Thursday, April 26, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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EDITORIAL
Healthy Mom, Healthy Baby

Rachel Summer Claire Friedman, MD

The birth of a child marks one of the most momentous and, some might say, miraculous experiences of life. The bearing of children, however, is always accompanied by the bearing of risks, to both mother and infant. Childbirth was the leading cause of death for young women and infants up until the last century, and it unfortunately still is today in the highest-risk developing countries, where as many as 1 in 51 women have a lifetime risk of death during the peripartum and postpartum periods.

In the United States and other industrialized countries, both maternal and perinatal mortality rates have plummeted over the last century, making pregnancy and childbirth a largely safe and healthy experience for the vast majority of women and infants. This dramatic increase in the safety of birth is one of the top achievements of modern medicine.

Interestingly, the move of childbirth from home to hospital over the course of the 19th century and the development of obstetrics as a physician specialty in the early 20th century did not, by themselves, herald much improvement in safety numbers. Puerperal fever—in most cases caused unwittingly by physicians moving among deliveries and autopsies without gloves or handwashing—was largely responsible for the uptick in maternal mortality during the 19th century. Despite compelling evidence from Ignaz Semmelweis and Oliver Wendell Holmes that simply cleaning hands and clothes between patients could reduce puerperal fever deaths to near zero, the medical community resisted adopting the new behavior.

Decades later, in the 1930s, the New York Academy of Medicine reported that hospital obstetric care had not, at that point, produced any measurable improvements in mortality for mothers or infants; women were still for the most part safer at home under the care of experienced midwives.1

Over subsequent decades, however, substantial improvements did finally lead to dramatic reductions in morbidity and mortality. Improvements included the eventual adoption of hand hygiene and sterile technique; better standards of training and obstetric skill; the discovery of antibiotics and medications to treat sepsis, hemorrhage and hypertension; the increasing safety of cesarean section; better prenatal care; and even vitamin D supplementation, which reduced cephalopelvic disproportion.

Where do we find ourselves in this early part of the 21st century? After decades of steady advancement, I would argue that the United States is again experiencing disturbing trends that may, like puerperal fever, be within our power as physicians to correct.

Childbirth in the U.S. is the most expensive in the world, and it constitutes the largest category of hospital payouts. Four million births annually lead to $50 billion in charges to federal and private insurance companies. The average total price for a hospital vaginal delivery is $30,000; it’s $50,000 for a cesarean.

Yet according to the World Health Organization, the U.S. is one of just eight countries where maternal deaths increased over the past decade. The U.S. also has the highest first-day infant mortality rate of any country in the industrialized world—50% more than all other similar countries combined.

With 99% of women laboring and delivering in hospitals, with continuous fetal monitoring, easy access to IV fluids, antibiotics and anti-hemorrhagic medications, and the option of cesarean delivery at the earliest sign of fetal distress, it would seem that we have the best technology available. So why are mortality rates increasing?

The answer is, perhaps, related to all that technology. The modern-day medicalization of childbirth, and most of the training I received in residency, treats the very fact of labor and delivery as a problem waiting to happen. Where there is pathology lurking around every corner, we have the heroic interventions ready to save the day. This is fantastic news for all the high-risk deliveries, but not necessarily so for the average healthy low-risk pregnant woman entering the typical U.S. hospital in early labor.

Rates of cesarean delivery have skyrocketed over the last few decades, and now hover at 30% across most of the country, well above the World Health Organization’s recommended 10–15%. Cesarean deliveries, especially repeat C-sections, pose increased risks to women; and as Dr. Mark Sloan reports in this issue of Sonoma Medicine, new evidence suggests increased risks to babies as well, with rising rates of asthma, Type 1 diabetes and inflammatory bowel disease correlated in children born via C-section.

What are we to do?
We want the technology when we need it, just as we are grateful to live near cath labs and trauma centers when the need for them arises. But just as the ER is not the appropriate place to go for treatment of a viral upper respiratory infection, the hospital may not always be the safest place to deliver a baby, and C-section may not be the safest or most cost-effective method.

As midwife Elizabeth Smith explains in her article, birth centers and midwifery models of care for appropriately stratified low-risk pregnancies may help decrease C-section rates without leading to worse outcomes for mom or baby. And as Dr. Tara Scott reports, a growing number of pregnant women in Sonoma County—including a significant proportion of Sonoma County physicians—are looking at the evidence and choosing planned home births to reduce the possibility of complication and intervention for low-risk pregnancies.

Indeed, having access to familiar surroundings, the freedom to move in space and positioning, and to eat or drink at will (now supported by recent evidence), along with access to non-pharmacologic interventions and continuous labor support, may contribute to reduced need for medical intervention, lower perceived pains of labor, and increased likelihood of a vaginal birth, whether at home, a birth center, or a hospital.

Many factors have led to the rising rates of C-section: changing expectations of childbirth; pain management options; economic and health care system influences; available technology; reduced physician skill in forceps and vacuum-assisted deliveries; and an increasingly litigious society, to name a few. But as widely varying cesarean rates in different hospitals suggest, physician behaviors and the hospital setting itself may increase risk. The healthy nulliparous woman entering a hospital in early labor or for postdate induction may, depending on the location and people involved, walk into a snowballing array of interventions leading to complications brought to her low-risk birth by the perception of her otherwise normal physiology as pathology.

The best example of medicalizing normal physiology into pathology is the famous Friedman (no relation) labor curve. Published in 1955 and based on the observation of just 500 laboring women, Friedman’s labor curve has defined “normal” labor progression and guided obstetric labor management ever since. Recent observational studies challenging his numbers have led to new ACOG guidelines that revisit normal labor progression as well as the very definition of active labor—the point at which interventions usually begin.

In a 2010 study of 233,844 newborns, researchers found that about half of all induced women who had C-sections for “failure to progress” had not reached 6 cm of cervical dilation—which by new guidelines indicates that they were not yet in active labor when their inductions were labeled as “failed” for not progressing.2 Giving women more time and support to get to active labor could lead to more vaginal deliveries; in fact, the adoption of these new guidelines may reveal that the only thing “wrong” with many laboring women has been the erroneous time clock we have been insisting they follow.

What is our job in the rest of this century? As physicians, it is our responsibility to be lifelong learners, advocates for our patients, and leaders challenging the systems that derail the health of our patients and communities at large. We must look hard at the available evidence and ask ourselves: What can we do to continue to reduce the risks of childbirth for both mothers and babies? How do we continue to use the technology and interventions when needed, while honoring the normal physiology inherent in the birth process?

Let’s start with prevention, because a healthy pregnancy begins before conception. We can offer effective contraception to prevent teen and unwanted pregnancies. We can counsel for smoking cessation, healthy diet and weight, increased physical activity, and cessation of substance abuse. In this issue, Jennifer McClendon, MPH, describes the success of Smoke-Free Babies, a Sonoma County program that offers services to pregnant women and new moms to help reduce smoking, thereby reducing risk to both moms and babies. And as obesity leads to increased risks for both mother and baby, Dr. Gail Altschuler offers a perspective on how physicians can help women maintain healthy weight throughout their childbearing years.

We can counsel women to choose the best setting for laboring, which for some women may not be at the hospital. We can help hospital labor and delivery floors have a more patient-centered, home-like environment, and encourage insurance coverage of evidence-based modalities like acupuncture, hypnosis and doula support to reduce the need for anesthesia and increase the likelihood of vaginal delivery. We can be mindful of how our own fears of what may go wrong and even the connotations of our medical jargon—incompetent cervix, inadequate contractions, failure to progress—may influence women’s confidence in their own bodies. We can find more and better ways to educate, inform and inspire women to be empowered in planning for birth as well as in authoring their own empowering birth narrative, wherever and however that birth occurs.

Finally, we can support organizations and policies worldwide that will provide women in developing countries with the antenatal care, skilled birth attendants, and lifesaving medications and interventions that will help more achieve the ultimate goal of every birth: healthy mom, healthy baby. ::

Dr. Friedman, a family physician at Kaiser Santa Rosa, serves on the SCMA Editorial Board.


Email: rachel.sc.friedman@kp.org

References
1. New York Academy of Medicine, Maternal Mortality (1933).
2. Zhang J, et al, “Contemporary cesarean delivery practice in the United States,” Am J Obstet Gynecol, 203:326.e1-10 (2010).

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