Friday, October 05, 2012

Optimal Care in Childbirth

I'm really excited to review Henci Goer and Amy Romano's new book Optimal Care in Childbirth: The Case For a Physiological Approach. In fact, I've put off writing about some other exciting developments in order to finish this review.

I've read through the whole book once and skimmed through many chapters a second time. That's no small feat, considering the book is a hefty 583 pages with small font.

Optimal Care in Childbirth is an outgrowth of Goer's two earlier books that made sense of maternity care research and obstetric practices: Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (1995) and The Thinking Woman's Guide to a Better Birth (1999). Henci Goer has been a medical writer, speaker, and consumer educator for the past few decades. Amy Romano is a nurse-midwife with clinical experience in both home and hospital settings. She currently works as a consumer advocate with Childbirth Connection.

So what is Optimal Care in Childbirth about? What does it accomplish? And is it worth the investment? My answer is an unqualified yes. Here's why:

Optimal Care in Childbirth is not simply an updated version of Goer's earlier books. It delves deeper into factors driving maternity care, analyzes an expanded body of research studies, and critiques even more forcefully the abundance of poorly designed research and the gap between research and practice  In Goer and Romano's own words, the book examines:
  • why the research shows so little benefit for physiologic care and so little harm from medical-model management
  • what’s behind the cesarean epidemic
  • what the research establishes as optimal care for initiating labor, facilitating labor progress, guarding maternal and fetal safety, birthing the baby, and promoting safety for mother and baby after the birth
  • the true, quantified risks of primary cesarean surgery, planned VBAC versus elective repeat cesarean, instrumental vaginal delivery, and regional analgesia
  • how the organization of the maternity care system adversely impacts care outcomes

The book begins with three introductory chapters. The first explains the impetus for writing the book. Goer and Romano note that while careful use of technology and obstetric intervention can save mothers and babies, injudicious obstetric practices do "considerable physical and psychological harm to mothers and babies." Their book sets out what optimal maternity care--"the least use of medical intervention that will produce the best outcomes given the individual woman's case"--can and should look like.

The second chapter examines the weaknesses of medical research. Although the rise of evidence-based medicine (EBM) is an improvement over the older GOBSAT (Good Old Boys Sat At Table) model of obstetric decision-making,  EBM has several downfalls. The privileging of randomized controlled trials (RCTs) often means that other kinds of studies are dismissed, even though they contribute important information. RCTs themselves are subject to poor design and flawed interpretation, and systematic reviews are no less immune to bias. Finally, EBM has become an almost inescapable dogma that precludes other ways of knowing and discourages individualization of care. Despite these drawbacks, EBM still holds promise for pointing to maternity care strategies that work to promote minimal harm with maximum benefit. Goer and Romano comb through the research literature, summarizing and clarifying what we do and do know know, explaining what works and what does not.

The third chapter gives readers an orientation to the rest of the book. They present their methods upfront, arguing that transparency is the best antidote to bias.

The rest of Optimal Care in Childbirth tackles the evidence and customs behind the following maternity care practices:
  • cesarean sections (including cesarean rates, repeat cesareans, and VBAC)
  • facilitating labor progress (induction, progress of labor)
  • guarding maternal and fetal safety (fetal monitoring, oral intake in labor, epidurals)
  • birthing the baby (second stage practices, instrumental vaginal delivery, fundal pressure, episiotomy)
  • promoting safety for mother and baby after the birth (third-stage management, newborn practices)
  • optimal practices for a maternity care system (supportive care in labor, midwife-led care, birth centers, and home birth)

Each chapter begins with an analytical essay explaining the historical and cultural influences behind the obstetric practice in question. The essays then summarize the evidence and examine how far evidence strays from practice. These essays are lively, impassioned, and wonderfully humane in tone. One would expect a book summarizing and interpreting medical evidence to be dry reading, but these essays are refreshingly enjoyable. Biting wit and humor intermix with thoughtful analysis and provocative questions.

Following the essays, Goer and Romano provide a concise list of strategies for optimal care based on the evidence. Here's an example of optimal care strategies from the chapter on second stage (pushing) practices:
The following strategies facilitate a physiologic second stage, maximize the chance of spontaneous birth, and minimize the chance of genital, perineal, or pelvic floor injury:
  • Encourage non-supine positions. 
  • Avoid interventions that restrict movement and position-changes. 
  • Make physical props available and encourage position-changes, enlisting labor companions to assist with support, encouragement, and mobility as needed. 
  • Encourage women to follow their spontaneous pushing urges. Discourage prolonged breath-holding. 
  • If coaching seems prudent, suggest open-glottis techniques rather than prolonged breath-holding. 
  • In women laboring with epidural analgesia, await a spontaneous bearing down urge before beginning active pushing efforts. Encourage open-glottis pushing when the urge develops. 
  • Use a supportive and encouraging communication style to promote the woman's sense of safety and wellbeing and diminish her fears. 
  • Guide the laboring woman in birthing the baby's head gently between contractions.

Finally, each chapter ends with several mini-reviews of the available research. The reviews carefully note inclusion/exclusion criteria, study design and limitations. and clarifying information. The mini-reviews are where you can really dig deeply into the research evidence. Mini reviews are numbered and organized by topic.

I was struck by how difficult it is to design studies that capture the nuances of an intricate physiological process. Despite mountains of research, very few studies measure more than one small element at a time. That is the nature of medical research, but it works poorly for understanding the complex, interconnected nature of human labor and birth. Too often, a study's design guarantees that very little difference will be found between the "control" (usually an intervention) and the "intervention" (sometimes another intervention, other times a physiologic practice such as oral hydration or walking during labor). Isolating one small practice while keeping the overall package of care unchanged usually shows minimal results.

I was amazed at how much information Goer and Romano were able to glean, despite the limitations of obstetric research. Overwhelmingly, the evidence points to the value of doing less--or rather, the value of understanding and supporting the physiological process so that labor and birth can unfold without undue complication or interference. It's not that obstetric technology has no place; it's just that most of the time, that technology could be safely replaced with patience, respect, careful observation, and following the woman's lead. In order to shift to this style of maternity care, we need studies that examine not just one small change at a time, but that compare entire packages or systems of care. Ambulation during labor in a conservative hospital environment might make little difference in the course of a woman's labor. Ambulation in a care setting that encourages mobility, provides a full range of non-pharmaceutical pain relief options, upholds maternal preference and autonomy whenever possible, and discourages routine use of technology is another story.

Optimal Care in Childbirth is a book we cannot do without. Imagine if every maternity care facility--from the busiest tertiary hospital to the smallest home birth practice--adopted all of the strategies for optimal care set out in Goer's and Romano's book. We would have a maternity care system that supports the wants and needs of laboring women, no matter their location or their individual health profile. We would have a system that delivers optimal care--promoting the physiological processes whenever possible and providing obstetric interventions judiciously and appropriately. We would have a system that uses fewer resources, leads to fewer physical and psychological complications, and has healthier, more confident, more satisfied mothers.

Optimal Care in Childbirth is available at and retails for $50. The authors have offered Stand and Deliver readers a special 15% discount and free domestic shipping through October 31st. Use coupon code MOQLM3W8. Also available on Amazon.

Disclosure note: Goer and Romano provided me with a review copy and invited me to participate in a referral program.


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