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Optimal Care in Childbirth by Goer & Romano

There really aren't many author duos that compare to Henci #Goer and Amy #Romano so this book was a safe investment, in spite it being an older publication (2012). You might remember Obstetrical Myths Verses Research Realities by Henci Goer, an excellent read, and potentially the first to illuminate the gap between conventional obstetrical management and the care model supported by the research. It was one of the first books I read on my own #midwifery journey and one of the first really strong examples for me in how to evaluate the literature critically.

Henci joined with Romano for this book, a nurse-midwife, also known for her critical thinking and logic within the clinical field of midwifery. They both testify that they believe "we have a maternity care system whose unconscious principles and resultant conscious practices fail those who should be its primary beneficiaries (p 1)." They both believe, as do I as a practicing nurse-midwife, that good practitioners are defined by their belief that childbearing families are fundamentally healthy and childbearing is a normal part of a woman's #psychosexual life. They also believe, as do I, that women should be treated holistically, taking into consideration their thoughts, feelings, concerns and priorities. Women should have the right to make informed decisions for themselves and their babies and practitioners should respect labor as an experience with its own lessons and rewards. Good practitioners will support rather than intervene unnecessarily and evaluate individuals rather than practice per a script or rule. When interventions are introduced, they should start small and only when necessary. All good practitioners should stay abreast of the medical literature.

Keep in mind it takes about seventeen years for new evidence to create change within clinical sites within the United States, so while this book is older it is still relevant. It offers an explanation for the gap - the chasm - between optimal care and current practice despite most practitioners' having good intentions. Having said that, books are not scholarly sources so this review is simply to inspire you to dig into the literature a bit deeper. Think critically about what you think you know.

Eight sections in this book reveal the sort of false dichotomy - or false reasoning - that is our current obstetrical care in the United States. The medical model is not the best management for women and children, as evidenced by our country holding the worst outcomes of all industrialized countries for decades now. Women are becoming more informed and are demanding better care and alternative options. This books provides an in-depth analysis of the evidence for #physiologicbirth, as of its publication date, redefining the standard of care for childbirth.

How has the Obstetrical Model Failed Women?

Two oppositional philosophies underlie the competing concepts of good maternity care, as argued by authors Goer and Romano. Clinicians who are medically minded start from the premise that pregnancy and birth are intrinsically difficult and potentially dangerous processes that when left to progress naturally, frequently result in catastrophe. The belief then is that women require aggressive screenings, intensive monitoring, and invasive interventions to prevent and treat their #pregnancy progression and #childbearing experience. Proponents of physiologic care however, practice with the philosophy that pregnancy and childbirth are inherently healthy and normal for the vast majority of women and their babies. They believe the best outcomes occur when clinicians promote and facilitate the nature process and reserve medical interventions for times when these measures prove inadequate.

Important consequences flow from the differences between these two philosophies in that the medical model defines success as a live mother and a live baby in reasonably good physical condition so that care is structured to prevent catastrophe. In contrast, the physiologic care model strives for optimal wellbeing of the mother and baby within the context of the family and broader society, which also encompasses morbidity and mortality, but goes a bit deeper and accounts for the childbirth experience, including physical and psychological health long term, #breastfeeding, mother-infant attachment and parenting outcomes.

The second consequence, as described by the authors is the difference in strategies for achieving good outcomes. Medical minded practitioners will adopt a "maximum approach from game theory and military strategy, known as minimax, which are designed to minimize the maximum potential losses." Accordingly, tests and procedures that were intended to prevent, diagnose, or treat uncommon complications are used frequently or routinely, although only a small minority stands to benefit from their use. The hospital policies which prohibit women from eating and drinking in labor are good examples of this. This is an effort to prevent the one in 3 million chances of dying by aspiration pneumonia. Another example is the induction of women at 41 weeks or earlier in effort to prevent the one in one-thousand chance that a healthy women will experience a stillbirth late in pregnancy. My favorite example of ignoring all logic is the refusal of most hospitals to support a woman's right to labor after a prior #cesarean for fear of rupture, in spite of there having been not a single death related to uterine rupture, but not recognizing she is more likely to die in the car ride to the hospital via an automobile accident or even get struck by lightning.

The physiologic care model however, is organized to "maximize positive effects and minimize negative effects" by focusing on the prevention of problems through optimizing health and wellness. These practitioners prioritize physical and psychological health and adaptation to pregnancy, labor, birth, and breastfeeding. Optimal outcomes are achieved by judiciously utilizing machines and medicines only when there is evidence that labor and birth has strayed from the normal physiologic process and preventive approaches have not been sufficient.

Iatrogenic harms are the "collaboratal damage" of maximin obstetrics, unfortunate but supposedly unavoidable side effects of the tactics used to safeguard the mother and infant. These may be increased pain and suffering, more complicated labor, fetal or newborn compromise, but in the long term, these may manifest as chronic health problems (pelvic pain, gastrointestinal issues), poor psychological outcomes (posttraumatic distress symptoms, depression, anxiety, or attachment disorders), or adverse effects on future reproduction (infertility, complications in future pregnancies). Ironically, the medical model seems to rely on more interventions to correct these issues, more pitocin, more monitoring, more surgical interventions, less contact between mom and child.

Clinicians working within a physiologic model however, minimize these interventions. We work to avoid medications appreciating their potential for risks to both mother and child. Instead, we utilize patience and supportive techniques for promoting labor progress. If #pitocin or pain medication proved advantageous, they would be administered in physiologic doses and without co-interventions to reduce the overall load of interventions and ultimate risks. Supine positioning for example, or closed glottis pushing, or amniotomy would be avoided if at all possible. A wellness oriented, low-technology approach is the preference for a physiologic approach without compromising outcomes.

Whose Needs and Concerns Take Precedence?

The medical model centers around the doctor and institutional staff. Their comfort and convenience are paramount, and they dictate rules and policies as if they are dictators within an environment in which human rights do not exist. The woman is a "patient" and is expected to comply no matter how uncomfortable or disruptive or even painful she finds them, without compliant. The doctor makes all decisions and may or may not informed the patient of those decisions and their consequences. The doctor makes decisions about the child's best interest, offering little trust or appreciation for the parent's role in decision making. The woman submits to the provider's authority, forfeiting her autonomy, bodily integrity, and physical and mental health whenever her provider deems appropriate.

Consider that "the doctor makes decisions according to what he or she deems acceptable risks, a determination often based on self-interested motivations such as protection from malpractice suits or time management. For example, the clinician who advises induction at 41 weeks to avert the one in 1000 chance of stillbirth often has no problem with the liberal use of cesarean surgery, which increases the risk of neonatal death by the same amount and confers excess risk of risk of pregnancy loss and perinatal death in future pregnancies" (2012, p 5).

Contrast to this model is the physiologic approach which puts the woman at the center. Mother and child are a single unit, whereas the medical model prioritizes one for the other. What is good for the mother, physiologically, is ultimately good for the baby. The care provider's role is to provide a safe environment, resources, advice, unobtrusive monitoring, and encouragement that will optimize her ability to cope with and overcome the challenges intrinsic to labor and birth. Decision-making is collaborative, mutual. The woman not only has the right to articulate her concerns and needs, but has a right both to informed consent and refusal. The goal is to accommodate the mother and her baby. Mothers are encouraged to move, be directed by her body, push when led, vocalize, drink to thirst, eat as desired, and utilize the restroom without first seeking permission. When the rare complication does occur, the woman actively participates in resolving it. Further, when she or baby requires medical intervention, they both continue to receive sensitive, respectful, high-touch care.

Medical management argues that the best care is that which offers proximity to specialized technology and those trained to implement such technology, specifically obstetricians within the hospital, preferably a tertiary center. Those more physiologic minded will argue that the mere presence of such technology leads to its over use and therefore iatrogenic harm without improving outcomes. Marsden Wagner was quite famous for his (paraphrased) statement, "The biggest intervention which harms women in childbirth is walking through the doors of the hospital."

The medical model really doesn't appreciate that childbirth is the transition into parenting. They don't conceptualize the price that is paid when this experience is problematic, even traumatic. "It also disregards how a model instilling the impression that women's bodies are incompetent to birth their children without expert help erodes a woman's confidence in her ability to care for her child" (2012, p 6). Attachment and breastfeeding are bonuses, not the expectation.

Increased use of tests, procedures, drugs, and restrictions has not paid off in healthier moms and babies. We have seen minimal improvements recently in the preterm birth rate, but it is still higher than it was in the 1980s and 1990s. The maternal mortality rate is rising, and experts believe that for every maternal death, there are at least 50 "near misses." While the physical damages mount, what is not even yet on the radar are the psychological damages inflicted on women and even on their partners and babies.

In the first year after birth, two out of three women participating in Listening to Mothers II reported depressive symptoms at the time of the survey, and in a follow-up survey, a full 9 percent appeared to meet all the diagnostic criteria for childbirth-related post-traumatic stress disorder. Nearly one in five had consulted a healthcare provider about their emotional well-being and nearly one in three reported that their emotional well-being interfered with their ability to care for their baby. Five percent had considered suicide. By all measures, "the medical model has failed dismally," states the authors.

"The choice of model is critical because it's assumptions and principles dictate care," state Goer and Romero (2012, p 6).

Obstacles Towards Change

Although the medical model is certainly paramount here in the United States, every group which has ever set out to design a healthy maternity care system or has worked to define quality maternity measures has articulated that the principles and practices of the physiologic care model were the gold standard. The wheel has been reinvented many times, but it fails to get rolling. Why? Well, there are many forces at play for maintaining the status quo.

Liability being one of the greater challenges, the belief is that the current medical model reduces provider liability by showing that everything possible has been done to prevent a poor outcome. A 2009 study demonstrated that 91 percent of obstetrical providers had been sued, which demonstrates this approach in fact, is not effective. It seems a bit of a self-fulfilling prophecy to imply that intervention-intensive management would avert bad outcomes. Another Marsden Wagner quote (2006), "If you play God, you will be blamed for natural disasters."

There is a sort of anxiety that is removed with the mindset that we can control outcomes with the various interventions available in childbirth. The natural process is a model of "anything can happen," right? When one has this mindset, they seek a high-tech environment, but those who feel more comfort with the normal, natural physiological process recognize that these interventions invite complications more frequently.

Economic incentives are yet another challenge to correcting our broken maternity system. Staffing and resources are better utilized when we can speed up labor and terminate the end of pregnancy surgically. Practitioners have better control of their schedules within this model, and work more convenient hours. High epidural rates support the anesthesia staff while non-pharmacologic support are not reimbursed. High technology interventions support increased billing opportunities and #NICUs are incredible profit centers. The ideal birth for purposes of cost gains is the scheduled cesarean.

Decision-based Evidence

It was hoped that as evidence grew in the field of obstetrics, which has really only been available within the more recent decades, that outcomes would change. Indeed they did improve cesarean rates for a short period and supported more access to VBACs, yet more recent studies have supported more interventive births. What we have though, are clinicians who lack the ability to critically think, to read beyond the abstract, to really understand research methodology, and ultimately, have allowed inerrancy in the research to misguide them in their practice.

The deck is stacked against physiologic care. The financial costs to society for the medical model is astronomical. The World Health Organization recommends reducing the cesarean rate to a mere 15 percent for improving the health outcomes of both mother and baby. This would save $3.4 billion dollars annually. The human cost is quite profound. #Midwives are change makers, but this work is arduous and consuming, even dehumanizing. We really do need all hands on deck.


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