Dear Henci Goer,

 

in Slovenia we are in the middle of public discussion about reorganization of the whole maternity care system with gynecological care for healthy women included. Group of different health care professional produce problematic document, Ministry of Health praise it, and in six weeks anybody can comment it.

 

As the representative of only non-governmental organization dedicated to improve conditions of becoming mother I’m kindly asking for clarification.

 

They insist that maternity unit with less than 1000 births per year is potentially dangerous because doctors and midwives don’t have enough experiences to recognize rare complications and are not skilled enough to help when CS, vaginal breech delivery is needed. So they say that the criteria for maternity unit is: more than 1000 birth per year (and something like 3-4 CS per week, 1-2 vacuum extraction per week, 1-2 breech and twins per fourteen days) – in such circumstances, they say, health professionals would have enough skills and experiences. And maternity units with less than 1000 births per year should be closed.

 

They say that with fewer procedures per year per hospital we put future mothers and their babies into danger – in small maternity units health professionals slowly lose their ability to recognize complication and to answer properly.

 

I think the first problem is to take procedures of maternity unit and not procedures of individual doctors. In the same hospital some of them are having more CS then others, the same for breech babies.

 

(In Slovenia we have some doctors and midwives who suggest vaginal birth if everything else is OK with mother and baby ... and some who suggest CS in advance – I know about scientific data about breech birth.)

 

What is the proper solution to enable the particular doctor in the maternity unit to be ready as a professional to recognized complication and to react on it in the best way? Is there really any scientific data about how many procedures per year (CS, vacuum extractions) doctor need to stay in excellent form?  What about sending them on regular training (once per year ... or something like that) into the tertiary hospital where there are women with high/er risk to practice ... or?

 

This is very important for our goal: we would like to help with establishing first freestanding midwifery birth center in Slovenia and we are working towards circumstances for home births, too. And of course we would like to have good maternity units/hospitals with doctors to help with CS and other procedures when needed ...  in reasonable radium. If the small maternity units are closed, there will be a problem with finding good location for birth center(s); and this would be also problem of background for home births. With centralization of maternity units - on the grounds of safety – we will lose an opportunity to broaden the choices of women to deliver at home, in birth center(s) or in hospital; we’ll be limited to the proximity of big centers.

 

So, maybe you can help me with your opinion.

And thank you in advance.

 

 

Best wishes,

 

Zofka,

 

Society Natural Beginnings www.mamazofa.org

 

Here are some basic data about Slovenian maternity system:

 

Slovenia: 21.856 babies born in the year 2009

Perinatal mortality for 2004 was 7,4/1000 births (for babies with birth weight over 1000 g 4,6/1000 births

maternal mortality (0-4 women per year):

1998-2001 12,5 /100.000 live babies

2000-2002 15,1/100.000 live babies

fourteen maternity hospitals, no birth centres, no official professional help available for home births, no autonomous midwifery practice

CS around 18-20%, very medicalized birth in general (enema and shaving still in use, active birth management with inductions and augmentation, women mostly lying in bed during labour and birth, episiotomy – half of vaginal births … etc) with some attempts to humanise it (13 of 14 maternity hospitals are Baby Friendly).

 

 

 

 

I'm going to see if my co-author on the new edition of Obstetric Myths Versus Research Realities will comment further because she took the lead on the chapters on midwifery, birth centers, and home birth. The short version, though, is as follows:

• Midwifery-led care produces the best outcomes: Midwifery-led care is care where the midwife is the primary careprovider for pregnant women and works independently--as opposed to under supervision of physicians. In this model, she makes the decision to consult, collaborate, or transfer care to the obstetrician-gynecologist based on the individual case.
• An integrated maternity care system produces the best outcomes: This is a system where low-risk women receive low-tech, high-touch care within their communities, i.e. care from midwives trained in normal birth care, a separate body of knowledge and skills that obstetrician-gynecologists lack, at home, birth centers, or small maternity hospitals, and high-risk women can be transferred to institutions capable of meeting their needs, whidh is high-tech care without losing the high-touch component. The problem with delivering care to all women in high-risk institutions is it leads to overuse of medical intervention, which, as your statistics makes clear, is already the case in Slovenia. As my co-author wrote:

But an optimal system of care must ensure that each woman accesses the “package” of care that will provide the most benefit with the least harm, given her individual circumstances, risk factors, health status, and preferences. In other words, that each woman must receive “the right care in the right place at the right time given by the right people”.¹⁰ The “right” combination of these elements, e.g., the "package" of care, will vary across the population of women receiving care, and may even vary for an individual if her health status changes. So, from a public health perspective, the architects of an optimal system of care must match the maximum number of women to the optimal package of care, and minimize the likelihood that women will get the wrong care, in the wrong place, at the wrong time, or from the wrong provider.  

Have you been in touch with the Royal College of Midwives in the U.K.? I think they could be helpful. The RCM has been working to implement new models of mother/baby centered care. The International MotherBaby Childbirth Organization could be helpful too. 

~ Henci

Zofka,

I am Henci's co-author. I would add to Henci's response that there are some established programs that are designed to keep clinicians skilled in managing complications even in low-volume maternity care settings. There is a list of such programs, with links, on this page: http://childbirthconnection.org/article.asp?ck=10262&ClickedLink=184&area=2#courses

I also strongly recommend this article: http://www.ncbi.nlm.nih.gov/pubmed/11978210 The article looks at the population-based outcomes of a region where low-risk women gave birth in a maternity unit without cesarean capability and high-risk women gave birth in a centralized hospital.  They looked specifically at whether lack of cesarean capability contributed to any bad outcomes and found that it did not.

Another consideration is that closing maternity units means that the average woman will live farther from a birth setting, increasing the chance that women will have unplanned home births or give birth en route to the hospital, which could have the effect of creating worse outcomes. Here is an excerpt from the book that addresses this concern:

However, two studies provide indirect evidence that, in the absence of a community-based facility, considerable numbers of women would give birth en route to hospitals or would have unplanned or unassisted home births, both of which increase the risk of poor outcomes. In addition to the 999 women who gave birth as intended in maternity homes in Norway, an additional 218 women who planned hospital births gave birth in the maternity homes because rapid labor progress or difficult weather conditions made travel to the hospital unsafe (Schmidt 2002)... Leeman and Leeman (2002) do not specify how many unplanned births took place at the rural maternity unit they studied, but they describe a case of a woman with placental abruption who, despite plans to give birth at the referral hospital because of a history of prior cesarean surgery, presented to the maternity unit with vaginal bleeding. She was urgently transported and had a precipitous vaginal birth soon after arrival at the referral hospital. Despite low Apgars, a neonatal seizure and evidence of intracranial bleeding, the infant had normal neurologic and developmental evaluations at 15 months. It is possible that presenting to the maternity unit instead of going directly to the hospital delayed the woman’s access to emergency obstetric care. However it is perhaps more likely that prompt diagnosis and ready access to urgent transport at the community-based maternity unit averted a worse outcome by helping the woman reach the hospital prior to birth, where her infant could then receive immediate intensive care.

Best wishes in your advocacy.

Amy