Controversies in childbirth. Exploring conflicts in current midwifery and obstetrics and the resulting neonatal dilemmas.
A joint meeting of The Forum on Maternity and the Newborn of the Royal Society of Medicine. with the Section of Obstetrics & Gynaecology.

Chair: Professor John Shepherd, President, Section of Obstetrics and Gynaecology, RSM

Maternal mortality – what can we do about it?
Dr Nynke van den Broek (NB), Senior Clinical Lecturer, Sexual and Reproductive Health, Liverpool School of Tropical Medicine (Co-author)

Being a woman or a newborn baby is difficult throughout most of the world, and the United Nations Millennium Development Goal No. 5, the improvement of maternal health, is crucially important when you consider that worldwide there are an estimated 600,000 maternal deaths annually. Almost half of all infant deaths occur in the first month of life, and this is directly related to the care a woman receives during pregnancy and childbirth. In addition women in sub-Saharan Africa and Asia also have to cope with malaria, HIV and tuberculosis, with gender equity still a very serious issue for most. There is also a strong probability that those who survive pregnancy will be left with lifelong morbidity.

The main causes of maternal death are well known - haemorrhage, sepsis, eclampsia, obstructed labour, and the complications of abortion and ectopic pregnancy. The maternal death rate in the United Kingdom is only 10 per 100,000, compared with an estimated 1000 per 100,000 in Malawi, for example. Too little is being done to correct this huge discrepancy in health statistics. In many resource-poor countries women continue to be undervalued and maternal deaths considered to be almost natural. There is a lack of political will to invest the necessary resources in promoting the health of women and their babies; good quality maternal health services are either unavailable or inaccessible. Delays occur in decisions to seek care - permission from another family member may be required, reaching a health care facility may be impossible for lack of telephone or ambulance, and then receiving the necessary care after arrival at the facility may only happen after significant delays at the facility itself. The latter, sadly is far from unusual.

There are three key maternal health services which should be but are not universally available. They are skilled birth attendance, access to emergency obstetric care, and quality care.

International health organisations have defined the Skilled Birth Attendant - an accredited professional, midwife, doctor or nurse, working in an enabling environment, and trained to proficiency in the skills needed to manage normal pregnancy, birth and postnatal care, to identify complications in women and neonates and to make appropriate referrals. We know that where these skills exist maternity mortality is reduced.

However, many women worldwide still use Traditional Birth Attendants (TBA). Women interviewed in Kenya for example have noted that TBAs are friendly and flexible, with 24-hour access, and they can be paid in kind (e.g. with chickens). Women sometimes object to using health facilities because transport is either not available or unaffordable, or there are simply no facilities; sometimes women have to bring along their own drugs and equipment e.g. gloves, cotton wool, oxytocin. Facilities are understaffed, and care is expensive. They may not be open 24 hours, and the staff are sometimes distrusted and suspected of performing operations such as caesarean section for poor indications.

Birth complications are impossible to predict, but we know that an estimated 15% of women will need emergency obstetric care (EmOC), to which all women must have access. In its basic form (BEmOC) this consists of the ability to administer parenteral antibiotics, oxytocic drugs, and anticonvulsants; to perform assisted vaginal delivery - instrumental or breech, manual removal of the placenta, or removal of retained products of conception following incomplete abortion, illegal or otherwise. Worldwide, midwives are being trained in these skills. Comprehensive EmOC requires caesarean section, blood transfusion and anaesthesia to be available.

The recommended minimum provision for a population of half a million is four facilities providing basic emergency obstetric care and one providing comprehensive emergency obstetric care. At present most developing countries have grossly insufficient coverage. Sometimes there are adequate numbers of facility structures but they do not function optimally. The caesarean section rate should be between 5 and 15% of all births in a population, and the case fatality rate should not exceed 1%. An assessment of four districts in Kenya showed the uptake of antenatal care, comprising only two visits, was 45%; the complication rate was not documented; skilled attendance at delivery was at a 9-15% level, and postnatal care was infrequently provided. This picture is common in many sub-Saharan and South East Asian countries.

The value of audit is undisputed, and the concept of "Beyond The Numbers" is very important to tell us why women die and what can be done to avoid unnecessary deaths. When the strengths and weaknesses of a healthcare system have been identified the recommendations for change can be simple, cheap, and effective; they must be evidence-based, and widely disseminated. Of course results must be monitored and improvements evaluated, using, for example, standards based audit.

We must always involve the women who use the services in plans for change. "The question is not why do women not accept the service that we offer, but why do we not offer services that women will accept?" (Obstetrician Mahmoud Fathalla, personal communication 1996).

The poor obstetric outcomes of ethnic minority groups in the UK – social or genetic?
Professor Philip Steer, Professor of obstetrics and gynaecology, Chelsea and Westminster Hospital, London

From 1988 to the year 2000 we collected data on over half a million births from 17 maternity units in North West Thames, and would have continued thereafter had not PIAG (the Patient Information Advisory Group), following passage of the 2001 Health and Social Care Act (section 60) through Parliament, insisted that we obtain informed consent from every woman to be included, which proved to be impractical. The data was error-trapped throughout, and all perinatal deaths were cross-checked with the Office of National Statistics.

The subject of this presentation will be almost 100,000 black African and Caribbean and South Asian women included in the N.W. Thames database, compared with over 300,00 white European women. Only a few percent of South Asian mothers classified themselves as single and unsupported, compared with 15% of white European mothers and almost 40% of black Caribbean mothers. Few South Asian mothers smoked tobacco, compared with white Europeans so these social factors actually favoured South Asian mothers. However, while the overall perinatal mortality per thousand total births (PNMR) in white European mothers during the study period was 6.35, it was 11.58 in black African mothers, 12.23 in black Caribbean mothers, and 9.0 in South Asian mothers. It has to be a matter of concern that PNMR among the ethnic minorities is substantially higher than that in the white European group. We examined the possibility that social deprivation was causing this, using the Carstairs Index (based on postcodes), the assumption being that people who live in deprived areas are themselves more likely to be deprived. However the fact that the ethnic minorities are substantially poorer than the white group explains little of the variation in PNMRs; nor does the distribution of single unsupported mothers. Although the effect of smoking is significant, our study shows that in a multivariate analysis ethnic origin is the most significant factor explaining PNMRs.

Although there are genetic variations between races leading to conditions which are of obstetric importance (e.g. sickle cell disease, cystic fibrosis), and the gene pool of some groups may depend on cultural factors - here I refer to the practice among many Pakistani communities of 80% first cousin marriages - we should also be considering other factors which may have a genetic origin that vary between races, and I will focus upon birth weight and the duration of pregnancy.

When we consider genetic variation between races, we must bear in mind that modern man and woman have probably descended from only approximately 2000 individuals who are believed to have existed about 120,000 years ago; as a result there is more variation in a single troupe of chimpanzees than in all of us humans. And 80% of all human variation has occurred within Africa.

The ethnic origin of mothers is known to determine the duration of their pregnancies, and it is our hypothesis that this has a genetic cause. The first clue to this was the observation about 30 years ago that black African babies born prematurely experienced much less respiratory distress syndrome than prematures from other groups. Our study confirms this in terms of transfers to special care. Furthermore large American studies have shown that over the last 30 years, black African-American babies have a lower PNMR before 36 weeks gestation, but higher thereafter 1;2. This is almost certainly because black African babies mature earlier; for example we know lung maturity occurs earlier3;4, and indicators of maturity such as passage of meconium during labour also occur earlier in gestation5;6. Earlier maturation has lead to a shorter gestation, to avoid the obstructed labour associated with the smaller African pelvis (and which causes such a toll of vesico-vaginal fistula and other complications in Africa).

South Asians on the other hand have the smallest babies and a correspondingly higher PNMR at all gestations. The birth weights of their babies are lower than those of all the other groups at the same gestational ages, even allowing for the smaller weights of the mothers. This genetic variation has probably evolved to take account of smaller South Asian pelvises to prevent obstructed labour, a potentially lethal complication which African mothers avoid by delivering earlier. Unfortunately, this genetically determined intrauterine growth restriction has the known disadvantage that it leads to a higher incidence among adults of diabetes, coronary artery disease, and hypertension, all prevalent conditions on the Indian subcontinent.

While analysis of the gestation-specific PMRs by racial group would indicate the need for induction of labour of white European women at about 42 weeks, we feel that induction should be considered for black African women at 41 weeks and for South Asian women at 40 weeks. Irrespective of whether these PNMRs have social or biological causes, our management should be appropriate.

We believe that these are genuine genetic racial differences, and to ignore them and apply inappropriate management strategies designed to suit white European women will disadvantage these racial minority groups, and is therefore discriminatory7.

References.

1 Allen MC, Alexander GR, Tompkins ME, Hulsey TC. Racial differences in temporal changes in newborn viability and survival by gestational age. Paediatr.Perinat.Epidemiol. 2000; 14:152-8.

2. Luke B,.Brown MB. The changing risk of infant mortality by gestation, plurality, and race: 1989-1991 versus 1999-2001. Pediatrics. 2006; 118:2488-97.

3. Robillard PY, Hulsey TC, Alexander GR, Sergent MP, de Caunes F, Papiernik E. Hyaline membrane disease in black newborns: does fetal lung maturation occur earlier? Europ J Obstet Gynecol Reprod Biol 1994; 55:157-61.

4. Berman S, Richardson DK, Cohen AP, Pursley DM, Lieberman E. Relationship of race and severity of neonatal illness. Am J Obstet Gynecol 2001; 184:668-72.

5. Patel RR, Steer P, Doyle P, Little MP, Elliott P. Does gestation vary by ethnic group? A London-based study of over 122,000 pregnancies with spontaneous onset of labour. Int.J.Epidemiol. 2004; 33:107-13.

6. Steer P. Prematurity or immaturity? BJOG. 2006; 113 Suppl 3: 136-8.

7. Balchin I, Whittaker JC, Patel RR, Lamont RF, Steer PJ. Racial variation in the association between gestational age and perinatal mortality: prospective study. BMJ. 2007; 334:833. Epub

Discussion.

PS: Rather than inducing the labours of women of mixed race early, perhaps we should investigate their genetic background and watch the progress of their pregnancies and the condition of their babies with somewhat more than the usual thoroughness. I believe that ultimately we will be establishing the genetic constitutions of individuals (rather than making assumptions on the basis of ethnic origin) in order to formulate advice and reach management decisions. There is considerable complexity even within ethnic groups; for example in Malaysia, the Chinese have a rate of fetal maturity similar to Western races, while Malaysians and Indians are different from the Chinese and similar to each other. It is also important to realise that in Africa there are significant genetic differences in different parts of that continent; groups of black Africans differ more from one another than do any groups of non-Africans from one another.

NB: In the developing world calendars possibly and ultrasound probably are lacking, so that gestational age is likely to be estimated on assessments retrospectively or by birth weight. Cultural differences and beliefs must be taken into account. When women in Malawi state their belief that pregnancy lasts 10 months, they are probably calculating in lunar not calendar months.

Chair: Dr. Luke Zander, retired general practitioner and founder of the Forum on Maternity and the Newborn, RSM

What do women want?
Beverley Beech, Honorary chair, The Association for Improvements in the Maternity Services (AIMS)

The title of my presentation, 'What do women want?', trivialises the huge range of problems with which we in AIMS are faced, by using the language of consumerism. The language of birth is about relationships, health, wellbeing, support and nurturing. Our maternity services should be the best possible, and should raise women's expectations rather than the reverse. A study of the advantages and risks of home birth as contemplated by mothers and the medical and midwifery professions shows how current obstetric practice can disempower and harm women emotionally, spiritually and physically (Nadine Edwards: Birthing autonomy). Society trivialises the impact and importance of birth; a television interviewer inquired about the concerns of the chattering classes, despite the same programme having told us that the concerns of the least articulate are identical with those of the well heeled and well educated. In AIMS we have learned that there is no difference in what women want by social class, but that there is a considerable difference in their understanding of the issues and their rights. The phrase "Am I allowed....?" introduces the most frequently asked questions from pregnant women; they need to understand that it is their body and their baby, and that the doctors and midwives exist to advise them. All too often the professionals use the language of permission: “We do not allow home birth”; “You must have the obstetrician's permission for a water birth”. This is not the language of partnership.

AIMS has found that most satisfaction questionnaires are superficial; they may elicit approval, but deeper discussion almost invariably reveals reservations. Birth plans are frequently not followed, and there is suspicion that they are the cause of irritation in the labour ward, resulting in lack of support and a higher incidence of interventions (Jones, 1998). Hospital generated birth plans offer options selected to suit the staff: acceleration of a slow labour by rupture of the membranes; choosing to have a partial shave, an enema, or an episiotomy (this was historical, but it exemplifies the principle). Women tend to accept that beliefs held by the professionals must be best practice (Porter & Macintyre 1984). They have no means of evaluating the high-technology births which they are offered; unquestioned, this has led to an increase in delivery by caesarean section (CS) from 9.6% in 1977 to the current 23%.

The media invariably focus attention on sensational headlines such as "Too posh to push", which headed an article implying that the rising rate of CS is due to the preferences of women, whereas fewer than 1% of our enquiries relating to CS are from women wanting it on demand. Among these very few some may have had a previous bad birth experience or may know someone who has, some who have been told "Once a CS always a CS", others convinced that they need the procedure because of breech presentation or twins, and those who wish to avoid damage to their genital tracts or to their sex lives. These are far outnumbered by women anxious to avoid CS, a procedure which seems straightforward to the professionals, but which has long-lasting effects for many women.

From their standpoint of ignorance women only know what they want when they have had ideal care, and want that again. There is evidence that the greatest satisfaction follows the least intervention (Jo Green et al. 1998). Consent is not "informed" unless full information has been given and understood; the cascade of interventions leading to CS is rarely advertised by obstetricians and midwives, and it is for this and many other reasons that AIMS publishes a range of informative books and leaflets. Women who avoid taking over-the-counter medication will accept epidural analgesia and drugs during labour without question, and without information on their possible adverse effects, yet those who want water births or want the relief of being in water during their labours often meet resistance. That a maternity ward even has a pool may be a well kept secret.

Women are widely unaware that the place of birth can have an important bearing on their achieving the much desired normal birth; when this is replaced by obstetric management the result may be a mother's feeling of guilt. Yet when the cascade of amniotomy, oxytocin infusion, epidural and episiotomy are followed by a spontaneous vaginal birth this will be recorded as normal in the medical record. It is not surprising if such a "normal birth" leads to disappointment and discouragement, but women can be reassured that there are ways in which truly normal birth can be achieved.

In a prospective study (Downe 2001) it was shown that only one first baby in six was born normally – entirely free of interventions; the figure for subsequent babies was one in three. Hospitals, however, claim at least a 40% normal birth rate. The risks of home birth are commonly detailed, the risks of hospital birth rarely if ever. "In antenatal care they make you anxious, and then try to reassure you." In seeking out and relying upon risk the medical model undermines women's confidence in their ability to give birth, made worse by leaving her alone with her partner for long periods in an unfamiliar place, and by putting pressure upon her to perform within a limited time period attended by midwives and doctors overworked because of staff shortages; this is a recipe for problems. Under such conditions midwives lose the social skills of care, and these are replaced by protocols, a system of care by tick boxes.

Small free-standing midwifery units, community-based midwifery teams, and caseload midwifery all enhance midwives' practice, improve their skills, reduce the need for CS, and give mothers and babies a good start in health. This responds to women's needs to be cared for by someone they know and trust, someone with whom they can develop a relationship, hardly possible when dealing with a large team. Obstetricians then become free to focus on and provide individualised care for the high risk mothers who most need it. At present our midwifery services are falling short of these requirements.

References:

Jones MH, Barik S, Mangune HH et al (1998). Do birth plans adversely affect the outcome of labour? British Journal of Midwifery, 6:1 38-41.

Porter M and MacIntyre S (1984). What is must be best: a research note on conservative or deferential responses to antenatal care provision. Social Science of Medicine, 9:11 1197-

Green J M, Coupland Va A, Kitzinger J V (1998). Great Expectations - A prospective study of women's expectations and experiences of childbirth, Books for Midwives Press, ISBN 1 898507 58 9

Downe S, McCormick and Beech BAL (2001). Labour interventions associated with normal birth. British Journal of Midwifery, 9:10 602-606.

An alternative birth - risk versus choice?
Dr Amali Lokugamage (AL), Consultant Obstetrician & Gynaecologist, Whittington Hospital NHS Trust, London

Being from Sri Lanka I have a keen interest in working with women in developing countries; I have trained in homoeopathy and acupuncture, use meditation, and have become used to translating the meaning and values of seemingly divergent medical paradigms to disparate groups of people. Here I shall address the fulfilment of birth across cultures.

Whereas midwives take an optimistic view of the outcome of pregnancy and birth, the medical model is always mindful of risk, concerned more with pathology than with physiology. Only after a good outcome will obstetricians classify the pregnancy as low risk. The Department of Health's National Service Framework for Women, Young People and Children has a familiar and praiseworthy vision, but doctors can be perplexed by women's choices, and being fearful of litigation place safety before comfort. They know that they and the maternity service are liable to bear the brunt not only of their misjudgments but of those of mothers themselves. Feeling the need to pre-empt poor outcomes we use risk as the systematic approach to dealing with the hazards and insecurities introduced by modernisation itself.

Childbirth activists criticise the over-medicalisation of birth, and in America this has been taken by some to the extreme of recommending unattended birth, with its unknown and unexpected dangers. Science uses epidemiology to navigate risk in medicine and to then make recommendations about safe practice, but it has its limitations. The epidemiology of risk relies on randomised controlled trials and evidence-based medicine, but these are herd measurements; the study of complex processes and complex interventions such as those seen in childbirth cannot always be assessed adequately with randomized controlled double blind trials. New advances in genetic epidemiology will soon guide us to the need to tailor necessary interventions according to genetic variations, requiring more personalized protocols in medicine. Individual genetic variation may limit the generalisability of clinical guidelines and protocols.

The holistic approach of Chinese medicine is sometimes interwoven into my diagnoses and treatments; this is the mind-body attitude, looking at the flow of energy and searching out disharmonies. The central tenet of this and other complementary forms of medicine is to recommend interventions leading to homoeostasis, balancing auto-regulatory mechanisms (Yin and Yang), to promote self-healing at organ level and emotional and social levels.

Healing is viewed differently across cultures and in different sectors of health care. It is not the same thing for practitioner and patient. So all explanatory models of health care, including those of modern professional medicine and psychiatry, are culture-laden and freighted with particular social interests. And so is our present understanding of healing. (Professor Arthur Kleinman 1981).

Natural birth is a bedrock of society, conferring huge health economic benefits and reducing postnatal psychological morbidity. Among its other advantages are that breast feeding rates are higher. Breast-feeding is linked to a reduction in population obesity and may thus have an effect on hypertensive disease in the population; it is also associated with a lower incidence of breast cancer. There is good evidence that reducing fear and anxiety in labour allows a more efficient process by an effect on the body's catecholamines; drug-free interventions such as the continuing presence of an experienced midwife, doula or other carer, and other interventions such as hypnotherapy, yoga and acupuncture promote a reduction in anxiety.

Science and maternal choice have to talk to each other despite having some divergent views. They need to walk a common path. Hence both sides need to work towards improving the experience of women going through pregnancy and childbirth. This means lobbying for the resources required to deliver patient choice.

Reference:

Kleinman A. (1981) Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Berkeley, Calif: University of California Press.

Discussion.

A consultant obstetrician: In our culture normal labour may be so defined by outcome, and prove to have been natural. What we term natural, with no possibility of intervention, can if rarely be a horrifying experience for the mother, with a disastrous outcome. He further reflected that independent midwives are now facing prohibitively high premiums for negligence insurance; this is due to the tension between society's wish for natural birth and its intolerance of risk and failure. BB: Mothers whose labours have been subjected to any number of interventions, but which end with spontaneous vaginal birth, are told that their labours have been normal; they can no longer accept this definition.

A former obstetrician, a mother who has experienced intra-uterine death and the birth of twins: What women want is a good outcome, and most women will accept any intervention which achieves this. To indoctrinate women in the belief that the only good birth is one achieved without interventions, not unusual now in western society, must be wrong. (This was greeted with applause).

A former research officer of AIMS: Most of the many women who come to us have had a bad experience in their first labours, although these may have been termed normal. They hope to achieve intervention-free labours - what they would regard as normal. Sadly a substantial number are suffering from post-traumatic stress disorder (PTSD) as a result of that first experience. Some of them, denied the option of birth at home, are seriously considering unattended labour.

An obstetrician "working in an impoverished hospital trust" which has a birthing unit for women who hope for labours without intervention, and which is provided with pools for water birth, expressed scepticism about the 'natural' status of water birth and its value.

A delegate expressed concern over the perceived stigma and the guilt felt by women who have been unable to achieve normal birth. A midwife was applauded when she remarked that women who felt that they had been in control of their choices, and that they had been in the right place at the right time, accepted necessary interventions happily. Women want both satisfaction and safety.

A doula chose the role for herself following her first labour in hospital, which she perceived as seriously mishandled, leading to the cycle of intervention which culminated in epidural analgesia and caesarean section; she vehemently expressed the feeling of having been robbed of a process of which her body had been capable.

A midwife made a plea for more government funding for the many more midwife posts which are needed to support caseload midwifery.

AL joined in the plea for more funding, but hopes that there may yet be a meeting of minds between the maternity activists and the obstetric professionals. A liberal attitude to choice in NHS trusts is highly valued by mothers and healthcare workers alike.

BB: Women whose birth experiences have led to postnatal depression or PTSD often internalise their feelings and are unable to express them for two or three years. Then they may come to us at AIMS. Reference has been made to the guilt some women feel following difficult labours; this is commonly relieved when they come and express their anger over the mismanagement of their labours of which they were well aware. Women themselves discovered the relief from pain in labour afforded by water, and it is extraordinary how difficult the acceptance of water birth has been when compared with the ready uptake of epidurals.

The chair: It was apparent to me in general practice that there is little experiential content in disease. We must recognise the difference between obstetrics, the medical care of a process, and pregnancy, which is a life experience. Outcomes in obstetrics are often measured by the yardstick of the cemetery, by mortality statistics. We need a dialogue of understanding between the providers and the receivers of maternity care, clarifying an acceptable balance between risk and benefit, with satisfaction always a part of the equation.
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