitary toilets or even a bed with clean linens. No one
understood the bio-hazards associated with hospitalization. Many times
the crowding was so bad (and the understanding of contagion so poor)
that women were made to share a bed with other patients. When they
went into labor, they become teaching cases for the students of the
medical school. As 'clinical material', they were repeatedly exposed
to invasive procedures and to surgical deliveries (such as the use of
forceps).
All
of this occurred long before the development of the germ theory of
disease, exam gloves, techniques of asepsis and sterilization, laundry
service, anesthesia or antibiotics. Never in the history of the human
species had large numbers of unrelated women ever been aggregated
in one place for childbirth. These early hospitals did for
contagion in childbirth what gay bath houses did for hepatitis and
HIV-AIDS, which is to say, to function as a vector which spread a
lethal infection to healthy and otherwise unrelated people.
Unfortunately,
the extreme biological hazards of this situation were accompanied by
an equally extreme level of preventable mortality. In some of the
larger hospitals of 19th century
Europe
, two (or more) newly delivered women and their babies died each
and every day, for months at a time. Medical professionals
and the lay public were both acutely aware that the maternal-infant
mortality rate was much higher in hospitalized patients than when
doctors and midwives attended to the mother in her own home. Obviously
the invasive procedures so central to the teaching and practice of
obstetrics somehow violated the ‘ecology’ of normal birth (to the
detriment of both mothers and babies), although the medical profession
could not explanation how or why.
The
‘ecology’ of natural systems is modern term describing a complex
set of ideas that did not exist in the 19th century. None
the less, the concept of 'ecology' is an excellent way to understand
the integrity and finely-tuned process crucial to normal child birth.
Biological, hormonal, psychological and sociological factors must all
work together to preserve, protect and promote normal childbearing.
Like the global climate, the ecology of childbearing is a
highly-orchestrated natural system with its own feedback loops and
self-correcting mechanisms. Its adaptive capacity is amazingly broad
and effective – a fact attested to by the survival of our species.
For healthy women in surroundings which preserve that ecology,
pregnancy and birth was normally successful. We know this statement is
true because the human species has survived (and in fact, thrived)
into the 21st century.
However,
the adaptability of any ecological system is never indefinite. The
delicate balance necessary to safe childbirth was seriously harmed
when laboring women became clinical material in the medical education
process. Clinical instruction in obstetrics was a double edged sword.
On the positive side, it greatly improved the understanding and
technical skills of the medical profession. This advanced the
knowledge-base of obstetrics and eventually led to many of the amazing
and life-saving abilities associated with modern medicine.
Unfortunately for childbearing women in the 18th and 19th centuries,
this happened long before the discovery of microscopic pathogens and
the development of the germ theory. Bodily intrusions (such as vaginal
exams and the use of forceps) and other medical and surgical
interventions caused iatrogenic complications to become the norm.
Epidemics of a fatal infection – hemolytic streptococcus which
caused septicemia or ‘puerperal sepsis’ -- gave the earliest
hospitals a terrible reputation and caused them to be thought of as
places where people died. As one can imagine, the obstetrical
profession was very anxious to fix this problem.
However,
it was not until 1881 that the knowledge necessary to correct these
problems began to emerge. Dr Louis Pasteur, a French physician now
known as the ‘father of pasteurization’, was also the first person
to formulate and teach the germ theory of infectious disease. By
understanding the role of bacteria in making women sick and how to
prevent cross-contamination through hand washing, use of antiseptics
and sterilization, the obstetrical profession was finally able to stop
the horrible epidemics of hospital-based fatalities. Improved
housekeeping standards, liberal use of antiseptics, access to aseptic
and sterile supplies, isolating the maternity wards from other parts
of the hospital that housed infected patients -- al combined to end
the mass causalities from childbirth septicemia in Europe (although
individual cases continued to occur). This ushered in what we now
refer to as “modern medicine”.
The Development of 20th Century Obstetrical Care in the
US
In
the early part of the 20th century, hospitals in the
US
proudly adopted these ‘new’ ideas and epidemics of childbirth
septicemia in American hospitals also become rare. But in spite of
everyone’s best efforts, an unusual number of septic fatalities
still occurred. As had been noted for centuries, doctors continued to
observe a much higher maternal mortality rate in hospitalized women
when compared to births attended by doctors and midwives in the
mother’s own home.
However,
the teaching and practice of all forms of medicine in an institutional
setting was, from the medical profession’s standpoint, ever so much
more satisfactory in every way. It was a godsend to have a nursing
staff available 24-7 and to have them keep meticulous notes on each
patient that doctors could refer to at a later time. Immediate access
to x-ray and lab services and fully staffed operating rooms really
bumped the practice of medicine up to a whole new level of efficiency.
Doctors were particularly impressed by the convenience that came with
having patients stay put in hospital beds, so that medical professors,
med students, interns and residents could make the rounds of all their
patients without leaving the building.
By
comparison, home-based maternity care was seen as the bad old way of
19th century. Making house calls was considered to be an
inefficient use of the doctor’s time. Also it often forced doctors
to provide care in grim circumstances, such as tenements and rural
farms, which deprived them of electricity and running water.
Surely
these ‘domiciliary services’, as home-based care was referred to
by the medical profession, were not appropriate for the new era of
‘scientific medicine’ and ‘modern medical miracles’. It was an
exciting time of bright promises and obstetricians were committed to
leaving behind the old-fashioned ways with all deliberate speed. The
principles of physiological management and the caregivers that
depended on physiologic process – mainly midwives and GPs --were
right at the top of the list of ‘bad old ways’ to be replaced by
the new ‘science’ of interventionist obstetrics.
How Obstetrical Intervention Became the “Norm” in the
US
In
1910, two influential East Coast professors of obstetrics – Drs.
Joseph DeLee and J. Whitridge Williams – had a theory. They had
observed that ‘aseptic’ techniques (a - not & septic -
infected = free from infection) were able to end the epidemics of
fatal infections, but not able to prevent all individual cases
of infection. This was particularly true for situations in which
medical and operative interventions were used (induction of labor,
repeated vaginal exams, episiotomy, forceps, manual removal of
placenta). So they advanced a simple hypothesis – were
doctors to conduct all births as
a surgical procedure, all
deaths from infection would be eliminated. They were describing a
two part process. First ‘birth’ should be distinguished from
‘labor’ and secondly, birth should treated with the same kind of
special sterile processes, special staff and sterile operating room
that was already being used for major abdominal surgery.
This
new configuration identified the physician’s role as focused
primarily on the birth as a surgical procedure, to be performed in
sterile garb and a ‘surgically sterile’ operating room. As a
surgical procedure performed by a physician, it came to be referred to
as “the delivery”.
Under
these conditions, labor was referred to by the medical profession as
‘the waiting period until the doctor was called’. During the long
and often tedious hours of labor, patient care was to be provided by
hospital nurses. They were instructed not to call the doctor until it
was time for the mother to be taken to the OR-type delivery room and
prepared for the ‘delivery’. Then the doctor, in his official
capacity as a surgical specialist, performed the highly technical
‘procedure’ of vaginal or operative delivery.
This was indeed worthy of the professional fee commonly charged
for the services of an obstetrician.
To
help guarantee the highest level of sterility and thus a safer birth,
doctors believed that it was necessary to use general anesthesia to
put the mother to sleep. Under chloroform or ether, the unconscious
mother would lie perfectly still, and thus not accidentally
contaminate any of the sterile sheets or instruments by moving around
or touching things. However, when birth is conducted under anesthesia,
the mother cannot make right use of gravity or push as effectively, so
the use of episiotomy and forceps seemed to make a lot of sense to
obstetricians.
Doctors
genuinely believed that routine use of episiotomy would protect the
mother’s pelvic floor. They likewise reasoned that episiotomy, together with forceps, would protect the baby’s head from being
battered on “the mother’s iron perineum”. In addition, the
medical world believed that obstetricians would never be able to use
forceps properly in difficult or emergency situations unless they
maintained their skills by using forceps routinely in every normal
case. It was agreed that the routine use of forceps was the only
responsible thing for obstetricians to do.
Unfortunately,
the abandonment of physiological management and its replacement by the
routine use of obstetrical interventions, resulted in a marked increase in maternal-infant mortality and morbidity. Between 1910
and 1920, maternal deaths increase by 15% per year. Birth injuries to
babies – usually the result of maternal anesthesia and the use of
forceps -- increased by 44% during the same decade.
In
addition to infection, there were other mortal dangers faced by
childbearing women. These were usually the result of poverty,
malnutrition, disease, overwork and forced childbearing.
As the educational level and standard of living rose, these
situations gradually improved. The great advancements in
maternal-child health that have occurred in the 20th century are
primarily the result of improved public health measures and economic
conditions. This was brought about by public sanitation projects,
better access to education, a better diet, adequate housing, improved
working conditions, appropriate access to medical care when needed,
the safety net of social programs and access to effective
contraception.
Only
a tiny portion of the gains made in women’s health and the overall
improvement in maternal and infant mortality rates associated with the
20th century can be attributed solely
to obstetrical interventions. However, the obstetrical profession has
always taken the lion’s share of credit for the dropping mortality
rate. They remains convinced that only
interventionist obstetrics stands between women and childbirth-related
death and disability.
Obstetrical
interventions, such as drugs, anesthesia, forceps and Cesarean, can
and are lifesaving for women or babies with serious complications.
Unfortunately, the obstetrical profession believed that all normal
labor and birth should be medicalized, using these same intervention
routinely on every childbearing women. And so the same interventions
used for complications became the standard of care for normal birth.
At the same time, the normal ways of providing care to healthy women
– physiological management -- was purposefully dismantled. This was
accompanied by comments from the obstetrical profession that there
should be only one standard for maternity care and that
standard should be an obstetrical one.
How19th Century Ideas
Contaminated
21st century Maternity Care
It
is a convoluted path that led from Dr Semmelweis’s time in the 1840s
to 21st century obstetrics in the US. However, it is
just a fluke of history that
the epidemic nature of puerperal sepsis in hospital settings of the
18th and 19th centuries influenced and defined the development of
maternity care for healthy women in the US in the 20th and now the
21st century.
As
consequence of the fatal epidemics of child birth septicemia in 19th
century hospitals, childbirth as a surgical procedure to be performed
by a physician became the ‘gold’ standard for the entire 20th
century. During the last two decades of the 20th century,
forms of medical and surgical intervention were ratcheted up to
include routine induction of labor, nearly universal use of epidural
anesthesia and frequent use of episiotomy and vacuum extraction. For
many women, ‘elective’ or medically unnecessary Cesarean has
become the crowing glory to the medicalized model of birth.
This
is particularly odd conclusion to a story and a strategy that started
out to prevent iatrogenically- generated epidemics of childbirth
septicemia as it occurred in teaching hospitals of Europe and the
Northeast coast of the
US in the late 1800s and early 1900s. However, its not too late to
reassess the situation and correct the problem by adopting a
science-based maternity care system that uses the principle of
physiological management when providing care to healthy women with
normal pregnancies.
“Primum
non nocere”
"In the first place, do no harm..."
bringing the Hippocratic Oath into
the 21st Century
Physiological:
…"..in accord with, or characteristic of, the normal
functioning of a living organism”
(Stedman’s Medical Dictionary definition of “physiological”
– 1995)
Physiological management is the
evidenced-based model of maternity care. It is associated with the
lowest rate of maternal and perinatal mortality, is protective of
the mother's pelvic floor, 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 complications and delayed or downstream complications
in future pregnancies. Physiological management is both safe and
cost-effective.
Conventional
obstetrics as applied to healthy women is the opposite of
evidence-based, physiological management. Its associated with
a high level of medical interventions,
obstetrical complications, anesthetic use, instrumental deliveries,
Cesarean surgery and post-operative complications including
emergency hysterectomy, delayed complications such as stress
incontinence and pelvic organ prolapse, downstream complications in
future pregnancies, long-term psychological problems such as
postpartum depression, lower rates of breastfeeding and increased
asthma in babies born by cesarean section. Conventional obstetrics
for healthy women is neither safe nor cost-effective. [see "What Every Pregnant Woman Needs to Know about Cesarean
Section", a systemic review of the scientific literature by the
Maternity Care Association of NYC available at www.maternitywise.org
A long over-due and much needed
reform of our national health care policy would integrate
physiological principles with the best advances in obstetrical
medicine to create a single, evidence-based standard for all healthy
women. Physiological management should be the foremost standard for
all healthy women with normal pregnancies, used by all practitioners
(physicians and midwives) and for all birth settings (home,
hospital, birth center). This “social model” of normal
childbirth includes the appropriate use of obstetrical intervention
for complications or at the mother’s request.