FISH CAN’T SEE WATER

THE NEED TO HUMANIZE BIRTH
Part 2

     
 
: Marsden Wagner, MD, MSPH



SOLUTIONS
So far we have not been clever enough, in developed or developing countries, to take the advantages of medicalized birth care while avoiding the disadvantages such as the drift to obstetric excesses. Humanizing birth has the potential to combine the advantages of Western medicalized birth with the advantages of redirecting the care so as to honor the biological, social, cultural and spiritual nature of human birth. There are several strategies for humanization of birth---- strategies which will put the woman and the family back in control of the birth of their own child while empowering the woman to believe in herself through experiencing what her own body can accomplish.
The first strategy is education. Those who control information hold the power. In the past the medical profession often has maintained control of medical care through protecting and withholding information. Patient confidentiality, a legitimate excuse for limiting access to information on individual patients, is now understood not to be an excuse for limiting information on grouped data such as hospital data and community data. The information revolution is profoundly changing medical care. The advent of the internet and world wide web is having a profound effect on bringing medical information to everyone. In the new millenium a global movement is demanding accountable and transparent health care practitioners and health care facilities (including hospitals) as a basic requirement of any democracy. Complete and honest information must be given to the public, even when it means giving up power and, in some cases, can be dangerous to the continuation of certain practices----maternal mortality rates a prime example.
Full information on the good and bad results of medicalized birth must be given to health care practitioners, public health officials, politicians and the public. In other words, everyone must begin to see the water that many doctors and hospitals are swimming in and see that in many cases it is full of sharks which may not eat the doctors but may sometimes eat women and babies.
The need to broaden the horizon of doctors concerning maternity care is not a new problem. In a medical book published in the year 1668 is the statement: Doctors who have never seen a home birth and yet feel competent to argue against it resemble those geographers who give us the description of many countries which they never saw. We must start by requiring doctors to look at the water in which modern maternity care exists in order to get a physiological standard against which they can measure all their experiences. In an obstetric training program in The Philippines, every doctor must attend a minimum number of planned home births. Every obstetric training program should require visits to planned out-of-hospital births, including birth centers and home births. Midwives and obstetric nurses in training need the same experience.
The education of women, especially pregnant women, is of paramount importance but here the issues is: what are the women told. In some places prenatal education programs are controlled by a few obstetricians who insist on giving only doctor-friendly information to pregnant women. Many anesthesiologists in the US have managed to gain access to prenatal classes where they preach the wonders of epidural block and usually say nothing about the considerable risks of this invasive procedure.
More recently, for some doctors to succeed in promoting women choosing cesarean sections for which there are no medical indications it is necessary to provide limited, highly selected information. (17 ) It is highly unlikely women would ever consider choosing CS if they were given the full scientific evidence on the risks for themselves and their babies. The key ethical issue is not the right to choose or demand a major surgical procedure for which there is no medical indication but the right to receive and discuss full, unbiased information prior to any medical or surgical procedure.
A liberated woman correctly strives not to be controlled by men, an effort even more difficult if she lives in a male chauvinist society. There are many ways in which women giving birth in hospitals in macho cultures are oppressed and given the message that they are not important and not free but controlled by an often belligerent staff ---for example they are told not to scream or make loud noise with labour contractions.
But if a woman accepts the medicalized, male dominated obstetric model of care with its selected information, she gives up any chance to control her own body and make true choices. Volumes have been written about how liberating and empowering it is for a woman to give birth when she controls what happens. Without fully informed choice, she will give up any control and comply with the wishes of the doctors and hospitals. Women who demand choice but get only selected doctor-friendly information unwittingly buy into the medical position. Sadly a few feminists who correctly fight for womens rights have been drawn into believing biased doctor-friendly information and as a result have unwittingly promoted the right of women to demand obstetric procedures which are dangerous to them and their babies.
A second strategy for humanization of birth is the promotion of evidence based maternity care practices. As mentioned earlier, using peer review and community standards of practice has failed to close the gap between present obstetric practices and the evidence. And in many places public health professionals and government agencies have failed to aggressively pursue closing the gap between obstetric practices and evidence, often out of fear of the power of the medical establishment. (13)
It has been an interesting and educational exercise for me to come to hospital obstetric units and present to the staff a simple table with their own rates of interventions ( induction, episiotomy, lithotomy, operative vaginal, cesarean section) in a column on the left and the evidence based rates opposite in a column on the right. The ensuing discussion is often characterized by more heat than light, always with at least a few doctors as concerned as I about the gap between their practices and the evidence. As we enter the era of post- modern medical care, the GOBSAT (Good Old Boys Sit Around Table) clinical practice guidelines of yore, royalist in sentiment and pompous in tone, will be replaced by evidence based practice guidelines approved by the community.
Another essential strategy in humanizing birth is: who is the primary care giver for women during pregnancy and birth. The tradition of doctors insisting on controlling their own practices with little or no interference from the community or its representatives goes back a long time. During the course of the twentieth century, the practice of doctors going on house calls disappeared. As long as doctors provide primary care to normal, healthy pregnant and birthing women, women will not be in control and humanization of maternity care will not happen.
Countries must work hard not to allow doctors from places with highly medicalized maternity care like the US to come and try to sell the country the visiting doctors own system of maternity care, a system where nearly every obstetrician and maternity hospital offers only one style of birth care---a style not based on scientific evidence but on the absolute control of the system by the doctors. Maternity care in the US, is a form of care with extreme medicalization. Doctors give primary care to over 90 % of normal, healthy women giving birth. As a result, birth has become a surgical procedure with high rates of unnecessary interventions. Women giving birth are disempowered and there are huge wastes of resources, financial and professional. Twice as much is spent per capita on maternity care as any other country and midwives are marginalized. This is not a system to emulate---the US maternal mortality rate, perinatal mortality rate and infant mortality rate are much higher than the rates in nearly every other industrialized country.
By contrast, midwifery has a long tradition of placing the birthing woman in the center with all the control in the womans hands and with the midwife providing the kind of support which will empower the woman and strengthen the family. For this reason, having primary maternity care in the hands of midwives is a central strategy in humanization of birth.
Countries might want to study the maternity care in countries much further along the road to humanization such as New Zealand, The Netherlands, Scandinavian countries. In these countries, over 80% of women see only midwives during pregnancy and birth (in or out of hospital) and they have some of the lowest maternal and perinatal mortality rates in the world.
Considerable scientific research has demonstrated four major advantages to autonomous midwifery: midwives are safer for low risk birth, midwives use less unnecessary interventions, midwives are cheaper, midwives provide more satisfaction.
First, there can no longer be any doubt that midwives are the safest birth attendant for low risk birth. One meta-analysis of 15 studies comparing midwife-attended birth with physician attended birth found no difference in outcomes for women or babies except for fewer low birth weight babies with midwives. (22 ) Two randomized controlled trials (RCT) in Scotland (23,24) and 6 RCTs in North America all found no increase in adverse outcomes with midwife attended birth. (18)
The most definitive study of the safety of midwife attended birth, published in 1998, looked at all births in one year in the US---over four million births. Selecting only singleton, vaginal births and removing cases of social or medical risk factors, they compared outcomes between midwife-attended births and physician attended births. Compared with physician attended births, midwife attended births had 19% lower infant mortality, 33% lower neonatal mortality and 31% lower low birth weight rates. (25)
After reviewing the extensive evidence for the safety of midwives, a recent article in an obstetric journal concludes: "A search of the scientific literature fails to uncover a single study demonstrating poorer outcomes with midwives than with physicians for low-risk women----evidence shows primary care by midwives to be as safe or safer than care by physicians." (18).
The second advantage of midwives over doctors as primary birth attendants is a drastic reduction in rates of unnecessary invasive interventions. Scientific evidence shows that, compared to physician attended birth, midwife attended birth has statistically significantly: less amniotomy, less IV fluids or IV medication, less routine electronic fetal monitoring, less use of narcotics, less use of anesthesia including epidural block for labour pain, less induction and augmentation, less episiotomy, less forceps and vacuum extraction, less cesarean section, more vaginal birth after cesarean section. (18)
The third advantage of using midwives as the principal birth attendant for most births is cost savings. While it varies from country to country, midwives salaries are almost always considerably less than doctors salaries. And of course, the lower intervention rates with midwives mean major cost savings. The data on cost saving is reviewed in a paper on midwifery in industrialized countries (18) where, for example, one study found a cost saving of US $500 for every case where a midwife is birth attendant.
Another advantage of midwifery care, often disparaged by advocates of medicalized birth, is the pregnant and birthing womans satisfaction with her care. The midwifery approach emphasizes the importance of womens satisfaction. The evidence in the literature is overwhelming: midwifery care is statistically significantly more satisfying to the woman and her family. (18)
Since hospitals are doctor territory and no woman has ever been in control of her own care in a hospital setting, another important strategy for humanization of birth is to move birth out of the hospital. There have always been and always will be women everywhere who choose planned home birth and need a midwife to attend the birth. But today, as a result of decades of propaganda about how dangerous birth is, told by doctors who are themselves afraid of birth and are told how safe hospital birth is, told by doctors who themselves need the security of hospitals, there are many women who have bought into the myth that home birth is dangerous.
It is unbelievable that obstetric organizations in some highly industrialized countries such as the US still have the same official policy against home birth which they wrote in the 1970s. At that time planned home birth was not separated from unplanned precipitous out-of-hospital birth which, of course, had high mortality due to preemies born in taxis, etc. Then when scientists separated out planned home birth, it proved to have perinatal mortality rates as low or lower than low risk hospital birth. A large scientific literature documents this, including when the home birth practitioner is a nurse midwife (26) or when it is a direct entry midwife (27-29). A meta-analysis of the safety of home birth, published in 1997, conclusively demonstrates the safety of home birth and includes an excellent review of the literature. (30)
So the real issue with home birth is not safety but the issues are freedom and sanctity of the family. For the over eighty percent of women who have had no serious medical complications during pregnancy, planned home birth is a perfectly safe choice. Any doctor, hospital or medical organization attempting to discourage a low risk woman from choosing home birth is denying basic human rights by withholding full unbiased information and limiting a womans freedom of choice of place of birth. The birth of a baby is one of the most important events in the life of the family and when the family chooses a planned home birth, the sanctity of the family must be honored.
Because of the frightening propaganda of many in the obstetrical profession about how dangerous birth is, many women want the freedom to control their own birthing but need the security of an institution. How can women today be in control of giving birth and be empowered by birth and be assisted by a midwife and still feel comfortable and protected by an institution? By choosing an alternative birth center (ABC) which is free-standing (i.e. out-of-hospital) and staffed by midwives.
The first essential characteristic of an ABC is that it is free of any control by a hospital. A hospital which claims to have a birth center is like a bakery which claims to sell home-baked bread. To be a birth center, the birthing woman must be in control of everything that happens to her and her baby. This means the ABC should be staffed by midwives using protocols made by midwives.
The type of care provided in an ABC is quite different from a hospital. In a hospital the doctor is always in absolute control while in an ABC the woman is in control. In the hospital the emphasis is on routines while in the ABC the emphasis is on individuality and informed choice. Hospital protocols are designed with all the possible complications in mind while ABC protocols focus on normality, screening and observation. In hospitals pain is define as an evil to be stamped out with drugs while in the ABC it is understood that labour pain has a physiological function and can be relieved with scientifically proven, non-pharmacological methods such as immersion in water, changing position and moving about, massage, presence of family, continuous presence of the same birth attendant.
In the hospital induction is frequent and uses powerful drugs which increase the pain and has many risks while in the ABC labour is stimulated with non-pharmacological methods including walking and sexual stimulation such as massage of the nipples. In the hospital staff are not always present but come and go and change every eight hours while in the ABC there is the continuous presence of one midwife throughout the labour. In the hospital the new baby is taken away from the mother for various reasons such as doing a newborn examination while in the ABC the new baby is never taken from the mother.
Are ABCs a safe place for a woman to give birth if she has had no complications during the pregnancy? This is a key question because in the struggle between the medicalized and humanized approaches to maternity care, the ABC is a big threat to doctors and hospitals and the industry producing all the obstetric technologies. Because medicalized birth is so expensive with costly hospital stay, highly paid obstetricians using so much costly high tech intervention, the doctors and hospitals must convince the public and those who control funding of health services that their way is the only safe way. Otherwise they will quickly lose much of their business. So obstetric organizations usually fight against all birth where they are not in control. Their first line of defense against any planned out-of-hospital birth is to label it unsafe.
The only way to determine if ABCs are safe is to turn to the scientific evidence. A thorough review of the scientific evidence on ABCs (31) reports that in the 1970s and 1980s there were a number of descriptive studies on ABCs. Then in 1989 a most important paper on ABCs was published: The US National Birth Center Study involving 84 ABCs and 11,814 births. (32) In the 1990s seven more studies compared ABC birth with hospital birth and one RCT was reported. The results of this research follows.
Regarding safety, the US National Birth Center Study had no maternal mortality and an intrapartum and neonatal mortality rate of 1.3 per 1000 live births, a rate comparable to the rates in low risk hospital births. The infant mortality rate and Apgar scores in the ABCs was also comparable to low risk hospital rates. Sixteen percent of ABC births were transferred to the hospital. Such rates of transfer of planned ABC birth to hospital because of complications compare favorably with the number of planned hospital births which are transferred to the surgical suite because of complications. The intention to treat analysis was used in which all complications, interventions and outcomes from ABC births transferred to hospital are included in the ABC statistics.
The safety of ABC birth is further substantiated by additional studies done in the 1990s in which the outcomes of ABC births---perinatal mortality, neonatal mortality, apgar scores, low birth weight rates---in all studies were as good or better than the outcomes with hospital birth.
In addition to the evidence for the safety of ABCs, these studies had further data on the characteristics of women choosing ABCs. After their ABC birth was over, 99% said they would recommend ABC birth to their friends and 94% said they would return themselves to the ABC for any future births. A RCT found that 63% of ABC women had an increase in self-esteem while 18 % of women with hospital birth had an increase in self-esteem. (31)
With regard to the promotion of breastfeeding, studies in the US, Denmark and Sweden all found significantly increased rates of successful breast-feeding in ABC women.
The review of literature on ABCs (31) compared a number of obstetrical intervention rates in the US National Birth Center Study with the rates of obstetrical intervention in all hospitals in one State (Illinois). In ABCs, 99% were spontaneous vaginal births compared to 55% of hospital births. Less than 4% of ABC births had induction or augmentation with artificial rupture of membranes and/or oxytocin compared with 40% of hospital births. Routine electronic fetal monitoring was done in 8% of ABC births and 95% of hospital births.
Regional or general anesthesia (including epidural block) was done in 13% of ABC births and 42% of hospital births. Operative vaginal birth (forceps or vacuum) was done in less than 1% of ABC births and 10 % of hospital births. Cesarean section was done in less than 5% of ABC births and in 21% of hospital births. Looking at these comparisons of interventions, clearly the logical question is not if ABC birth is safe but if hospital birth is safe.
As the news about the safety of ABCs spreads, more and more are being established. In the past ten years, Germany has gone from having one ABC to now having over 50 ABCs. In Japan, a network of midwife birth houses provided a significant part of maternity services the first half of the last century but during the American occupation, US Army doctors and nurses put pressure on the Japanese to close the birth houses. Now, however, there is a resurgence of birth houses in Japan.
Compared to hospital births, home births and births in ABCs are safe, much cheaper, use far less unnecessary interventions, are more satisfying to the woman and family. In other words, out-of-hospital birth is an important strategy in humanizing birth care.
Another strategy in humanizing birth is to integrate out-of-hospital and in-hospital birth care and practitioners. This was accomplished with excellent results in Fortaleza Brazil with community based traditional midwives collaborating closely with hospital obstetricians. (33) This model program, which had gained world wide recognition, was sadly eliminated when the visionary obstetrician who established it died. Data from places like Australia show that when home birth midwives and local hospital doctors collaborate, fewer babies die and everyone learns from each other.
Birth is political. An essential strategy is for advocates of humanized birth to be politically active. Politicians and government agencies make crucial decisions about maternity care and their education about and involvement in humanization of birth is essential.
Advocates of humanized birth must warn politicians and policy makers of the use of scare tactics by some of the more reactionary elements of the medical and nursing establishment who raise the issue of safety and claim without a shred of evidence that humanized birth is dangerous---that midwives are less safe than doctors and out-of-hospital birth less safe than hospital birth.
Another common scare tactic is for some obstetricians to say that every out-of-hospital birth transported to the hospital is a train wreck. The answer to this criticism is of course. A competent out-of-hospital midwife will only transport those few cases where there is a serious problem requiring surgical interventions not available in the home. So for the obstetricians who have never attended a home birth (in many places this is nearly all obstetricians), these out-of-hospital transports with problems are their only experience with out-of-hospital birth and they erroneously assume these cases are representative of all out-of-hospital birth. This is like the auto mechanic who sees several Mercedes with mechanical problems and concludes all Mercedes are no good, forgetting that for every Mercedes he sees in his shop, there are a thousand Mercedes running fine and therefore not brought to his shop. This is why doctors need to experience out-of-hospital birth first hand.
These scare tactics are motivated by the attempt of some doctors (and sometimes even nurses) to protect maternity care as their territory. Often doctors attempt to overwhelm legislators with technical language which implies that only doctors can possibly understand so the listener must simply trust me, Im a doctor. Politicians and policy makers should be urged to ask those making these scare statements Please show me the scientific data to prove what you are saying. It can also be illuminating for legislators to ask those making scare statements how many out-of-hospital births they have attended.

CONCLUSION
The final solution is to evolve new social and political forms for the medical profession and for medical care. And there are obstetricians joining in the effort to find these new forms for their profession. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people. For those who fear chaos, remember Churchills warning: democracy is the worst form of government until one considers the alternatives.
This turn around has started in places with local public committees deciding on health care policies and priorities---post- modern maternity care. Everything about pregnancy and birth----how it is perceived by society, how the pain of birth is endured by women, how birth is managed by birth attendants---are highly cultural. Local control leads to empowerment of women which, in turn, leads to a stronger family and society---local women need to give birth in local waters. People have been swimming in the physiological, social and cultural primordial sea for a long, long time, can see the water, know where the sharks are and are adept at eventually finding their way forward to reclaiming humanized birth.










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BRIEF CURRICULUM VITAE
MARSDEN WAGNER, M.D., M.S.P.H.

BIRTH San Francisco, California, USA

EDUCATION
B.S. University of California at Los Angeles (UCLA)
M.D. UCLA School of Medicine
Internship in pediatrics, UCLA Hospital
Resident physician in pediatrics, UCLA Hospital
Chief resident physician in pediatrics, UCLA Hospital
Post-doctoral Fellow of National Institutes of Health at the UCLA Schools of Medicine and Public Health
M.S.P.H. Post-graduate degree in perinatal epidemiology and reproductive science, UCLA

EXPERIENCE
6 years Assistant Professor of Pediatrics and Public Health, UCLA School of Medicine and UCLA School of Public Health
3 years Co-Director, Bureau of Maternal and Child Health, California State Department of Public Health
6 years Director, UCLA-University of Copenhagen Joint Health Service
Research Center, Copenhagen, Denmark
15 years Regional Officer for Women`s and Children`s Health, World Health
Organization Regional Office for Europe, Copenhagen (responsible for Women`s and Children`s Health in 45 industrialized countries)
Present Private Consultant

SELECTED PRESENTATIONS
Testimony given before the US Congress, British parliament, French National Assembly, Italian Parliament, Danish parliament. Scientific papers and lectures presented in 45 countries. As an example, in the year 2000 presentations in: Australia, Brazil, Canada, China, Denmark, England, France, Ireland, Italy, Japan, North Ireland, Russia, Singapore, Sweden, Thailand, USA (Chicago, Honolulu, Seattle, Los Angeles, Eugene, Washington DC, Phoenix)

SELECTED HONORS AND AWARDS
Including, as examples: Professional Achievement Award, UCLA School of Medicine; Alumnus of the Year, UCLA School of Medicine 1995; Living Treasure Award, Mothering Magazine USA

PUBLICATIONS
112 scientific papers and 8 scientific books published in English, German, French, Spanish, Russian, Italian, Japanese, Chinese, Swedish and Danish.

 
 


 
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