Imagine for just one moment that we were to see the introduction of standardised oncology treatment. If every patient that was diagnosed with some type of cancer was given the exact same care, the same drugs, the same surgery, the whole lot. Would you expect to see see a rapid improvement in cancer survival rates, or the exact opposite?
Now stop imagining things and absorb this one statement:
Standardised care is actually the reality for pregnant women and their babies in modern maternity care.
Hospitals are busy places with hundreds of patients coming and going daily. The logistics of providing the safest service to all those people is hard to comprehend. Everything from the emergency department, all the wards, different departments, staffing, sterilising equipment, to changing the sheets, and feeding everyone, needs to be organised. It’s an enormous undertaking. The best way to do it, or so modern belief systems hold, is to centralise it all.
Maternity care is a large part of what many hospitals do. Making it work efficiently must have seemed like quite an achievement way back in the day when women left their village midwives in droves and headed to hospital. At this point in history around 99% of women give birth in hospital, and millions of babies are born in hospitals every day.
Hospitals have a job to do! The customer service dilemma of maternity care means that they need to provide a standardised care plan to each pregnant woman. In some instances this can work out, but in others it is proving to be a disaster. Women and babies can not be standardised, they are each unique. Each woman presents with a different body and different health, each baby develops at a different pace.
Take for example, the routine induction of labour in women who go past a certain gestation. Every human baby will develop their teeth, the ability to walk, and talk, at a different age. Some might be born with a tooth, some might be gummy at nine or ten months. Neither is a problem. They are both perfectly normal variations of infant development. However when we assume that each and every human baby is ready to be born because their mother is forty-one weeks and two days into pregnancy, we start running into problems.
It is absolutely impossible to guess which babies will be allergic to peanuts. Or if we go back to our cancer analogy, which patient will tolerate chemotherapy well, and who will suffer terribly. It’s equally impossible to know which woman and baby will have a smooth induction, and which pair will end up having an emergency caesarean for foetal distress after hours of exposure to synthetic hormones.
Induction is just one example of how standardising maternity care is creating unsafe birth conditions for women and babies though. There are countless other tests and interventions in pregnancy and labour that, when used routinely, do not improve safety. They make the organisation of large institutions easy, they may give some women the idea that they are being kept safe by the expert use of technology, but they are actually not always linked to significant improvements in safety.
Comparing maternal mortality from 1970 – 2014 with the caesarean rates from the corresponding years, we can see this in action. Between 1970 and 2014 we can see that the caesarean rate went from 5.5% to 32.2%. With that increase, we would expect to see a decrease in maternal death. If hospitals were providing safe maternity care, that would be the natural result of increasing caesarean rates. However what we see is something quite different. The maternal mortality rate from 1970 was 21.5 , and in 2014, despite having dropped to 12 per 100,000 in 1990, the maternal mortality rate hit 28 per 100,000.
What about the stillbirth rate?
On the surface it may appear that the increase in technology and standardised maternity care between 1970 and 2014 had contributed to a decrease in stillbirths, but we need to remember that correlation does not equal causation.
In his well known essay Fish Can’t See Water, Marsden Wagner explains that as follows:
“The slight fall in the perinatal mortality rate the past 10 years in these countries is due, not to any fall in foetal mortality, but only to a slight improvement in neonatal mortality associated with neonatal intensive care and not with obstetric care. In highly developed countries, all attempts to show lower perinatal mortality rates with higher obstetric intervention rates have failed.”
This theory makes a lot of sense. Neonatal intensive care units can do truly remarkable things now. In 1970 we could never have imagined it, but neonatal care is entirely separate to obstetrics.
Now let’s go back to imagining things
Your mother is diagnosed with cancer. The doctor says that they can’t do any scans or blood tests until she has had the symptoms for a twelve weeks. Twelve weeks after the scans they’ll do six weeks of chemotherapy, followed by surgery, followed by four doses of radiation, and everything will be roses. No one has even LOOKED at her tumour yet …. but they have this plan of attack ready! Would you feel confident? or would you feel terrified. Would you think your mother was getting the best available care, or would you think this care plan was insane?
Wouldn’t it be safer for pregnant women and babies if we used testing, scanning, and interventions in labour and birth based on the individual health of women and their babies, rather than on hospital protocols that are designed to make the hospital operate efficiently?
For cancer treatment to be even remotely successful it requires highly tailored, individualised care plans and swift action. Birth isn’t remotely comparable to cancer though, because it’s a normal physiological part of a woman’s life. Pregnancy is the ultimate sign of health, not a potential death sentence like cancer, and yet pregnant women receive far too much unnecessary testing and labour intervention. Conversely they don’t receive enough, support, comfort and unbiased information.
The time has come for maternity care providers to move through this phase of efficient, standardised, conveyer-belt style care, and into personalised care. This would have multiple benefits. It would save huge amounts of money, because healthy women and babies would no longer be undergoing unnecessary procedures and testing, and it would free up time for the very small number of women and babies who actually require the support of modern obstetrics. If we wouldn’t accept oncology care being standardised, there’s no reason for women to accept standardised maternity care.