Tuesday, August 11, 2015

Revolutionizing Childbirth in an Intervention-Driven Society

Despite a decrease in the rate of premature birth, other areas of maternity care in America continue to suffer.  The United States continues to fall short on some significant quality and cost concerns. Fatality, intervention, depression, and cost rates are up, while satisfaction with care is down. This post is an in-depth description of the causes of these problems, like the cascade of medical intervention, a lack of awareness and acknowledgment sub-par maternity care, and deficient healthcare coverage. Also covered in this text are some suggested solutions. Providing risk-appropriate care, encouraging evidence-based practice through education and support of expectant women and families, and ground-level requests for maternal-fetal centered care are only a few of the ways that the United States can begin to put itself in among other industrialized countries. Grassroots education by doulas and childbirth educators and offering risk-appropriate maternity care are two of the most highly prioritized steps because controlling these issues will create a positive domino effect.
The process of giving birth has changed considerably over the course of humanity’s existence.  Women have come quite a long way from the times of laboring in a cave and wrapping a newborn in a pelt, particularly in the United States of America.  The cave is replaced with luxurious birthing suites and the finest medical technology on the ready 24 hours a day, 7 days a week.  Animal pelts have been exchanged for perfectly breathable swaddling blankets made from a blended fabric specially formulated to replicate the feeling of the womb.  Women and children that would not have survived during Paleolithic times are protected from complications with life-saving medications and procedures.  It all sounds so positive and beautiful, as long as no one looks too deeply.  Americans spend a fortune on maternity care, but save fewer lives than countries with lower intervention rates.  The emotional health of American families is also suffering, with rates of postpartum depression and negative emotional and developmental impacts on children increasing as well. Over the past 12 years, there has been a 56% increase in the amount of surgical births in the United States, and a sharp incline of births in which Pitocin was administered (Coeytaux, F., et al, 2011, p 1).  While there are no studies proving better outcomes, data exists showing misusing these procedures caused maternal and infant mortality rates to rise.   Many states have banned or refused to license the same midwives that delivered babies at home over the last century.  Maternity and postpartum care cannot be considered a success in the U.S. until spending and fatalities are controlled and citizens are once again in charge of their own healthcare.
The Detriment of Medical Overreach
            According to the CDC, about 23% of pregnant women underwent induction of labor in 2010, with 32.8% of women giving birth via cesarean in that same year (Martin, J., et al, 2012, p 4). Inducing labor in a pre-eclamptic mother can save the life of both herself and her unborn child. Performing an emergency cesarean is necessary to preserve the health of a fetus when the umbilical cord has prolapsed, or the fetus has begun to show signs of true distress. Over time, people have developed technology to make giving birth safer for mothers and children. However, the rates at which both of these procedures are occurring are considerably higher than recommended by multiple organizations, and are expensive-both emotionally as well as economically.  

Induction/Augmentation of Labor
Induction of labor is the act of artificially forcing labor to begin. Augmentation is the act of altering an already present labor process. Induction and augmentation may be done with several different methods.  Sometimes medications like prostaglandins are used to thin and dilate the cervix, or a synthetic oxytocin called Pitocin is used. A provider may artificially rupture the membrane that contains the amniotic fluid (breaking the water) in an attempt to intensify contractions, or insert a balloon catheter into the cervix to encourage effacement and dilation (the thinning and opening of the cervix). None of these procedures are without risk. Any time that an object is inserted into the vagina, there is a risk of transferring bacteria and encouraging infection. Synthetic prostaglandins have been linked to uterine hyperstimulation with maternal vomiting, diarrhea and fever, while amniotomy is associated with fetal distress and injury, umbilical cord prolapse, and possible bleeding from the placenta, and all of those risks increase the likelihood of a necessary cesarean section as treatment (Tenore, J., 2013). Labor induction has been strongly linked to an amplified risk of cesarean.  This is even more likely if induction methods are used before the cervix is favorable for birth.

Cesarean Section
            Surgically removing a fetus from the uterus is called a cesarean or c-section.  It is estimated that 1.5 million women have cesarean sections annually, and that number is on the rise (Guise, 2010). It is the most common surgery in the United States, with just over 32% of women birthing via cesarean (Martin, et al., 2012). This is considerably higher than the recommended rate of <15% by the World Health Organization (2015).  While cesarean birth began as a means to save lives, it is used too frequently to schedule convenient birth times, to choose a child’s birth date, or even to just relieve a mother that may be ready to end her pregnancy discomforts. There is some information attributing rising cesarean rates to the fear of pain and/or the toll vaginal birth takes on a woman’s body. An online survey of 752 American women found that those who were more fearful of birth were four times more likely to opt for elective surgical birth (Stoll, et al., 2013). Maternal risks of cesarean include hysterectomy, cardiac arrest, longer hospital stays and readmissions, anesthetic complications, blood clots or loss/transfusion, infection, and death, while fetal risks of cesarean section include respiratory distress, increased NICU stays, and increased development of asthma, autoimmune disease+, obesity, food allergies, Type 1 diabetes, and more (Childbirth Connection, 2012). The same review from Childbirth Connection stated that “data conflict but suggest that more women may experience PTSD or PTSD symptoms after cesarean delivery in general and unplanned cesareans in particular” (2012). This is an unacceptable side effect for a woman for one of the most important days of her life.

Increased Financial Costs
            The cost of maternity care in the United States is out of control. Susan Brink (2013) offers a wonderful explanation in her article written for USNews.com:
The economic issues of maternity care are huge. The present system of fee-for-service payments, in which physicians and hospitals are paid for every service they provide, encourage more intervention rather than less: a C-section is more profitable to doctors and hospitals; every dose of pain mediation has a profit incentive; and drugs to induce and speed up labor can add to the bottom line…. If insurers begin to use bundled payments—one set fee for pregnancy, rather than a payment for each service—the financial incentives will begin to move toward rewarding low-cost care and high-quality results (p 2).
            With Medicaid covering 48% of all births, medical overreach via induction and cesarean section is costing tax payers millions nationwide (Howell, E., et al, 2013). Both Medicaid and private insurers are getting a poor return on their investment because maternity care plays such a major role in the healthcare system. Maternity care charges exceed those for any other condition, and cesareans are the most common operating room procedure in the U.S. (Andrews, R., 2006).

Increased Fatality
A maternity related death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. In September of 2010 the United Nations placed the United States 50th in the world for maternal mortality — with maternal mortality ratios higher than almost all European countries, and rising over the past several years (World Health Organization, 2010). The leading causes of maternal morbidity were listed as hemorrhage, blood clots and cardiovascular conditions that were all considered preventable. The CDC (2014) released a comparative report in 2014 stating that infant mortality rate was about 6.1 per 1,000 live births, placing America 26th in the world (p 2).
These numbers are staggering and tragic. In a country with full access to medical technology, clean facilities and water, and the best healthcare that money can buy, American women and their unborn children are dying at alarming rates and something must be done to get childbirth back on track.
Transforming Childbirth in America

Increasing Awareness
One issue surrounding the maternity care crisis in America is the lack of acknowledgment that there is a problem. This has changed recently with the proletarian movements of organizations like BirthNetwork, Improving Birth and The International Cesarean Awareness Network. These groups promote informed decision making, mother-friendly maternity care, and educational/emotional support. Membership is mainly driven by birth workers and experienced families who are hungry for change. Meetings and avocation help to bring evidence-based care to the forefront, making both mother-friendly care a standard.  Admitting there is a problem is the first step.

Offering Education & Support
The ins and outs of childbirth are no longer common knowledge. What you used to learn from animals in the barn, an older sister, neighbor or friend, is not provided anymore. Due to lifestyle and occupational changes over time, many women have not witnessed birth prior to their own. Providers and medical staff cannot carry the burden of teaching every family all that they need to know about pregnancy, birth, and postpartum periods, along with keeping everyone safe and healthy. Staff will also likely have other patients to attend to during labor, and cannot be expected to be present throughout the birth process of every patient.

Childbirth educators. A person that teaches new parents what to expect during pregnancy, birth, and the early weeks of parenthood is called a childbirth educator or CBE. The CBE should have experience in the field at minimum, though many are trained and certified. Organizations like CAPPA, Lamaze, and International Childbirth Education Association (ICEA)    all train and certify childbirth educators. Classes vary on the needs of the family and the style of the educator. Some may be a one day workshop course, while others may be weekly meetings lasting several months.  The main goals of these classes are to cover signs of labor and what to expect, pain management techniques, information on making informed decisions about health care, how to properly care for postpartum mothers and newborns, and generally minimizing fears for the inexperienced family.

Doulas. A doula is a woman who is trained to assist another woman during childbirth and who may provide support to the family after the baby is born, depending on her training. A birth doula focuses on emotional, physical and educational support during the birthing process, while postpartum doulas focus on support during the early weeks following the birth. Both jobs are essential to the health and well-being of a mother and her family. Recent Cochrane Reviews (2003) show that while continuous labor support was essential to positive outcomes during birth, the best results occurred when women had continuous labor support from a doula with a 31% decrease in the use of Pitocin, 28% decrease in the risk of C-section, 12% increase in the likelihood of a spontaneous vaginal birth, 9% decrease in the use of any medications for pain relief, 14% decrease in the risk of newborns being admitted to a special care nursery, 34% decrease in the risk of being dissatisfied with the birth experience. This huge benefit is another key to unlocking the puzzle of cost and safety issues (p 4).

Making Alternative Methods Safe

Birth Centers. A birth center is a facility for giving birth that focuses on family-centered care. Family and staff work together to make informed decisions. Birth centers offer a more natural approach to care in that they don’t usually do routine interventions. Recent studies have found that “for women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes” (Benatar, S., et al, 2013). Also, with a projected savings of nearly $1,163 per birth center birth, it is imperative that these facilities are made available to more women (Howell, E., et al, 2013).This is an approximate $11.6 million per year savings to the Medicaid program. (Howell, E., et al, 2013).

            Legalizing homebirth. While the number of out-of-hospital births is increasing, still about 99% of births in the U.S. occur in hospitals (MacDorman, M., 2014). The issue with this this number of non-homebirths is that these births are largely attended by obstetricians- professional surgeons. These providers are not trained in minimizing intervention of the birth process, they are trained how to properly handle any medical emergencies that may arise. However, giving birth is a normal, non-emergent event in the majority of cases. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician. Hiring surgeons to attend births has contributed to the rise in cesarean and labor induction rates in the U.S. due to their lack of training in the field of normal birth. This is compounded by the fact that midwives who are trained to attend standard birth have been banned in many states. Banning certified professional midwives, or CPMs, has actually created more risk. Without access to safe midwifery assistance, some families choose to give birth unattended, at home.  After observing nearly 17,000 cases, a recent study has confirmed that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies (Cheyney, M., et al, 2014). In her review of this study, CNM Geradine Simkins (2014) writes: “Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system” (p. 3). Creating the availability of midwifery care to all low-risk families can help Americans lower mortality rates and costs.

            Vaginal birth after cesarean section. Although many governing organizations recommend vaginal birth after cesarean for most cases, America has a nearly 90% repeat cesarean rate (CDC, 2012). A recent review of studies found “stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans” (Guise, 2010).  This is unnecessary surgery with needless risk to the mother and to the child, facilitated by gratuitous spending. In order to gain control over spending and fatality rates, regulating the availability and safety of vaginal birth after cesarean is essential. The American Academy of Obstetrics and Gynecology recently released guidelines to encourage VBAC, reducing unnecessary cesarean sections.

 Continued Healthcare Reform
            Creating coverage of homebirth midwives, doulas, and childbirth educators is essential. Doing so would save tremendous amounts of money by way of benefits of these providers that have already been discussed above. This is not just an issue that varies from individual to individual. With nearly half of all births paid for by Medicaid, the program could cut costs remarkably by paying for preventative care with appropriate education and support (Howell, E., et al, 2013). A group of midwives, obstetricians, and other stakeholders brought together by the not-for-profit Childbirth Connection, published a consensus document calls for policies allowing women to choose where to give birth, whether by midwives, family physicians, or obstetricians (Carter, M.C., et al., 2010). Notably, consumers are beginning to demand such choices. Childbirth Connection, the American College of Obstetricians, and the American Medical Association have identified the services that should be covered, and these services include a care facility that is appropriate for the patient’s maternal-fetal risk.  In spite of this advice, out-of-hospital birth is still very difficult and even impossible for some women to access which forces them into a care facility that is more invasive and more costly. Sometimes these women choose to give birth at home unattended by medical staff.

Certified Professional Midwife Ina May Gaskin (2013) offers a vivid summation of how childbirth may feel for women in the U.S.:
Where the techno-medical model of birth reigns, women who give birth vaginally generally labor in bed hooked up to electronic fetal monitors, intravenous tubes, and pressure-reading devices. Eating and drinking in labor are usually not permitted. Labor pain within this model is seen as unacceptable, so analgesia and anesthesia are encouraged. Episiotomies (the surgical cut to enlarge the vaginal opening) are routinely performed, ….Instead of being the central actor of the birth drama, the woman becomes a passive, almost inert object - representing a barrier to the baby's eventual passage to the outside world. (p. 156).
American citizens cannot be gratified with this level of care. It is important that a higher level of service is demanded, expected, and fought for. The number of deaths occurring daily must be lowered. The amount of spending on birth must decrease. Both of these goals can be achieved. One of the first steps is to provide access to appropriate care for every birthing woman, whether that be an obstetrical surgeon, doula, childbirth educator, homebirth midwife, or other care provider that supports vaginal birth after cesarean. If each woman is able to access care that is appropriate for her case, labor augmentation and cesarean rates will inadvertently come down as well. With fewer augmentation and cesarean cases, maternal and fetal mortality rates will decrease. The snowball that is maternity care reform can start with only one snowflake. The time is now.

posted by: Abby Moore, Birth Doula

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