Evidence-Based Maternity Care: What It Is and What It Can Achieve
By Carol Sakala and Maureen P. Corry
As midwives, we strive to give the best possible care to our moms and babies. Ideally that care should be based on evidence rather than opinion, what is convenient, or what is more lucrative. Evidence-based maternity care is determined by the systematic review of the best available research to ascertain which practices are effective, least invasive, and most likely to cause limited or no harm to expectant mothers and their infants. This report addresses physiologic maternity care; maternity practices which are overused in modern maternity care, but which expose mothers and babies to rosk of harm while contributing little or no benefit; and maternity practices which are effective, but underused in current maternity practice. The report also addresses the financial impact of today’s maternity care as well as that of evidence-based maternity care.
Physiologic maternity care provides both short term and long term benefits to mothers and babies. Such care cooperates with how the mothers’ and babies’ bodies work throughout the childbearing cycle and facilitates the process of labor, birth and establishment of breastfeeding. Any interruption of these natural processes can be justified only if the practice is shown to do more good than harm. Midwives generally provide a physiologic approach to maternity care, with attending benefits for moms and babies. Long term benefits of physiologic maternity care include avoiding the risk of harm resulting from medical interventions used during the perinatal period.
Overused interventions in maternity care today include induction of labor (41%, medically attempted), epidural analgesia (76%), and cesarean section (32%), based on a 2005 survey of hospital births, Listening to Mothers II. These interventions have increased greatly in recent years and while appropriate in a small percentage of births, should not be used in large numbers of birthing women because they are associated with increased risk to moms and babies. Women have the right to make an informed decision regarding such interventions, based on their safety and effectiveness in addition to the individual circumstances. Other overused interventions are continuous fetal monitoring (71%), rupture of membranes (65%), episiotomy (25%) and a number or routine prenatal care practices. Johnson and Daviss (2005 study) cite the rate of such interventions in CPM managed births as the benchmark “for what the majority of childbearing women and babies who are in good health might achieve.”
Underused interventions are generally noninvasive, effective and have no known or minor risk of harm to mother and infant, and as such, are appropriate for general use. These include use of prenatal vitamins and stopping smoking in pregnancy, ginger for nausea and vomiting, methods to avoid preterm birth, external version, continuous labor support, noninvasive methods of pain relief in labor, delayed and spontaneous pushing, pushing in a position other than lying on the back, delayed cord clamping, early skin-to-skin contact, assisting in breastfeeding initiation and duration, and others. The financial impact on families of such care is minimal, with many incurring little or no cost. Evidence for VBAC is also presented.
Currently, the care of birthing mothers and their newborns is the most common reason for hospitalization today, with a price tag far greater than for any other single hospital condition. Overused interventions greatly increase the cost of maternity care while exposing mothers and babies to increased risk with little or no benefit. Conversely, underused interventions cost much less and convey benefits with minor or no risk to mothers and babies.
Barriers to implementing evidence-based maternity care revolve around financial considerations, specialist orientation for care of most low risk mothers, opinion-based care as the “usual pattern” of maternity care, loss or lack of professional knowledge and skills for physiologic maternity care (due to limited exposure), and quite a number of other factors.
In conclusion, I found Evidence-Based Maternity Care a very useful resource and definitely worth the read. Because the publication contains so much information, I have presented the high points only. The entire text of Evidence-Based Maternity Care: What It Is and What It Can Achieve, by Carol Sakala and Maureen P. Corry (the 2008 Milbank Report) may be downloaded at http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf.
Article review by Merrilyn Reeves, LM, CPM