"Evidence-Based Maternity Care: What It Is and What It Can Achieve," co-authored by Carol Sakala and Maureen P. Corry of the nonprofit Childbirth Connection analyzed hundreds of the most recent studies and systematic reviews of maternity care. The 70-page report was issued collaboratively by Childbirth Connection, the Reforming States Group (a voluntary association of state-level health policymakers), and Milbank Memorial Fund, and released on Oct. 8, 2008.
Overuse of high-tech measures
The report found that, in the U.S., too many healthy women with low-risk pregnancies are being routinely subjected to high-tech or invasive interventions that should be reserved for higher-risk pregnancies. Such measures include:
- Inducing labor. The percentage of women whose labor was induced more than doubled between 1990 and 2005
- Use of epidural painkillers, which might cause adverse effects, including rapid fetal heart rate and poor performance on newborn assessment tests
- Delivery by Caesarean section, which is estimated to account for one-third of all U.S births in 2008, will far exceed the World Health Organization's recommended national rate of 5 to 10 percent
- Electronic fetal monitoring, unnecessarily adding to delivery costs
- Rupturing membranes ("breaking the waters"), intending to hasten onset of labor
- Episiotomy, which is often unnecessary
In fact, the current style of maternity care is so procedure-intensive that 6 of the 15 most common hospital procedures used in the entire U.S. are related to childbirth. Although most childbearing women in this country are healthy and at low risk for childbirth complications, national surveys reveal that essentially all women who give birth in U.S. hospitals have high rates of use of complex interventions, with risks of adverse effects.
The reasons for this overuse might have more to do with profit and liability issues than with optimal care, the report points out. Hospitals and care providers can increase their insurance reimbursements by administering costly high-tech interventions rather than just watching, waiting, and shepherding the natural process of childbirth.
Convenience for health care workers and patients might be another factor. Naturally occurring labor is not limited to typical working hours. Evidence also shows that a disproportionate amount of tech-driven interventions like Caesarean sections occur during weekday "business hours," rather than at night, on weekends, or on holidays.
Underuse of high-touch, noninvasive measures
Many practices that have been proven effective and do little to no harm are underused in today's maternity care for healthy low-risk women. They include:
- Prenatal vitamins
- Use of midwife or family physician
- Continuous presence of a companion for the mother during labor
- Upright and side-lying positions during labor and delivery, which are associated with less severe pain than lying down on one's back
- Vaginal birth (VBAC) for most women who have had a previous Caesarean section
- Early mother-baby skin-to-skin contact
The study suggests that those and other low-cost, beneficial practices are not routinely practiced for several reasons, including limited scope for economic gain, lack of national standards to measure providers' performance, and a medical tradition that doesn't prioritize the measurement of adverse effects, or take them into account.
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