W-n-P: Section three: Safety in CB, Functional HC system + 21st century Maternity care

The Basic Elements for Increased Childbirth Safety;

* The maternity services as a continuum of care
in a healthy population and the critical role
a functioning healthcare system


The history of midwifery (now called ‘maternity’) care as provided by
physicians & midwives; practical aspects professional mfry practice


Historically care of healthy women during normal childbirth was always called midwifery, regardless of the gender or educational background of the birth attendant. While this is surprising to the modern ear, the word ‘midwifery’ was routinely used in 18th and 19th century to mean the discipline of providing care to essentially healthy childbearing women during a normal, spontaneous childbirth, whether the practitioner was a midwife or medical doctor.

As a descriptive term for normal childbirth services, ‘midwifery’ was used in medical journals, hospital department name plates and the titles of books on “Midwifery and Churgery” (1832) written for physicians. A British medical textbook published as late as 1956 was called: “Midwifery and Gynecology in Modern Medicine”. Today we would use the term “maternity” care to mean the general care of healthy childbearing women during pregnancy and childbirth.

But before the era of ‘modern’ medicine, the historic discipline of midwifery/maternity care had little offer in the face of life-threatening medical emergencies. Unfortunately, the category of practitioner – MD or midwife — didn’t matter, because so many important scientific discoveries had yet to be made. For example, the simple technologies we now use routinely for risk-screening  and monitoring the health of pregnant women and their unborn babies had not yet available, so no prenatal care was provided during pregnancy by either midwives or doctors. Birth-attendants were usually not called until the labor was well underway, when they met the mother-to-be for the first time.

Imagine arriving at the home or hospital bedside of the laboring woman with absolutely no previous medical information, previous knowledge of that the mother-to-be has a history of heart disease or dangerously high blood pressure, or risk-screening for potential complications of her pregnancy, such as placenta previa or multiple gestation. It wasn’t until the early 20th century that new scientific discoveries in the biological sciences created “modern medicine” that this changed.

Over the course of the 20th century, new information-gathering techniques made it possible to detect the vast majority of clinically-significant abnormalities and complications. This allows both physicians and midwives to refer mother or new baby to higher levels medical or technological services as indicated. While it is critically important to screen for potentially life-threatening condition, it is equally vital that obstetrical and perinatal medicine is available and that the mother or baby have timely access to these life-saving medical services.

This simple equation — a dependable process for detecting potential or actual complications, coupled always with access to effective medical treatments — has always been and continues to be the core of modern maternity care regardless of whether the providers were physicians or midwives.


Access to a Comprehensive Hospital Services: the final link in the safety net


However, the safety of childbearing women in any part of the world requires access to the advanced medical services that can only be provided by a modern healthcare system. In order to receive the benefit of medical services, high-quality maternity care is necessary for someone – usually a trained birth attendant — to identify the need for and appropriate timing of medical and surgical interventions.

Over the last century, the art and science of professional midwifery was specifically configured to meet a new and more effective level of safety for childbearing women and their unborn or newborn babies. Professional midwifery in the modern era is an evidence-based healthcare discipline whose goal is to provide quality maternal and newborn care.

Evidence-based care is defined* as a combination of:

  •     the best research evidence available at the time the decision must be made
  •     the clinical experience of its practitioners
  •     the informed choice of individual patients, in this case, childbearing women and their families.  *

*definition from ACNM website

In addition to time-tested methods for supporting normalcy in healthy childbearing women, midwifery practitioners are formally educated and clinically trained in techniques developed by modern sciences that make childbearing safer and reduce human suffering, which includes consultation with medical service providers as indicated and referral of cases with serious abnormalities or complications.

The professional practice of midwifery combines the art and the modern science of physiological management, which is to say that midwifery continues to be primarily a non-allopathic discipline. Its contemporary practitioners provide personalized maternity care to an essentially healthy childbearing population, which includes the use of preventative measures, appropriate emergent assistance and emergency interventions as indicated. As noted above, this includes timely transfer to medical care whenever required by the health status of mother or baby, or if medicalized care is requested by the family.


Safe, cost-effective, compassionate Maternity Care in the 21st century


The most basic purpose of maternity care is to protect and preserve the health of already healthy women. Its goal is a cost-effective model that is able to preserve health and effectively prevent or successfully treat complications during pregnancy and childbirth. 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.

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.  According to a consensus of the scientific literature, evidence-based maternity care by birth attendants trained in physiological (non-interventive) management generally achieve “maximal results with minimal interventions”. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.

For these statistical outcomes to be meaningful, these data must encompass the full spectrum of reproductive mortality and morbidity over the course of a woman’s entire reproductive life. This would include delayed and downstream complications, serious problems in subsequent pregnancies, future fetal or neonatal loss and overall cost of care to individuals and society.


Critical elements of safety for healthy childbearing women


People rarely understand what actually makes childbirth ‘dangerous’, and as a result have a lengthy set of wrong assumptions.  Reduced to its most basic level, the single most dangerous aspect of childbirth is simply  to have lived before the in the new biological sciences that resulted in the discoveries that created scientific healthcare. This begin in 1881 with the germ theory of infectious and contagious disease, which began the modern era of public sanitation and personal hygiene, followed by development of aseptic principles and sterile surgical technique.

However women living today in parts of the world that don’t have a functional healthcare system, or for geographical or economic reasons, don’t have access to the services of modern medicine, face the same

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Deprived of these late 19th and early 20th advances every childbearing woman would have an unacceptably high risk of preventable deaths and disabilities, a situation little different that had she lived in the 5th century BCE of the ancient world. Lack of access to contemporary healthcare and/or a failure to use maternity care services during pregnancy and childbirth can and does result in preventable deaths. Whether  she is laboring today in a third world country, or is a member of an affluent family in a wealthy country that, for religious or other reasons, rejects modern healthcare, the result would be the same unexpectedly high rate of maternal and infant mortality.

One study of a religious group in the midwest that rejected all forms of modern healthcare and instead had unattended births had one maternal death for every 57 women who give birth, and 23 unborn or newborn baby deaths out of a total of 344 births. This appalling mortality rate is approximately the same as those in the pre-scientific, pre-antibiotic era of medicine (17th, 18th and 19th centuries) and current levels for Afghanistan and sub-Saharan Africa.

Essential Elements of the Childbirth Safety Net:

There is not the slightest doubt about the central importance of a modern functioning healthcare system in the childbirth safety net. But high-tech hospitals services are not required by the vast most healthy women when they receive appropriate maternity care during pregnancy, childbirth. The single most efficacious strategy for eliminating preventable mortality associated with pregnancy and childbirth consists of maternity care based on three simple aspects of that balance safety and cost-effectiveness, and apply regardless of the planned place-of-birth.

They includes (a) risk-screening & regular maternity care during pregnancy and referral to medical services as appropriate, (b) an experienced birth attendant(s) present during active labor, birth and immediate PP-neonatal period who is trained and equipped to deal with common childbirth emergencies; {c} and parents’ agreement to use of emergency medical services whenever indicated.

Maternity care that make the critical difference:

(1) Access to risk-screening, regular prenatal care and referral to medical treatment whenever necessary (the 3 Rs)

(2) The presence of an experienced birth attendant during active labor, birth and immediate postpartum-neonatal period who is trained, equipped and able to function as a ‘first-responder’ in the event of a complicated or emergent situation

(3) Access to maternity and neonatal care providers when need or if requested by the family, and comprehensive hospital services in case of emergency

When these three essential forms of maternity care are provided by trained and experienced birth attendants such as California licensed midwives, the maternal mortality rate falls to nearly zero and a perinatal mortality rate of (don’t remember, will research), which is statistically equivalent outcome for childbirth at term (37+ wks) in the United States.

When maternity care was  provided to essentially healthy women within a functional healthcare system there was no statistical significant difference in outcomes for the three different categories of birth attendants (a) empirically-trained midwife-attended; (b) professionally-trained midwife attended; and (c} hospital-based, obstetrically-managed, OB, MD or CNM-attended childbirth. Contrary to popular opinion, hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.

[citations for Claude Burnett-Rook NC study, Ken Johnson CPM2000 pub. BMJ, Canadian midwives 5yr. prospective study, last 5 years of the Licensed Midwifery Annual Reports (on-line 2010-2014) and CDC’s NVSRs for term childbirth in the US]

URL to Five Models, Five Perspectives, Five Insights  

http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Childbirth_risks


Practical Aspects of Modern Midwifery

Practitioners of modern midwifery routinely provide injections of vitamin K to the newborn after its birth to prevent the rare but real risk of a potentially-fatal blood clotting disorder in neonates. Rhogam is administered to Rh-negative mothers to prevent dangerous fetal sensitization in future pregnancies. Midwives also suture minor (1st and 2nd degree) perineal lacerations, which includes the administration of local anesthetic prior to suturing. This prevents the risk, expense and family disruption of the new mother-new baby relationship that a hospital transfer to perform this minor procedure would entail.

Midwifery practitioners are also trained to respond in emergent situations that can arise during the childbearing period. This sometimes includes the use of emergent measures that may resolve the emergent condition without need for further interventions, or help to stabilize the situation while arranging for immediate access to necessary medical services.

The Professional Midwife’s Role as Primary-Responders in Emergent Situations

Emergency response measures are a fundamental aspect of professional midwifery as 21st century, scientifically-based health care discipline. Science-based techniques that make childbearing orders-of-magnitude safer include the use of modern cardio-pulmonary resuscitation, which includes resuscitative devices and oxygen as appropriate.

Techniques that promote safety of childbearing women also include modern methods to control excessive postpartum bleeding and prevent or treat maternal hemorrhage via administration of anti-hemorrhagic agents, such as misoprostil in tablet form, injections of methergine and pharmaceutical oxytocin (brand name ‘Pitocin’) and providing intravenous fluids as needed.

As trained first-responders, midwives initiate an emergent transfer of care via Emergency Medical Services whenever such care is appropriate.