by Jane Beal, PhD, CD(DONA), CCE(BWI), CLS
After a friend had a “pushed” birth followed by an unnecesarean a few years ago, I gave her a copy of Henci Goer’s The Thinking Woman’s Guide to a Better Birth. She had a VBAC the next time around, arriving at the hospital just in time to push out her second baby girl with her body’s own power. She was overjoyed!
Like The Thinking Woman’s Guide, Henci Goer’s new book, Optimal Care in Childbirth, co-authored with Amy Romano, MSN, CNM, presents research that supports evidence-based practices in maternity care. It specifically advocates physiologic birth and expectant management. But unlike The Thinking Woman’s Guide, the intended audience is not expectant parents, but caregivers: doctors, nurses, doulas, childbirth advocates, and midwives. Its purpose is not to help parents make wise decisions in childbirth (indeed, the complexity of the information presented here makes this book inappropriate for most laypeople), but rather to change practices in obstetrics and midwifery.
Optimal Care has been endorsed by Helen Varney Burst, CNM, Ina May Gaskin, CPM, and Penny Simkin, PT. It’s been adopted as part of the reading list for the NARM examination and as a textbook in some certified nurse midwifery training programs. This shows that it is already reaching the next generation of midwives. But it could clearly benefit doctors-in-training as well.
The book presents extensive mini-reviews of several hundred controlled randomized trials conducted between 1990 and 2010. The authors use these mini-reviews to support well-reasoned arguments against the liberal use of cesarean surgery, elective repeat cesarean, elective induction, augmentation of first stage labor, continuous electronic fetal monitoring, the use of IVs, the non per os (“nothing by mouth”) dictum, and epidurals. They further question the need for actively managed second stage labor, instrumental vaginal delivery, fundal pressure, episiotomy, actively managed third stage labor, and the harmful interventions of current, wide-spread newborn practices, including suctioning, immediate cord clamping, and separation of mothers and babies after birth. They make extensive, evidenced-based recommendations for optimal care in childbirth instead.
Goer and Romano make crystal clear that America’s over 30% cesarean epidemic is completely unnecessary, caused by economic factors (cesarean is quicker and more profitable than vaginal birth), legal factors (surveys show that doctors believe they will not be sued, or if sued, they will not lose if they have performed a cesarean, but this assumption has proven false) and social factors (convenience). It is not caused by a sudden inability among American women to give birth vaginally. The authors point out the risks to mother and baby from the first cesarean as well as risks in subsequent pregnancies. (Compare to Goer and Romano, “Vaginal or Cesarean Birth: What is at Stake for Mothers and Babies?”) They do the same with the subject of induction. Clearly, patience is never a greater virtue than when it is practiced by caregivers during childbirth. This point, and many others, are made persuasively.
Just three things gave me pause while reading this book: the recommendation to begin an induction of labor 18 hours after PROM (p. 157); the characterization of “the doula paradox” (p. 427-34); and the lack of strong support for homebirth (p. 501-30).
About PROM and induction: I’ve smelled chorioamnionitis in the labor room before, and as the colloquial saying goes, it ain’t pretty. No one wants a bacterial infection in the laboring mother to put the newborn at risk of sepsis, which usually necessitates a full work-up in NICU and antibiotics for both mother and newborn in hospital. That said, PROM is not the cause of infection. Bacteria is. And it’s the number of cervical exams after PROM that puts mothers at higher risk of bacterial infection. So the “optimal strategy” is not induction 18 hours after PROM; it’s no cervical exams after PROM.
Goer knows this. She advises in The Thinking Woman’s Guide, in her section "The Bottom Line on Induction for PROM," “refuse vaginal exams before active labor” (p.68), and “wait at least 24 hours before inducing unless you show signs of infection” (p. 69). In fact, 75% of women will spontaneously start labor by 24 hours, and 95% will deliver by 28 hours (see Constance Sinclair, A Midwife’s Handbook, p. 143), but only 50% of women will spontaneously start labor by 18 hours after PROM. So starting an induction at 18 hours is 10 hours short of a physiologic birth for 45% of women.
As midwife Gloria Lemay points out, in Europe, the recommendation is that babies be born within 24 hours after the first cervical exam – giving the mother weeks before induction might be necessary if no cervical exam is performed after PROM. In fact, when mothers experience PPROM (Preterm Premature Rupture of Membranes), most American doctors will sit on their hands while mothers are on bed-rest, waiting for the baby to mature as much as possible to increase the chance of survival outside the womb. They do wait for weeks with PPROM. And what if PROM is actually PPROM? Not all due dates are accurate. Again, patience is a virtue!
About the “doula paradox”: Optimal Care argues from survey data that doulas are not always welcomed or appreciated by hospital staff, which can lead to conflict, but on the other hand, doulas can be manipulated by hospital staff into “gaining cooperation” from the mother to submit to unwanted procedures. The authors conclude: “women are better off with doulas than not, but whichever path to doulas take, all too often they and the women they serve lose” (p. 430).
This strikes me as an oversimplification of the results of the 2003 Cochrane systematic review of 15 RCTs of continuous female labor support vs. usual care, summarized online here, which may be beside the point anyway. Goer and Romano’s evidence shows that choice of primary caregiver, not the doula, has the most effect on maternal outcomes in childbirth. Yet the authors do not consider the educated and experienced doulas who are steering women toward primary caregivers with low intervention and cesarean rates. And what does the Listening to Mothers II survey say about doulas? 88% of women gave doulas an “excellent” rating for their support, above both midwives (68%) and nurses (68%). That’s not a paradox. That’s the result of women actually getting the emotional and physical support they want in labor – from their doulas.
About homebirth: The authors ask the question, “Do we know if home birth is safe?” (p. 506). They note that “women perceive homebirth to be safer than hospital birth because they can trust their care providers, have autonomy, and avoid interventions that they do not want and are not supported by evidence” (p. 509). That sounds positive, but the authors go on to say:
"Improving hospital care may in fact be the most important strategy for improving the safety of home birth. If hospitals respected informed consent and refusal, if physiologic care was standard, and if hospital-based providers reliably offered evidence-based treatments for complications, fewer women would choose home birth…" (p. 509).
If. If. If. Maybe “Do we know of home birth is safe?” is not the most useful question. Clearly, homebirth can be safe for low-risk women with a skilled caregiver in attendance, and it appears that, statistically, such homebirth results in lower mortality and morbidity rates for mothers and babies than hospital birth. It’s more affordable, too. Even for high-risk women, midwifery care can be an excellent option that promotes maternal physical health and emotional well-being, which are of course related. Worldwide, midwifery care is essential to resolving preventable complications of childbirth, as the World Health Organization clearly explains in “10 Facts on Midwifery.” More midwives are needed everywhere, especially in the developing world, where hospitals may not be accessible or may refuse care to impoverished women. But the fact is, less than 2% of American women give birth at home.
So, as Miriam Perez points out, a better question might be, “Is hospital birth safe?”
In their conclusion, Goer and Romano make the argument that America’s maternity care system should be led by midwives, who would care for the majority of women using expectant management, while high risk cases could be co-managed with obstetricians (p. 450-51). European maternity care systems run on this model, and they have better maternal and perinatal outcomes than America does. Unfortunately, with fewer than 12,000 midwives in the country (about half of them CNMs and the other half DEMs, CPMs, RMs, or LMs), midwives are not in a position to handle the number of births in this country without doctors: almost 4 million per year. In contrast, there are about 40,000 obstetricians in America today. So many more thousands of midwives need to be educated and trained to fulfill Goer and Romano’s goals. Yet programs to educate them are few, and many are not affordable. Thus, what needs to happen to improve hospital birth in America right now is that the education and training of doctors needs to shift to support physiologic birth.
If more midwives held leadership roles in teaching hospitals, where they could be recognized as “experts in normal birth” and instruct residents, then doctors would learn a great deal that could change the maternity system overall. (This is currently happening in at least one hospital in the Denver area where I serve, as well as in hospital where midwife Betty Anne Daviss serves in Canada, so it is not as unlikely as it may sound!) If ACOG were to change many of its recommendations to doctors, advocating expectant rather than active management, this would also make a huge difference. But the economic, legal, and social factors currently working against change are powerful.
One of the most significant of these factors is consumer demand for pain relief medications in the form of epidurals, which necessitates additional active management and often results in cesarean, especially when labor slows in first stage or the mother cannot make effective pushing efforts in second stage. Historically, we know that women led the way in demanding the “right” to pharmacological pain relief, following in the footsteps of Queen Victoria. Many women today may be unaware of the risks involved in making this choice, and caregivers certainly bear responsibility for negative outcomes that result from the epidural intervention (I’ve personally seen a woman paralyzed by a mis-managed epidural), but I think it’s important to acknowledge that the epidural epidemic is consumer-driven. The “failure of obstetric management,” as the authors call it, at least in this case, is shared with mothers demanding drugs in labor. That’s where childbirth educators have a key role to play, one which is not discussed in this book. Doulas can help, too, for their presence reduces the use of anesthesia and analgesia, but they attend fewer than 5% of births in America today.
Optimal Care in Childbirth is an ambitious book. In it, the authors have synthesized a tremendous amount of information in support of physiologic birth. So it is an incredibly valuable resource. Despite a few caveats (discussed above), I recommend it to all childbirth educators, doulas, nurses, midwives and doctors. If the strategies for optimal care in childbirth provided in this book were followed by caregivers in America, more mothers and babies would live and thrive.
