If You're an Expectant Mom, or Know One...PLEASE READ THIS!!!

Allison,

I absolutely agree with you that there can be, and should be a common ground between health care providers who embrace allopathic, naturopathic and holistic approaches to patient care. These philosophies do not necessarily need to be mutually exclusive.

I have personally experienced a moderate level of pregnancy and childbirth management, as well as a more hands-off approach to patient care. I have also been on the "giving" end of these two types of patient care approaches and have been the witness to these different approaches in numerous scenarios through labor support and through the stories of my students.

To me, a "managed pregnancy" is a pregnancy in which someone else (most likely a health care provider--doctor, midwife, nurse practitioner...) directs, or manages the progression of the pregnancy through ordering tests (regardless of proven efficacy), maintaining a very rigid schedule of prenatal exams, making recommendations to the pregnant woman based on protocols, rather than a very personalized approach--that might include taking into consideration social, personality/character, economic, medical and past history factors.

I absolutely agree that there are times when medical management during pregnancy and childbirth are important, if not crucial. When pregnant women are found to have conditions such as placenta previa (the placenta partially or completely lies over the cervical opening), placenta accreta, blood clotting disorders, pre-existing heart, lung or thyroid disorders, a higher level of "management" is definitely in order. And, in many cases, these women are not candidates for a home birth experience, and ought to be guided in a different direction.

However, there are many other scenarios in which women are told they are "high risk" and that level of risk is arbitrary, at best. For example, if a 36-year-old woman who is in excellent health, had a couple of previous healthy, no-complication pregnancy and deliveries becomes pregnant for a third time, she will still be told she is "high risk," and treated as such, simply because of her age. In reality, her present health status and past history ought to be equally considered.

I would like to clarify something about my position as this dialog goes on: I am a mother of three young children. I birthed all three of my children in the hospital. Two of those three births could have just as well occurred at home with no difference in safety outcome to me or the baby. I am not strictly a "home birth advocate" as Dr. Tuteur would like to pit me to be. I can see the potential value in both cases--hospital or home birth. What I am, is an advocate for the best possible treatment of mothers and babies--which includes applying medical technology when it is truly warranted, and holding off when studies, present circumstances, health history and intuition suggest otherwise.

Can all maternal deaths be avoided? No, absolutely not. Have we made great strides in reducing the number of maternal and neonatal deaths in the past 200 years? Yes. But, as I made the point earlier, the two main things that have helped us achieve these goals are prenatal care and antibiotics. (Both of which are still unequally distributed in our socitey.)

Technologies such as constant, or near-constant Electronic Fetal Monitoring, elective labor inductions, elective c-sections, and artificially breaking a woman's amniotic sac are all technologies and techniques that RAISE a woman's level of risk during childbirth...not prevent death or illness. And these are also tools that fall under the blanket of "heavily managed" childbirth.

Technology is great, when chosen wisely. I tell my Lamaze class students this every class session. But so is using a healthy dose of restraint. And as health care providers who are trained to utilize and apply technology, we sometimes have a difficult time doing that.

Kimmelin Hull, PA, LCCE
author of A Dozen Invisible Pieces and Other Confessions of Motherhood

An ancient principle of the practice of medicine is "Primum non nocere" which means "First, do no harm. It is helpful to look at the context in which the phrase appears. Hippocrates admonishes the physician "to help, or at least to do no harm." For obstetricians, "harm" means one thing above all else: death, of the baby or the mother. The secondary meaning of "harm" is permanent disability such as brain damage of the baby or an obstetric fistula of the mother. Everything that is done in modern obstetrics is done for the express purpose of reducing harm.

Obstetrics has been spectacularly successful in reducing harm. Neonatal and maternal mortality rates have fallen to levels so low that the average person may never meet someone who has lost a term baby due to labor complications, and will never even hear about a woman who has died in normal labor. Every one of the supposedly "unnecessary" medical procedures that homebirth advocates complain about has been instrumental in achieving these successes.

Obstetrics has been transformed from primarily disaster management, to disaster prevention. Moving from management to prevention has meant the application of technology to women who, in retrospect, may not have needed it. Doing "no harm" in obstetrics, as in the rest of medicine, now means preventing known harms from occuring at all, not waiting until they occur and treating them.

Childbirth in nature is inherently dangerous. That's not surprising. Pregnancy has a very high failure rate, too. Approximately 20% of all established pregnancies end in miscarriage and that is a normal part of human reproduction. Approximately 1% of all mothers and 7% of babies will die in childbirth or immediately thereafter, and that is a normal part of human reproduction, too. Modern obsetrics now prevents approximately 99% of maternal deaths and 90% of neonatal deaths. The most common reasons for maternal death used to be pre-eclampsia and eclampsia, hemorrhage, and obstructed labor among others. Those are still the most common causes of maternal death in countries that don't have access to modern obstetrics. The most common causes of neonatal mortality used to be prematurity, congenital anomalies, and obstructed labor, among others. Those are still the most common causes of neonatal death in countries that don't have access to modern obstetrics.

Homebirth advocates look at the current low rates of neonatal and maternal mortality and think that interventions, monitoring and testing aren't routinely necessary. They don't realize that the current low rates of neonatal and maternal mortality are the RESULT of interventions, monitoring and testing.

Dr. Tuteur and Kimmelin,

Thank you both for such a frank, candid, powerful and educational discussion. I really appreciated reading both of your posts, and am still "digesting" all of the information.

I am wondering how you each would "operationally define" the phrase "managed pregnancy"? It seems that the home-birth advocates define this term in only the negative, whereas the medical profession-advocates define this term in only the positive.

As a mom who had a high-risk delivery (with none of the risk factors!), and any future pregnancy will likely be an automatic "high risk" pregnancy, I welcome my pregnancy being "managed"...but I believe I am defining this as: being "cared for" by adequate health insurance coverage, caring physicians and nurses, a wonderful doula, access to competent hospital (or homebirth) professionals, my own knowledge and experience, and drugs or technology for myself and baby (if needed). I have worked in the "medical/health" field, as well as in the "wellness and prevention" field, and feel that there is some common-ground between the two...at least, there are common goals of creating a healthier society, with better access to health care, less health disparities and a "coming together" of traditional and CAM disciplines.

What are your thoughts?

"And as far as your claim, Dr. Tuteur, that the stats on the 2005 Maternal Mortality report, compiled via the efforts of the WHO, UNICEF, UNFPA and the World Bank, are ERRONEOUS"

I did not say that the WHO stats are erroneous. I said that you copied the wrong column. The numbers I presented ARE the WHO stats.

"Many will claim, that the problem initially began when we, as a culture, decided to tightly "manage" pregnancy and childbirth as if it were a disease state--when we began meddling in a process much further beyond providing good quality prenatal care, and access to antibiotics which, indisputably DO make a big impact on mother/baby outcomes."

Yes, and they will be utterly, totally and completely wrong. That's what I mean about exploiting the tragedy of maternal mortality. Most of the maternal deaths in the US are caused by LACK of access to technology. The pregnancies of those women should have been managed MORE.

Homebirth advocates don't seem to understand that childbirth is INHERENTLY dangerous. It is a leading cause of death of young women in EVERY time, place and culture. According to Save the Children, the day of birth is the MOST dangerous day of the entire 18 years of childhood. The only people who appear to be unaware of this fact are homebirth advocates.

In the last 100 years American obstetrics has lowered neonatal mortality 90% and maternal mortality 99%! In the absence of "managing" pregnancy, approximately 225,000 babies and 39,000 mothers would die EACH and EVERY year. American obstetricians believe that the neonatal and maternal mortality rates can be lowered even further, but that involves MORE technology, not less.

Amy Tuteur, MD

Dr. Tuteur, thank you for the correction on the figures from the chart.

However, my point remains the same. As an industrialized nation that spends oodles of money per pregnant woman I, for one, would expect our country to have THE BEST maternal survival outcomes when compared to other countries that boast similar qualities of health care. We have access to THE BEST medicines, diagnostic instruments, research institutes...so why wouldn't the US find itself at the very top when it comes to maternal well-being? It comes down to philosophy. It comes down to how we, as health care providers approach our patients to begin with...even before we start talking tests and risk factors and statistics.

Many will claim, that the problem initially began when we, as a culture, decided to tightly "manage" pregnancy and childbirth as if it were a disease state--when we began meddling in a process much further beyond providing good quality prenatal care, and access to antibiotics which, indisputably DO make a big impact on mother/baby outcomes.

And as far as your claim, Dr. Tuteur, that the stats on the 2005 Maternal Mortality report, compiled via the efforts of the WHO, UNICEF, UNFPA and the World Bank, are ERRONEOUS...I'm sure the family members and friends of each and every woman that dies during pregnancy, childbirth or in the postnatal period do not find those deaths to be ERRONEOUS. Whether intentional or not, this type of statement is indicative of the callous attitude that has come to roost in our health care system.

And I do not speak in hypotheticals here. I worked in a very prominent university medical system for several years after graduating from PA school. I saw it all the time.

When we talk about how women of lower socioeconomic status tend to be those at higher risk for pregnancy related complications and maternal death, I have to ask the question: is it because their uteruses...their bodies...are that much less capable of handling pregnancy, labor and delivery and the postnatal period, or is it because their socioeconomic status puts them at risk for receiving LESS THAN OPTIMAL CARE? And I bring this up, because I have seen this too. Over and over again.

I have seen surgeons delay scheduling badly needed surgeries in patients, primarily because they were insured under Medicaid. I have witnessed people who over-use the emergency room because they can't afford health care insurance and therefore don't have a primary provider--and end up being labled "frequent flyers" and regarded as little more than a nuisance...even when they finally DID present with a serious complaint. Is this an abuse of the system? Sure. But the system is set up to encourage this type of abuse to begin with. I have watched patients who are thought to be so uninformed--often times individuals of a minority race-- treated as if they didn't deserve to be given choices about what happened to their bodies, whether in childbirth, in the ER, in surgery, in general medicine...that they were just given medication, or underwent procedures without TRUE INFORMED consent.

As healthcare providers, we don't like to face these uncomfortable truths about the profession in which we work. It's easy for us to say, "yeah, but that's not me." We did, after all, go into medicine because we wanted to HELP people. But the fact is, our medical system on the whole is very broken--and the issues brought up in Ina May Gaskin's article, and in this on-going discussion, are one element of that broken system.

If we all continue to claim, "yeah, that's not me;" thereby perpetuating the broken medical system...perpetuating the under reporting of maternal deaths...perpetuating the over use of medical interventions surrounding the time of childbirth that put woman at all sorts of risk for complications that RARELY get explained to them...then we will never approach a time of healing this brokenness.

It takes courage to face hard statistics--statistics that suggest we could be doing better. But the fact is, maternity care in the United States could be SO MUCH BETTER. And the demand for that improvement is either going to come from the health care providers themselves, who are really willing to face those stats head-on, and do something to change them, (such as the almost 33% c-section rate our nation now boasts) or from the customers of the health care industry (the empowered women who will demand more, or take their "business" elsewhere.

Kimmelin Hull, PA, LCCE
author of A Dozen Invisible Pieces and Other Confessions of Motherhood

You didn't read your chart very carefully, and have quoted completely ERRONEOUS data. Go back and look at the chart again. You quoted deaths per entire COUNTRY, not deaths per 100,000.

The correct figures are (deaths per 100,000):

US - 11
UK - 8
Switzerland - 5
Sweden - 3
Norway - 7
Netherlands - 6

Moreover, it is not a coincidence that the countries with lower rates of maternal mortality are among the "whitest" countries in the world. Race is a risk factor for maternal mortality, partly for socio-economic reasons, and partly for reasons we do not understand. The maternal mortality rate for white women and for minority women are almost the same in these countries as they are in the US. The difference is that the US has a larger proportion of women of color in the industrialized world.

The leading causes of maternal mortality in 2005 were pre-existing medical conditions, pre-eclampsia and eclampsia, and hemorrhage, among others. Contributing factors include advanced maternal age, and increasing numbers of pregnancies involving twins or higher order pregnancies.

The keys to lowering maternal mortality are improved prenatal care, improved healthcare in general, and increasing healthcare access for minority women.

Amy Tuteur, MD

I think there are a couple very important things to look at in the article I referenced with my original post (see link to article at bottom of this post)

1) As Sasha pointed out, Ina May's entire purpose of the article is to start a dialog. Are we truly reporting the totality of maternal deaths or not? (In fact, in the WHO's 2005 report, referenced later in this post, this question is asked of all coutries) The information Gaskin cited from the CDC and WHO suggests we are not. Getting to the root of the problem--defining the CAUSE of death, as pointed out by Dr. Tuteur, and then assessing which of those maternal deaths are preventable...is the end point Ms. Gaskin is going for.

The other issue the article brings up is the fact that, as a country, we spend more medical dollars per pregnant woman than any other country around the world. Logically, one would assume, this would translate into having the lowest maternal mortality rate. The unpreventable causes of maternal death are unpreventable, no matter where you live, to a large extent. But the PREVENTABLE ones ought to be caught, treated, or AVOIDED in a country where patients and providers have access to technologies, information and statistics than those in less fortunate, less advanced, and less enlightened locales.

If you paste the following link into your browser: http://www.who.int/reproductive-health/publications/maternal_mortality_2...

you will find a 2005 report by the WHO (the most current available from which, I believe, Gaskin draws much of her information)that lists all data, by country, of maternal death rates world-wide. It is a 48 page report, much of it dedicated to discussing HOW this information is collected. Skip to page 30, and you will find the concise list.

Here are some stats of the number of maternal deaths per country, per 100,000 women:
US - 440
UK - 51
Switzerland - 4
Sweden - 3
Norway - 4
Netherlands - 11

I pull the stats from the northern European countries for two reasons:
1) These are countries in which midwifery care for pregnancy and childbirth is very common--either in or out of the hospital, and
2) Their reporting is more likely to be accurate (or closer to accurate) than other countries around the world. This being said, even the WHO asserts that the numbers provided in their own report are likely grossly underestimated.

There's no doubt that 99% of maternal deaths (defined, by the WHO, as deaths that occur in women from the start of pregnancy to 42 days after the end of pregnancy) occur in third world countries - and most of those in subsaharn Africa. I don't think this is a surprise to anyone.

But the point here is that, in the developed world, we are still not performing as one would expect for how much money we spend per pregnant woman, how much technology we have access to, the prenatal care that women in the US ought to be able to take advantage of, the antibiotics that are more readily available to us than any other place in the world, etc. There is still a huge gap.

I truly believe Gaskin's article is much less a promotion of home birth, as it is a call to look into the numbers, discuss what we can do better, as an entire culture (hospital birth, home birth, doctor-attended or midwife attended) to take better care of women in this very important time in their lives.

To view Gaskin's complete article, paste this link into your browser:

http://docserver.ingentaconnect.com/deliver/connect/lamaze/10581243/v17n2
/s3.pdf?expires=1216215994&id=45121330&titleid=10348&accname=Guest+User&checksum=27EA34D618E4B36007DBE98CE014FFEE

I encourage all to continue to plug away at this discussion. After all, whether doctor, midwife, doula, childbirth educator, PA or patient...surely we all want to see the same result at the end of the day: healthy women who are able to care for their children!

Kimmelin Hull, PA, LCCE
author of A Dozen Invisible Pieces and Other Confessions of Motherhood

"The Safe Motherhood Quilt Project is a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.

The Quilt Project's sponsor is the Safe Motherhood Initiatives, USA, an organization founded to improve maternal mortality rates in the United States.

The quilt is made up of individually designed squares; each one devoted to a woman in the U.S. who has died of pregnancy-related causes since 1982. One quilt square is designed and dedicated to each mother's memory and may mention the date and place of death and the name of the woman. The Safe Motherhood Quilt is the voice for women who can no longer speak for themselves."

These quotes are taken directly from Ina May Gaskin's Safe Motherhood Quilt Project web site (7/12/08). Dr. Tuteur made several points about Ina May's efforts to publicize maternal mortality in the U.S. I think the above statements say quite a bit to refute Dr. Tuteur's assertions. Despite Dr. Tuteur's statement that Ina May is cynical about this issue, Ina May makes several very key points that desperately need to be addressed: we don't even know how many American women are dying in this country in the first year after giving birth, due to birth related causes. WE DON'T EVEN KNOW! No matter the "why", that is a huge problem. She also points out that African American women and other minority women die at a much greater rate. And finally, her quilt project is meant to publicize these women's deaths so we'll all CARE and hopefully look more closely into a system that doesn't even bother to count them. Her assertion that the midwifery model of care is much safer is only one idea here and it's hardly a cynical ploy to try and alert all of us that maternal mortality is a very big problem. I'm sure if Dr. Tuteur would like to join forces with Ina May and work on this problem, Ina May would welcome the effort. It's going to take some serious commitment on everyone's part to change our system of maternity care in positive ways and bring this rate down to something we can all feel proud of. Please look at the Safe Motherhood Initiatives web site so you can see all this organization is doing to improve the rate.

Sasha

Gaskins' article is part of an appallingly cynical publicity ploy. Ms. Gaskin represents herself as shocked at the current rate of maternal mortality. As far as I can tell, Ms. Gaskin herself, and direct entry midwives in general have done NOTHING (no research, no education, no fund raising and no outreach to victims' families) to reduce the incidence of maternal mortality. Apparently, maternal mortality is not the real issue; criticizing obstetrics (inappropriately and unfairly) is the real issue.

If you visit Ms. Gaskin's Safe Motherhood website, which is supposedly devoted to maternal mortality, you will notice something rather curious. There is NO information about the causes, treatments and research into maternal mortality The site is exclusively devoted to criticisms of American obsterics ("Did you know…that the Centers for Disease Control estimated in 1998 that the US maternal death rate is actually 1.3 to three times that reported in vital statistics records because of underreporting of such deaths.").

Look at the page of "related articles". There are no scientific papers about maternal mortality. There is nothing about the epidemiology of maternal mortality. Twelve of thirteen articles are about medical mistakes. Gaskin wants to leave the impression that maternal mortality is caused by obstetric interventions. Indeed, in her public discussions, she is quite explicit. CafeMom reported:

"Most of these deaths are iatrogenic, Ina May explained. Iatrogenic means the treatment of the physician, the drugs administered and the surgeries performed harm rather than heal. The danger warned about in the Hippocratic Oath, which says "First Do No Harm," is as freshly applicable today as it was thousands of years ago.

In reality, as Gaskin almost surely knows, iatrogenic deaths represent a tiny fractions of maternal mortality. However, Gaskin doesn't mention the real causes, because that might require some action; the real causes include lack of health coverage, limited access to healthcare, racial inequalities, advanced maternal age and multiple pregnancies. Virtually every woman who succumbs to a pregnancy related illness or complication has one or more serious risk factors. Virtually none of these women could possibly be cared for by midwives. It is cynical in the extreme to exploit these personal tragedies simply to publicize homebirth midwifery.

Amy Tuteur, MD