California College of Midwives
UCSF Meeting July 30, 1999
Routine Hospitalization -- Help or Hazard?
Reasons for what seems to be unreasonableCountless contemporary studies and historical sources of vital statistics for childbirth have identified that healthy women with low to moderate risk pregnancies who are cared for by non-interventive practitioners (midwives or physicians) in non-medical settings (client home or OOH birth center) have outcomes that are equally safe as measured by perinatal mortality to hospital-based birth services. [1] These same mothers are many time less likely to experience maternal complications or be subjected to unplanned or unwanted use of medical interventions such as continuous electronic fetal monitoring, induction / augmentation of labor, narcotics, anesthesia, episiotomy, forceps, vacuum extraction or admission of the baby to the NICU. For instance, they are 3 times less likely to need a Cesarean and more than 10 times less likely to have an episiotomy. The cost for non-interventive birth services in a domiciliary setting is 3 to 6 times less than hospital care. [2]
Upon hearing these facts 99 out of a 100 people think the speaker must have made a mistake. Don’t you mean it the other way around? they ask, isn’t a hospital always safer? They assume you got the data backwards because to most Americans such an idea seems counter-intuitive or even preposterous. We all know that hospitals are the very best place to be when you have any kind of medical emergency. We see it all the time in the movies and on television. People are fighting to get into hospital -- not fighting to stay out of them. Why wouldn’t that apply to childbirth which may be a "normal" process but it is still unpredictable with well-known potential hazards. When a problem does occur, people correctly recognize that time is of the essence, and when minutes count, surely already being in a hospital would give you the vital edge.
While each of these statements is "true" in certain limited circumstances, they do not reflect "truth" as an inclusive examination of the topic. Most people don’t see the-*/- "big picture" -- a series of factors that are not instantly apparent but none-the-less impact on the relative risks and benefits of childbirth services in different setting. Two aspects to be addressed are the realistic dangers hidden within the seeming safety of the hospital and how greater safety than one would anticipate lies within the seemingly increased risks of non-interventionist home-based midwifery. In other words, what is fact and what is fiction and why?
This investigation is complicated by the fact that hospitalization refers not only to a physical building but also the interaction with hospital employees, a professional staff, technological equipment, a bio-hazardous environment and a collection of standards, policies, routines and staffing patterns. They are complex places like airports. In addition there is the unpredictability of personal abilities and personality conflicts-- differing skill levels and personal bias among the staff which affects how those resources are allotted and what actions are taken (or not taken) on behalf of the patient.
Hospitals are not an "it" and therefore not "good" or "bad" per se but rather each individual’s experience is either good or bad (salvific or hazardous) depending on the specific collection of staff members and circumstances present at that point in time. This makes it hard to separate the influence of physical place, finite resources (number of available operating rooms, etc) from the influence of staff and medical careproviders as they interact with one another and with the patient. Safety or hazard is influenced by all those factors and in the final frame, we see that a fundamental characteristic of hospitalization is complexity and the unpredictability that introduces.
A study of the practices surrounding hospitalization for childbirth in the US reveals many pertinent topics. From this examination one can fairly easily see how routine hospitalization of healthy mothers can and many times does introduce its own hazards and thus provokes its own unique dangers. It is the aggregate of these dangers that are reflected by the absence of the superior results for hospital-based care that were anticipated and the unanticipated good outcomes for non-interventive midwifery in out-of-hospital settings. From there it is possible to propose changes that would help close the gap between domiciliary and hospital-based care, although the basic characteristic of physiological childbearing simply doesn’t naturally lend itself to institutional care. As mentioned earlier, certain facets of institutionalization such as staffing problems, bio-hazards, continuity of care issues and personality conflicts and the like are also inherent. The best that both styles of practice can offer is informed consent relative to identified risk/benefit trade-offs which occur in each system.
What keeps the potential benefit of routine hospitalization for
Healthy Childbearing Women from being realized?1. The biological nature of childbirth as a spontaneous process and the unintended consequences of institutionalization with its increased likelihood of disturbing a delicately-balanced physiological process:
A veterinarian acquaintance remarked that if he were to interfere with the spontaneous birth process of a horse the way routinely done with childbearing women in American hospitals, it would be a disaster for the mare and he would be guilty of veterinarian malpractice. Do the principles of animal husbandry have anything to do with human birth? Well, both categories deal with mammals and that function of mammalian biology described as "spontaneous" process -- those aspects of physiology that are neither voluntary OR involuntary. Example are sleeping, sneezing, breathing, emptying the bladder, let-down reflex for breast milk and sexual function -- all things that you can consciously choose to disrupt or at least postpone but cannot command. Birth is in many ways like a slow-motion sneeze. You can’t make it happen on purpose. Likewise, when you get to that just right place, you can’t stop it either. For instance, if you try to stifle a sneeze, it still happens but feels weird and unsatisfying. In extreme cases, normal physiology can become pathological through conscious or unconscious interference.
The physiological process of normal childbearing is a non-erotic facet of human sexuality, using the same biological structures and the same relationship to psychological and social factors. People tend to feel psychologically comfortable giving birth in the same private places and social circumstances as they would feel comfortable having sex. Childbearing (both labor and birth) is an emotional as well as a physical experience. Predictably childbearing women require (or at least benefit from) actual physical and psychological privacy. Emotional tone and content matters a lot to laboring women. To complicate things further, these emotional needs change during the course of the labor, depending on where in the process the mother is and how she is feeling about it and about the people (or absence of people) who surround her. [3]
The maternal emotion of fear particularly influences the physiological process of parturition. Some mothers are afraid of labor, especially the pain. Others are afraid of medical procedures and made anxious and stressed by hospitalization. Fear in the first stage usually slows or even stops labor. Depending on the phase of second stage (expulsive labor) maternal fear can either stop its progress or may, paradoxically, trigger a "fetal ejection" reflex and a precipitous delivery -- a left over fight-or-flight response from our earliest ancestors who were chased by lions and tigers and bears.
Unfortunately, fear at any time makes labor many times more painful. This can so totally inhibit the biology of childbirth that medical interventions are the only immediate solution -- administration of drugs for pain and other drugs to stimulate the uterus. The risks of these drugs are many, and include fetal distress, the need for anesthesia and the increased use of vacuum extraction or CS. Given such a medically-intervened with birth, the baby may well need some time in the NICU. If it picks up a hospital superbug (antibiotic-resistant microbe) in the nursery, the infection will require long and expensive treatments. Fear costs us all money in this sense.
The problem is that institutions as currently designed, staffed and managed are not very private, are not very successful at dealing with unique emotional needs, and don’t have a lot of other options except the use of drugs and surgery to treat what began as a psychological interference. Institutions frequently must depend on medical and surgical solutions to treat situations that were originally psychological problems. This happens in part because of the hospital’s need to be cost-conscience about staffing levels and limitations imposed by the institution’s need to protect itself from malpractice litigation. These and other aspects of team dynamics and staffing patterns all seem to conspire to keep hospitals from being flexible enough to anticipate the needs of physiological childbearing and to meet the individual emotional needs of each laboring women over several hours or even days of labor.
The absence of this ability is one reason why hospitalization may actually provoke dangers during childbearing that are not present when the mother is being cared for in her own home.
2. Continuity of Care issues -Continuity of care refers to familiarity and on-going relationship between caregiver and patient, knowledge of the patient’s history and present circumstances and actual time spent with the patient. In an ideal world, laboring mothers would be cared for by the same practitioner who provided their entire course of prenatal care and that same practitioner would be present through out the entire labor, would conduct the birth him or herself and provide the same continuity of care during the postpartum and neonatal period. Unfortunately this is extremely rare -- only a community-based midwife with a very small practice can routinely offer this kind of care and even then competing duties, a sick child or vacations can still disrupt these carefully laid plans.
When more than one person is pivotally involved in providing care one of the great challenges is appropriate and timely communication. Every parent knows that even with only two of them to account for, this kind of crucial communication is tricky. Keeping tract of when the baby was diapered, last feed, napped or given medicine may seem simple but despite our best efforts important information still falls through the cracks. As children get older and perhaps a babysitter or school teacher gets added to the mix, it gets even more challenging to keep track of regular life plus special permission to visit a friends house after school or stay up past their normal bedtime. Multiply this times several children and several simultaneous caregivers and you have some idea of the nature of the problem. When you consider the number of people involved in providing contemporary maternity care, one can appreciate just how hard it is to keep everybody informed at the right time with the information so central to the mother and baby’s safety. One can also appreciate how rare it is in today’s healthcare system to be cared for by someone with whom you have an on-going relationship.
In addition to doctors and nurses, other people such as employees of the doctor’s office (who has prenatal records), ward clerks at the hospital (who makes up the hospital admission chart), lab and x-ray technicians, med students, interns, residents, other specialists (anesthesiologist, perinatologist, etc) are all part of the "team". All of these people have (or don’t have when they should) crucial information. An error by anyone of them can be reiterated throughout the system and the mistake magnified, sometimes with catastrophic results. Some systems of redundancy have been devised to keep this from happening but such complexity inevitably breaks down from time to time.
Dr. David Rubsamen, MD, an expert on obstetrical malpractice litigation, has characterizes the problem as not so much one of dropping the ball in the first place but not catching it on the first bounce. When many different people are involved without the full-time presence of a knowledgeable practitioner, it is all too easy for each person to think that someone else is fielding those fly balls. Dr. Rubsamen has estimated that 25% of obstetrical litigation involved the actions or inactions of L&D nurses, most often a communication breakdown between the nurses at the hospital and doctor who was not. Major areas of conflict in accountability occurred in regard to what was said, whether a call was made and when the call was made. [4]
In addition to communication problems associated with continuity of care are the unmet relationship needs of the mother. Her experience is less than optimal when she must instantly expose herself physically and psychologically to a long line of strangers, often ones doing vaginal exams on her. Lack of continuity also interferes with the caregiver’s ability to provide the quality of emotional support made necessary by the inherent nature of physiological childbearing. Labor room nurses don’t usually have any prior knowledge or personal relationship with their patients and also are hampered by the limitations of an institutional environment, with its restrictive protocols and constantly changing staffing patterns (nurses must cover for dinner breaks, new admission, emergencies, etc).
Doctors don’t sit with their patient during labors. Even if they come to the hospital when the mother is admitted, they will either return home or go to sleep in the call room. They are only continually present for the last 30 minutes before the birth and sometimes not that long. In our area, many obstetrical patients don’t actually get to know their doctors either. At least one obstetrical practice in the San Francisco bay area has a call group of 30 different OBs. If the 24 hour shift changes during the time the mother is in the hospital, she may be cared for during labor by two or more doctors she has never even met as well as 2 to 6 strange nurses and multiple other hospital employees.
Lack of continuity of care often results in communication breakdown and inability to meet the psychological needs of laboring women. Because of the nature of allopathic treatment, akin to the use of power tools, a "small" mistake can have exaggerated consequences. In a domino effect, problems originating from a lack of continuity of care can escalate into a medical emergency that is ultimately reflected in maternal-infant outcomes statistics that favor non-interventive care in non-medical settings.
3. Nosocomial and Iatragenic Hazards.Iatragenic refers to practitioner error. Nosocomial refers to complications or death resulting from hospital employee error. In some instances (such as hospital-acquired infections) it may not be possible to identify the individuals who participated in the chain of events leading to the negative outcome. Many of the problems with hospital care noted in previous categories referred to systems failure rather than direct errors that can be traced to a specific individual. From the standpoint of the childbearing women this fine distinction means very little. However, clear identification of problems does assist in their correction.
A major aspect of nosocomial and iatragenic error, while ascribed to individuals, arises out of the nature of allopathic medical practice. Unlike many other "healing arts" practiced around the world, the German tradition relies heavily on very potent drugs, invasive and potentially dangerous diagnostic procedures and surgery. One allopathic physician described drug treatment as giving the patient a different disease with preferable symptoms in an attempt to turn an acute disease process in to a chronic one that the patient could more comfortably live with. The more potent the pill or more dramatic the surgical procedure, the more it is like using power tools. If you are using a hand saw and "slip", you may cut yourself very painfully and even need stitches. If you slip using a power saw, you may amputate a limb and even bleed to death awaiting the ambulance. While power tools do the work quicker, they are also quicker to get out of hand and wreck more devastation for the same original "error". This is known as the "shadow side" of a system. The bigger, better, faster it is, the more its unintended consequences.
Hospitalization is particularly problematic as applied to maternity care. Unlike the typical patient who is hospitalized because of sickness, childbearing women are typically in the bloom of good health when admitted and usually give birth to healthy babies. The only other medical discipline that shares this characteristic relationship to healthy patients is plastic surgery in which a potentially life-threatening service is provided to people who are initially healthy. State regulation of hospital maternity units came about early in the century due to the obligation of careproviders to prevent nosocomial exposure of healthy women and babies to the bio-hazards that are normal to medical institutions. Epidemics of hospital-acquired staph and strep infections have gone through hospital nurseries causing death or disability of healthy newborns time and again, as even the best vigilance is not equal to a perfected system. There are no perfect systems. Within the last two years 25 different strains of Vancomycin- resistant staphylococcus have emerged in addition to a potentially deadly mutation of pseudomonas and Group A strep (both common hospital pathogens). Vancomycin-resistant enteroccocus (VRE) have been cultured in 100% of the hospitals tested in the greater Bay Area. Outbreaks of necrotizing faciitis have occurred on the East Coast and in Quebec, with maternal deaths in each instance. [5]
Another important aspect of nosocomial and iatragenic errors in American hospitals are the limitations or deficiencies of the "system" itself. Unlike the commercial airline and nuclear power industries, the healthcare industry has not concentrated its efforts on safety systems, multiple redundancies and close examination of "near-misses" for their instructive and remedial qualities. In fact, most near-misses are hidden either by the individual (due to professional embarrassment) or by the institution (fear of litigation). Many aspects of the system depend to an inordinate extent on extreme vigilance of a single individual. When a moment’s inattention occurs (often the result of staffing shortage - i.e., system failure), the individual is made to bear 100% of the blame and no accountability, responsibility or remedial action is taken by the institution. Thus the type of problem is endlessly reiterated without hope of correction. [6]
Last in this litany of failures is that of individuals in the system to realize that, in the absence of life- threatening conditions, life-saving techniques (including prophylactic hospitalization and routine obstetrical procedures) can of themselves be life-threatening. Until rather recently (1970s), blood transfusions were sometimes given "prophylactically" during simple surgeries (CS or hysterectomy) just in case there was excessive bleeding. That is no longer medically acceptable. It is pretty easy for us to see the folly of that today (what with blood-born diseases such as hepatitis and HIV) but the danger of dying from mis-matched blood or an allergic reaction to a transfusion have been know for 50 years or more. There are other unexamined circumstances of this kind involved in hospital-based maternity care.
Following is a list of the most frequently applied obstetrical interventions for a typical hospital birth and the iatragenic and nosocomial complications associated with them:
Artificial rupture of membranes resulting in pathways for infection or prolapse of the umbilical cord (requires emergency CS)
Restriction of oral fluids, use of IVs - restricting maternal mobility, confinement to bed, increased perception of pain and likelihood of narcotics analgesia
EFM - significant increase in Cesareans without equal improvement in perinatal outcome
Oxytocin augmentation of labor resulting in
need for narcotics and possible respiratory depression of neonate,
need for anesthesia with maternal hypotension and/or fetal distress
hyperstimulation / tetonic contraction of uterus/ iatragenically-induced fetal distress or more rarely, uterine rupture
subsequent postpartum hemorrhage
Increased ratio of operative delivery -- forceps, vacuum extraction or cesarean section;
Nosocomial-acquired infection; infection with antibiotic-resistant pathogens
Medication errors (wrong drug, wrong dose, wrong patient)
Drug reactions (anaphylaxis or chronic organ failure);
Anesthetic accidents
Surgical mistakes such as inadvertently cutting of bladder or bowel, tying off a ureter Surgical laceration of the unborn baby
Neonatal respiratory distress following general anesthesia, forceps or vacuum extraction
Wound infection following episiotomy or Cesarean section
Post operative pulmonary embolism after Cesarean surgery
Operative or post-operative maternal hemorrhage necessitating blood transfusion with risk of allergic reaction/shock and exposure to diseases carried by blood products -- hepatitis, HIV (this can put fathers, siblings and other family members at risk due to their communicable nature and untreatable status)
Infrequent neonatal complications includes mix-up of babies or abduction
In spite of these many nosocomial risks, hospitalization does not prevent or reduce the incidence of maternal-infant complications such as failure-to-progress, malposition of the fetus, genetic defects, prenatal sources of cerebral palsy or the rare complications of childbirth such as amniotic fluid embolism. Therefore routine hospitalization of healthy women, mathematically speaking, tends to add nosocomial and iatragenic risks to those which occur naturally from genuine complications.
4. Absence of full time practitioner (physician or professional midwife) when laboring women are hospitalized. This problem is exacerbate by staffing shortages, census fluctuations, inadequate training, inexperienced personnel and the limitation of the scope of practice of nursing. Nurses are not trained or authorized to act independently.
Recognizing potential complications in time to institute remedial action -- the "nip it in the bud/head it off at the pass" theory is one of the primary contributions of professionals to maternity care. Its beneficence is what we all hope for ourselves and our loved ones when pregnant. For this goal to be realized, someone must recognize the signs of complications and symptoms must be correctly identified -- all in a timely manner. That means physical presence of an experienced caregiver with an adequate knowledge base and the ability to respond, either personally and/or communicating to the person(s) with the authority and skill to intervene.
It is hard to count on this kind of response in today’s typical hospital as physicians don’t stay with laboring women and nurses don’t usually have the time. More to the point, the scope of practice of the nursing profession does not include either the formal education, skill sets or authority to make many of these crucial decisions. Regardless of how well trained or experienced staff nurses may be, they do not have the legal authority to make independent medical judgements or independently carry out necessary remedial actions. They must depend on phone calls to others and hope they communicated clearly enough and that the doctor responds quickly enough. What an odd system. Nursing staff should be present to assist the practitioner and not instead of a practitioner:
Only practitioners are formally educated and trained to detect the full spectrum of possible complications and likewise skilled and legally authorized to deal immediately with the emergent situations that sometimes befall women in active labor. It is this capacity for immediate medical response that is one of the primary reasons that families choose hospital-based obstetrical care (rather than community-based midwifery) and why they bear the added expense of those arrangements. Unfortunately, the majority of labors are not attended by practitioners -- either the attending physician, a professional midwife employed by the obstetrical group or a midwife employee of the hospital. As long as mothers are primarily cared for by those without the requisite training, skill and authority to identify and respond immediately to potentially problematic situations, bad outcomes will occur that conceivably would have been avoided through the immediate intervention of an on-site practitioner.
Labor and delivery units should be primarily staffed by professional midwives who are present and awake in the immediate area of the laboring woman during the time women are in active labor or hospitalized due to complications requiring "intensive" intrapartum care or observation. Until they are, laboring women maybe in the hospital but if her physician is not, that "edge" associated with hospitalization will be missing for many when they need it most, resulting in preventable deaths and disabilities and less than optimal statistics for institutional care.
5. High percentage of chance or happenstance associated with the timely use of emergency life-saving measures / lack of universal access to 24 hour emergency services -- in house anesthesia & surgical scrub technicians, sufficient number of ORs, laboratory and x-ray services, on-site blood banking, adequate staff for one-to-one:
Several obstetrical emergencies come instantly to mind for physicians and malpractice insurance executives when you mention domiciliary care. What about fetal distress, cord accidents, premature or delayed placental separation, neonatal respiratory distress, postpartum hemorrhage? they ask. "Can’t tell me that these emergencies don’t occur" and as a former L&D nurse myself, I do not argue their reality. "What are you going to do if there is a bleeding problem for the mother or a breathing problem for the baby?" they say in an incredulous tone of voice. The unvoiced thought is "Midwives (and home birth families) must be crazy".
Emergency intervention is really the place where the "rubber meets the road" so to speak, where hospitals have a change to strut their stuff. Sometimes they get high marks and flying colors. But not consistently and not often enough. What every long-time employee will describe is the high proportion of emergent situations in which things either worked or (or didn’t) based on a series of seemingly random factors. Many time the most dramatic "save" -- the kind that makes everyone proud of their job -- occurred because the right person was in the right place at the right time but all of those "rights" were not part of the system. Many appropriately timed interventions are more luck than planning. The nurse had already done her hourly check of vital signs and only went back in the room to retrieve her ballpoint pen when she happened to notice the pool of blood. The doctor who usually doesn’t make rounds at night just happened to stop by right when the bleeding was discovered. The anesthesiologist happened to still be on the unit because he was unusually slow in leaving that night. Or all of those same transactions occurred in reverse -- like star-crossed lovers, the same unpredictable happenstance worked against everyone and instead of a save it was a tragic loss, made even worse by the knowledge that theoretically at least, it was a "preventable" death.
Since the full-time presence of an experienced practitioner (physician or midwife) is not customary in American hospitals, the discovery of the problem is often unduly delayed. Staffing levels, ratio of nurse to patient, the census of patients in labor at the time, the use of new graduates, inexperienced nurses, personnel from a temp agency or "floats" from another floor that are unfamiliar with the hospital routine will all influence the discovery of a problem and/or the appropriateness of the initial responses to it. The nurses may be really busy, inattentive to the mother’s requests, she may not be a native English speaker or the nurse simply does not pick up the initial or subtle signs of an impending emergency.
Continuous Electronic Fetal Monitoring may seem like the perfect answer to these staffing problems but in actually, it often means that the nurse is sitting out at the desk watching a bank of 4 to 8 monitors instead of being at the bedside. Not every problem is initially visible on the EFM screen at the nurses station. One published study on the patterns of care of L&D nurses documented that the nurse is out of the room 79% of the time. When present in the labor room, she is only performing personal care for the mother 6% of the time. That means that about 94% of the time family members are the only consistently watchful and supportive presence. [7] No matter how good the nurse is, she can’t see through walls. Managed care is reducing the number of professional staff in all areas of hospital care including the L&D, so staffing shortages are not going to go away.
Emergency response times and appropriateness depends heavily on the level of 24 hour emergency service staffing. Most hospital in the US are community or second level institutions without full-time services. Unless you are referring to level 3 hospitals, experienced nurses will describe that the same medical emergencies at 3 p.m. on a weekday will have a whole different time frame than ones that happens at 3 am. Its especially bad on week-ends, holidays and in poor weather.
Last but certainly not the least of it, this topic is not compete without factoring in the price paid for prophylactic hospitalization. The equation must figure in the detrimental aspect of routine hospital care in which certain dangers are provoked. The very nature of institutionalization increases the number of labors that become medicalized, either through medical need or as a "risk reduction" hospital policy thought to reduce law suits or to assure that the hospital or obstetrician will be held blameless in any litigation that might arise. Some proportion of healthy mothers or babies will experience these same "emergent" conditions listed above -- not primarily due to the vaguarities of Mother Nature, but rather the interventions of Modern Man. Having provoked the problem, the hospital will subsequently take credit for having successfully "saved" the mother from this nosocomial complication.
For instance, artificial rupture of the mother’s membranes (breaking her water) to speed up labor greatly increases the risk of cord prolapse. Pitocin use increases the need for narcotics pain meds and anesthesia, which together increases the incidence of fetal distress, operative delivery and maternal hemorrhage. Neither of these account for the psychology of haste that pervades hospital-based obstetrical care and the propensity of tired, stressed, over-worked physicians to try to "get things over with". One of the fore fathers of obstetrics described in an 1839 textbook [8] that for every one woman saved by manual removal of an adherent placenta, 100 mothers were lost due to the routine use of manual placental removal done to hasten the process so the doctor could go home. Manual removal of the placenta was still being done routinely when I retired from nursing in 1976. Pitocin augmentation of labor seems to have replaced it as a time saving tool for the 1990s.
Even though the hospitals continue to take credit for saving childbearing women from the many complications associated with interventive hospital care, the statistical analysis will favor those settings and those caregivers who do not routine apply medical interventions to healthy mothers.
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Changes that would reduce the hazards of hospitalizations
and level the playing field between
institutions and non-interventive care:
Some aspects of hospitalization are immutable, like bio-hazards, the propensity of power tools to get out of hand and problems of staffing and shift changes. But others things do lend themselves to change. Here are some suggestions:
1. An educational campaign is needed for both the lay public and childbirth professionals acknowledging the benefits of the non-interventionist care. This would permit recognition of the dangers of over-treatment that are associated with routine use of obstetrical interventions and the real but small risk of under-treatment associated with the midwifery model of care. This improved level of information clears the way for the meaningful use of informed consent. Given a clear understanding of the issues, many hospitalized patients would choose non-interventionist (i.e. midwifery model of care), thus reducing the ratio of nosocomial and iatragenic complications associated with hospitalization.
2. Integrating non-interventionist care standards for healthy mothers into ACOG guidelines for obstetricians so doctors are not forced to over-treat women for fear of being criticized by others or unable to defend themselves in court
3. Hospital L&D units should be primarily staffed by professional midwives -- professional nursing staff should be employed to assist practitioners, not instead of professional midwives or physicians
4. Create physically separate "birth centers" within hospitals for healthy mothers with normal pregnancies where they would be cared for by midwives or family practice physicians using non-interventive, mother, baby and family-friendly standards
5. Improve the quality of public knowledge about spontaneous childbearing to reduce the number of mothers-to-be who are terrified of normal labor
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While these changes would reduce the tension between non-interventist midwifery and hospital-based obstetrics, it would not change the ratio of those choosing home-based birth services. Regardless of the efficacious record of domiciliary midwifery, home birth is about as popular as celibacy -- that is to say, about as many women are interested in it as are drawn to become celibate nuns in a convent.
A more practical analogy is the unwillingness of most American to forgo air conditioning on a sweltering hot day. Only a tiny number of people who could choose air conditioning will instead prefer to use an electric fan. Some do this because they dislike the noise of the air conditioner motor or object to the environment impact of added energy use, or have rightly identified that air conditioning disrupts the body’s natural acclimatization process. But folks with this kind of "true grit" are rare indeed. Most people with access to air conditioning vastly prefer it to melting down in a puddle of perspiration. The same kind of preferences tend to apply to labor -- mothers would rather be cared for in the "cool" of the hospital than gritting their teeth and sweating it out at home. One can anticipate that community-based care will remain a minority choice in perpetuity. However the lessons it has to offer in non-interventionist care are valuable beyond their actual numbers. Community-based midwifery is an important national resource and should be protected as such.
Conclusion
The issue is not a contest between hospital versus midwifery statistics but rather having the very best system that we can have. It is pretty clear that better maternity care is not primarily a matter of more hospital beds, expanded use of technology, additional numbers of obstetricians and it certain is not about the suppression of midwifery. Rather it is to bring about balance and discernment that aims at improving both hospital and out of hospital care by rectifying the tensions between the two. One of the best ways to do that to integrate of the midwifery model of care into the mainstream so that we return to a single unified standard in which non-interventionist care and non-medical birth setting are well articulated with the healthcare system. Were we to do that, the care in hospitals and the care in client homes and OOH birth centers would all be safer and more satisfactory both to professionals and the families they serve and it would be cost effective. In addition, these changes would help remedy the problems that have made obstetrics the loss leader on the malpractice insurance industry. That makes it a triple header and a win-win solution for all of us.
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References:
1. Safety of Childbirth Alternatives by Peter Schlenzka; 75 citations www.goodnewsnet.org/weekly/Default.htm;
Obstetrical Myths versus Research Realities, Henci Goer, 1997 ; Care in Normal Birth: A Practical Guide,
World Health Organization, 1996
2. The Cost effectiveness of Home Birth, Anderson et al, JNM Jan Feb 99,
Midwifery care, social and medical risk factors and birth outcomes in the USA, J of Epidemiology &
Community Health May 1998; Midwifery & Childbirth in America, Judith Rook, CNM, 1997
3. Maternal Emotions, Niles Newton, Ph.D., 1997, Birthing normally, Gayle Peterson 1981, The Complete Book of
Pregnancy and Birth, Shelia Kitzinger, 1983
4. Dr David Rubsamen, The Obstetrician’s Professional Liability - Awareness and Prevention
5. www.goodnewsnet.org/weekly/quebecMatdeath98.htm, www.goodnewsnet.org/weekly/bacteria.htm
6. Errors in Medicine, Lucian Leape, MD; JAMA Dec 21, 1994, Vol 272, no 23
7. Supportive care by maternity nurses: Work Sampling in an Intrapartum Unit, Gagon & Waghorn, 1996,
Birth, 23:1 1-6; The Preventable Cesarean Prevention Program, Helen Gordon & Mary Sagady, CNM
8. Edinburgh Midwifery and Churgery, published 1839, Stanford Medical Library