The practices of birth attendants and the safety of birth

MIDWIFERY, 1986, 2, 3-10 © Longman Group I986

The practices of birth attendants and the safety of birth Marjorie Tew

M o d e r n m a t e r n i t y services are organised on the a s s u m p t i o n t h a t birth is m a d e safer b y the use o f obstetric i n t e r v e n t i o n s b a s e d on a d v a n c e s in science a n d technology. W h e n results are i m p a r t i a l l y analysed, however, it is consistently found t h a t on b a l a n c e b i r t h is m a d e less safe b y the i n d i s c r i m i n a t e use o f even these sophisticated interferences w i t h the n a t u r a l process, just as it was in the past b y their p r i m i t i v e predecessors. T h e safety o f b i r t h d e p e n d s p r i m a r i l y on the h e a l t h status o f the p a r e n t s a n d is m o s t likely to be i m p r o v e d b y m a t e r n i t y care w h i c h provides a h e a l t h y e n v i r o n m e n t for p r e g n a n c y a n d u n i m p e d e d delivery, reserving i n t e r v e n t i o n s for specific cases o f extreme pathology.

THE ROLE OF BIRTH ATTENDANTS Throughout history there have been many records of women, unattended, giving birth simply and safely. Biologically, this is what the female m a m m a l has evolved to do. But manifestly, women have not always found the process simple and safe and have felt the need for a companion or helper, so that some system for birth attendants has become an integral part of most cultures. Most often these attendants have been mature women, experienced in the practices traditional in their culture but without formal training. Such attendants predominate in the less developed countries today and did so in the more developed countries before the 20th century. Till then relatively few midwives were trained, but their

Marjorie Tew, 121 Bramcote Lane Wollaton Nottingham NG8 2NJ Manuscript accepted 17th Sept. 1985

training was largely based on mistaken conceptions about the anatomy, physiology and pathology of reproduction. The education of doctors in the process of normal childbirth was similarly illfounded, but their surgical skills were developed and invoked when complications arose. In the last 50 years medical knowledge has widened apace. The training of doctors and midwives has become longer, more rigorous and sophisticated, with attention increasingly directed to the techniques of obstetrics rather than to the arts of midwifery. Where Western medicine is practised, modern birth attendants are masters of impressive technological skills which encourage them to take an active role in managing the delivery rather than the restrained role of providing watchful support while the natural process takes its course. The purpose and justification for birth attendants, with or without formal training, is to make birth safer for mother and child and so to promote their future health, physical and emotional. There is no doubt that the wise care of attendants can make birth safer, but no doubt also that some of their ministrations can make birth less safe.

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'Pre-scientific' practices and their resu Its The necessity for hygiene was little recognised and less practised in the more developed countries until well into the 20th century and in the less developed countries later still. Though it had been known since the observations of Semmelweis around 1860 that puerperal sepsis could be carried from infected to unaffected women on the insufficiently cleansed hands of attendants, frequently doctors, appropriate antiseptic regimes were not enforced. As a result in England the maternal death rate from puerperal causes remained high until the introduction of the sulphonamide drugs in the 1930s (Registrar General, Annual). The use of unclean instruments to cut the umbilical cord or unclean dressings on the stump can be followed by tetanus, which has persisted as the chief cause of neonatal death in some less developed countries in recent years (Mangay-Maglacas and Pizurki, 1981). A widespread current practice among traditional attendants in less developed countries is the massaging of the mother's abdomen to position the fetus before birth, a practice condemned as harmful by exponents of modern medicine. They would be equally condemnatory of former practices in England. In the 17th century some 'midwives sought "to help" the birth by forcibly stretching the reproductive parts, sometimes tying the reluctant woman to the obstetric chair and in more obstinate cases by tossing her in a blanket, rolling or rocking her, or by other violent measures', not surprisingly with adverse consequences (Donnison, 1977). It was observed that poor country women did best in childbirth and this, according to the celebrated physician of the period, William Harvey, was because 'they more often escaped the "officious" attentions which many midwives thought it their duty to give and in consequence Nature was allowed unimpeded to take her course' (Donnison, 1977). Fortunately these more boisterous interventions later fell into disuse in favour of patient, supportive techniques and, if these failed, passing the buck to male accoucheurs. Originally the latter were called in only to abnormal labours, but increasingly in the 18th

and 19th centuries they were engaged to attend the labours of the more affluent, healthy mothers. They were even more ready to 'help' the birth with surgical interventions, in particular the application, often unnecessary and premature, of forceps. But their interventions did not in fact make the process safer, for a higher maternal death rate was recorded among the well-to-do than among poorer mothers attended by midwives (Donnison; 1977). This perverse outcome, at total variance with the general experience that higher mortality and morbidity are associated with poverty, persisted well into the 20th century. In 1930-32 the maternal death rate was highest in Social Classes I and II, those most likely to be treated by doctors, and lowest in Social Class V, those least likely to have professional attendants of any kind (Ministry of Health, 1937). Following the Midwives Act 1902, trained midwives sent for medical assistance in an increasing proportion of complicated deliveries, but a study of the records of midwives attached to the Queen's Nursing Institute, 1905-25, showed that the maternal death rate rose in step with this increased participation of doctors (Fairbairn, c1930). By 1936 many of the organisations employing salaried midwives, whose patients were often 'overburdened, undernourished, living in insanitary conditions and far from specialist aid' had maternal death rates half or less of the national average (Hansard, 1936). Thus though the natural process of childbirth resulted in many casualties, the evidence was consistently that the obstetric interventions then available resulted in even more. But this evidence was apparently disbelieved or its significance rejected as repugnant to theoretical reasoning, when further developments of the maternity service were organised. This repeated the reaction of an eminent Edinburgh obstetrician in 1870 who disputed the official statistics, which showed that the maternal death rate was far higher in hospital than at home, because they 'led to the absurd conclusion that mortality should be lower for poor women attended by imperfectly educated midwives in filthy dwellings than for well-to-do patients attended by experienced accoucheurs in salubrious conditions' (Duncan, 1870).

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The expansion of the English maternity service after 1900 and its results Because of the public concern that maternal and perinatal death rates had not shared the substantial decline since 1870 of the death rate for the total population, more resources were allocated to the maternity service. Around 1900 nearly all births took place at home, but by 1927 provision had been made for 15% to take place in hospital and by 1937 this proportion had risen to 340/0 . Both the maternal and early neonatal death rates, however, were actually higher in 1935 than they had been in 1921. Then the use of the sulphonamide drugs started a remarkable decline in maternal mortality which continued, influenced also by other factors, to reach a very low level by the 1970s (Registrar General, Annual). By 1950 perinatal mortality had become the more urgent problem. During the war fewer medical facilities were available to the maternity services, but pregnant women were given priority in food rations, together with dietary supplements. The perinatal mortality rate (PNMR) which had fallen by only by 6% between 1931 and 1939, fell by 33% between 1940 and 1948. This impressive rate of decline was not, however, maintained and fell back to only 6% in the first 10 years of the National Health Service, while the proportion of births in hospital continued to increase (Registrar General, Annual).

The increase in hospitalisation after 1950 and its results The description, hospital, was used to cover two types of institution which were not separately distinguished in official statistics until 1969: consultant hospitals where the management of labour is determined by obstetricians though mostly carried out by midwives, and general practitioner maternity units (GPUs) where midwives carry out even more of the deliveries but follow far less interventive regimes, similar to those used in domiciliary midwifery and favoured by the nonspecialist doctors. The policy has always been that pregnancies expected to be at high risk or in

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which complications develop at any stage should be delivered in consultant hospitals. A nationwide survey of perinatal mortality, in the direction of which obstetricians were closely involved, was carried out in 1958 (Butler and Bonham, 1963). The P N M R per 1000 births was found to be lowest for births at home (19.8), but only slightly higher in GPUs (20.3) where the treatment was similar; in contrast it was 2.5 times higher in consultant hospitals (50.0) where by then 49% of births took place. It was assumed that this excess mortality was entirely due to the fact that the hospital births included a greater proportion at higher predicted risk, but no analyses of the data were ever published to justify this assumption. On the contrary, analyses of the limited relevant data that were published indicate that the assumption could not be justified (Tew, 1978, 1985a). The results in fact confirmed the evidence of earlier centuries that mortality is highest where interventions are most used; in other words, that in the majority of cases, obstetric intervention in the natural process makes birth less safe. But as before, the evidence was misinterpreted or ignored. The policy of hospitalisation was intensified to reach 94% by 1981 and the range of interventions extended, so that an ever diminishing proportion of births was accomplished by the unimpeded natural process.

The negative correlation between hospitalisation and perinatal mortality The real consequences of increasing hospitalisation and the obstetric management of childbirth were obscured by the concomitant decreases in perinatal mortality, coincidental trends that were observed not only in England but also in most other countries, including those less developed. It was, and continues to be, widely assumed that the former trend caused the latter, though no attempt was made to justify the assumption with a valid analysis of data. Such an analysis can be carried out of the English data for the years 1969-1981, when consultant hospitals are separately distinguished in the official statistics. This shows that the years when the percentage of births in hospital increased most were the years when the P N M R

Table 1 Trends in perinatal

mortality

and hospitalisation,

Perinatal mortality per 1000 births

Year

Actual

%age change from year before

1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981

23.4 23.5 22.3 21.7 21.0 20.4 19.3 17.7 17.0 15.5 14.7 13.3 11.8

+0.4 -5.1 -2.7 -3.2 -2.9 -5.4 -8.3 -4.0 -8.8 -5.2 -9.5 -11.3

England

& Wales

Births m consultant hospitals

Rank of change

Rank of change

%age change from year before

% of all births

12 7 11 9 10 5 4 8 3 6 2 1

1½ 5 4 3 1½ 6½ 12 6½ 8 9½ 9½ 11

+4.9 +3.6 +4.2 +4.4 +4.9 +1.8 +0.5 +1.8 +1.4 +1.2 +1.2 +0.9

69.6 73.0 75.6 78.8 82.3 86.3 87 9 88.3 89.9 91.2 92.3 93.4 94.2

Source. Registrar General and Birth Statistics

•1969-70

12-

Correlation coefficqent = - 0 . 8 7 (P < 0.001)

11-

•1971-2 01973-4

10-

•1972-3

9-

• 1976-7

87

• 1970 1

0

e1978 9

E 6 _ e-

•1974-5

~5-

e1975-6

4-

e1977-8

3-

e1979-80

2-

O1980-1

1-

I 1

I 2

I 3

I 4

I I I 5 6 7 Hospltahsation

I 8

I 9

I 10

I 11

I 12

Fig. 1. Scattergram of ranks of proportional changes in rates of hospitalisation and perinatal mortality. Rank 1 denotes the greatest increase in hospitalisation and the greatest decrease in perinatal mortality Rank 12 denotes the smallest increase in hospitalisation and the only increase in perinatal mortality. (This figure is taken from Tew M (1986) Do intranatai interventions make birth safer? Trends in Obstetric Interventions and Perinatal Mortality)

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decreased least and vice versa, so that the statistical correlation between the trends is very significantly negative. The statistics are detailed in Table 1 and illustrated in Figure 1 (Tew, 1986). From them it can be inferred with a high degree of confidence that the P M N R would have decreased more if the proportion of births subject to intervention had not increased, or indeed had decreased. The interventions practised in English hospitals after 1969 were far more sophisticated and carried out with far more surgical precision and clinical hygiene than those used in earlier periods, yet their effect has been the same: to make birth less safe than it would otherwise have been. This implies that it is intervention itself, and not simply the quality of it, which increases the danger. I f maternity care had always been the same for all social classes, as it is in England today, mortality among the well-to-do should always have been lower than among the poor, for the basic factor determining safety in childbirth is the health status of the parents, which depends on the standard of living which their wealth or income can sustain. In the more developed and many of the less developed countries, there have been great improvements in the standard of living, and hence in the health status, of an increasing proportion of the population over the years. Consequently, without any medical care, reproduction by healthier parents would have become safer. It could be made even safer by medical care which improves the environment in which pregnancy and delivery take place, in particular, ensuring good diet, hygiene and inspiring confidence. But the evidence is, as it has always been, that it is made less safe by medical care which impedes the natural process.

Births at higher predicted risk Such conclusions, so challenging to conventional doctrine, may be less reluctantly accepted as applying to pregnancies and deliveries without complication, which it is agreed make up over 75% of births in England, but not as applying to the remainder. There may well be specific pathologies where obstetric interventions are life-saving, but evidence based on randomised control

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trials of the effectiveness of particular treatments, if it exists, is hard to find. There is, however, reputable evidence which decisively refutes the claim that obstetric management is the more essential and beneficial the higher the degree of predicted risk at the time of delivery. This evidence comes from the survey of British Births 1970 to which, as to its 1958 predecessor, obstetricians made a major contribution. As an instrument for analysing the data gathered, a Labour Prediction Score (LPS) was constructed. Each birth was given points in relation to its degree of risk in respect of factors, listed in Table 2, which include those arising in the first stage of labour; the sum of the points, or score, represents a measilre of that birth's overall risk. The births could then be classified into sub-groups made up of individual births with the same score the same degree of risk. These sub-groups of births, with the associated deaths, could then be divided according to where the birth took place, so that PNMRs for births at the same level ofpre-delivery risk but subject to different methods of care could fairly be compared. These last detailed data were not published in the Report (Chamberlain et al., 1978) but were released in 1983 to the present author in response to her request (Tew, 1985b). The results are presented in Table 3. They show that as the degree of risk increased, so did the proportion of births in hospital--a finding to be expected from the maternity policy. But a finding not to be expected if the maternity policy were really designed for the benefit of infants is that the Table 2 Labour Prediction Score (LPS)--Singletons Weights given to risk factors

Factor

Low

Risk Moderate

Antenatal prediction score Previous caesarian section

0

1

2 4

Hypertension/toxaemia Antepartum haemorrhage

0

1

2 2

Duration of pregnancy Duration of 1st stage Fetal distress Breech presentation

0 0 0

1 1 1

2 2 2 or 4 4

Source: British Births 1970 vol 2

High

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Table 3 Births and perinatal mortality rates by labour prediction score (LPS) and place of delivery All births Level of risk

LPS

Number

Very low Low Moderate High Very high

0-1 2 3 4-6 7-12

7488 3723 2273 2417 427

% age at each score

PNMR/1000 births

Percent

Hospital

GPU & homer

Hospital

GPU & hornet

45.9 22.8 13.9 14.8 2.6

58.7 68.8 76.6 84.0 96.5

41.3 31.2 23.4 16.0 3.5

8.0 1 7.9 32.2 ~ 53.2 162.6

3.9* 5.2** 3.8*** 15.5"" 133.3

Levels of significance. *p
P N M R was higher in hospital at every level of risk. Moreover, although it was twice as high for births at very low risk, the excess was much greater in the low, m o d e r a t e a n d high risk groups, a n d this excess was very likely to be a thct a n d not a statistical chance. T h e P N M R was greater also in the very high risk group, t h o u g h this m a y be a chance finding due to small numbers, since only 15 of the births were not in hospital. T h e P N M R for high risk births in G P U s a n d home (15.5) was actually slightly lower t h a n for low risk births in hospital (17.9). It is i m p o r t a n t to note that the P N M R s in G P U s and h o m e were h a r d l y different for births at very low, low a n d m o d e r a t e risk, which suggests that the methods o f i n t r a n a t a l care there succeed in overcoming a r a n g e o f predicted risks. In m a r k e d contrast, the P N M R in hospital multiplied as the LPS increased, which suggests that the methods o f i n t r a n a t a l care there intensify the risks. This exemplifies the theory, often expressed b y the F r e n c h obstetrician, Michel O d e n t , that the fetus a l r e a d y at increased risk is least able to withstand the stresses of obstetric interventions. Obstetricians were not m a d e aware of these findings of a c t u a l experience, a n d indeed most continue to be unaware. As in the past, they are personally involved chiefly with deliveries in which complications have developed, n a t u r a l l y or iatrogenically, from which they conclude that n a t u r e unassisted is a p o o r midwife and that the n a t u r a l process, w h e t h e r or not a complication

has arisen, can usually be i m p r o v e d by the use of m a n a g e m e n t techniques, products of advances in science a n d technology. However, the specific techniques were not first evaluated to ensure that they would be a d v a n t a g e o u s in the circumstances in which they c a m e to be used.

Results of specific interventions O n e such aspect of m a n a g e m e n t is i n d u c t i o n of labour. This is u n d e r t a k e n on medical grounds when the greater d a n g e r is believed to lie in the c o n t i n u a t i o n of the p r e g n a n c y , as in p o s t - m a t u r ity, suspected i n t r a - u t e r i n e g r o w t h r e t a r d a t i o n a n d certain m a t e r n a l morbidity. A retrospective study by obstetricians, however, has shown that induction does not reduce the dangers of postm a t u r i t y . A c o m p a r i s o n of 2000 i n d u c e d and spontaneous labours otherwise m a t c h e d led to the conclusion ' t h a t a p r e g n a n c y prolonged after 42 confirmed weeks of gestation m a y affect p e r i n a t a l outcome, b u t i n d u c t i o n of l a b o u r does not i m p r o v e this a n d t h a t u n c o m p l i c a t e d p o s t - m a t u r ity is not an i n d i c a t i o n for induction of l a b o u r ' (Gibbs el al., 1982). T h e present a u t h o r is not a w a r e of a n y valid study which demonstrates that growth r e t a r d e d babies thrive better with intensive p a e d i a t r i c care t h a n in utero, b u t induction has been found to p r o d u c e m a n y babies i m m a t u r e b u t not growth r e t a r d e d (Hall et al., 1980). I n d u c t i o n is also u n d e r t a k e n on n o n - m e d i c a l grounds to suit the convenience of medical staffs or of the mothers. This must have been the reason

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why, in the 1970s, the p r o p o r t i o n of births which were i n d u c e d was not m u c h smaller for those without as for those with ' c o m p l i c a t i o n or anom a l y ' ( M a t e r n i t y Statistics, 1981), or at lowest predicted risk ( C h a m b e r l a i n et al., 1978) and w h y fewer births occur at week ends a n d public holidays (Macfarlane, 1978). T h e i n d u c t i o n rate trebled from 13.4% in 1964 to 39.4% in 1974, r e m a i n e d a r o u n d 37% till 1978, then nearly halved to 18.8% in 1982. T h e official figures do not disclose w h e t h e r all indications shared equally in the early increase a n d the recent decrease, b u t w h a t e v e r the indication comprising it, the years when the induction rate increased most were usually the ones when the P N M R decreased least. This implies that the P N M R would have decreased m o r e than it actually did, if fewer births h a d been induced. Specific studies b y obstetricians support this inference; they have found t h a t the P N M R would not have been r e d u c e d b y an i n d u c t i o n rate above 9.5% (O'Driscoll et al., 1975) or 8 % (Williams and Studd, 1980). T h e r e are biological reasons w h y intervention to induce l a b o u r can increase the need for, or certainly be followed by, further interventions, such as analgesic, including epidural, and anaesthetic, electronic fetal monitoring, forceps delivery and caeasarian section (Yudkin et al., 1979; Inch, 1982), b u t these are u n d e r t a k e n also after the spontaneous onset of labour. Singly or in c o m b i n a t i o n , they too have, to a greater or lesser degree, adverse consequences for the baby, increasing the risk of fetal distress a n d neonatal difficulties in b r e a t h i n g a n d sucking ( C h a m b e r lain et al., 1975). This is reflected in the fact that the negative correlation between the P N M R a n d the rate of hospitalisation, the p r o x y for interventions as a whole, is even stronger t h a n between the P N M R a n d the i n d u c t i o n rate only (Tew, 1986). Studies of w e l l - m a t c h e d groups of women in E n g l a n d a n d also in H o l l a n d have found, not only that obstetric interventions were carried out much m o r e often in the consultant hospital than in the G P U or home, b u t also t h a t complications p r o m p t i n g the interventions were themselves very m u c h m o r e likely to develop in a hospital setting (Klein et al., 1983 D a m s t r a - W i j m e n g a , 1984).

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CONCLUSION Despite the g r e a t changes that have taken place in the q u a l i t y o f interventions, the findings o f recent years have r e p e a t e d those of earlier times:- t h a t l a b o u r is safest when it is least interfered with. T h e evidence is, as it has always been, r e p u g n a n t to the m a j o r i t y of o r t h o d o x obstetricians, but it accords with the experience of the more discerning minority. I f its objective is to serve the interests of its recipients r a t h e r t h a n its providers, the m a t e r n i t y service should be based on a principle that evidence supports. I n the words of e m i n e n t D u t c h and F r e n c h obstetricians, ' . . . t h e ideal obstetrical organisation brings aid to w o m e n and children who need help (the pathological group) a n d protects the h e a l t h y ones against unnecessary interference and human meddlesomeness' (Kloosterman, 1978). T h e key question t o d a y for an obstetrician or midwife is 'how not to disturb the physiology of the birth process' (Odent, 1984).

References Birth Statistics (Annual 1974-81) Office of Population Censuses and Surveys, HMSO, London Butler NR, Bonham D G 1963 Perinatal Mortality. Churchill Livingstone, Edinburgh Chamberlain G, Philipps E, Howlett B, Masters K 1978 British Births 1970 vol 2. Heineman, London Chamberlain R, Chamberlain G, Howlett B, Claireaux A 1975 British Births 1970 vol 1. Heineman, London Damstra-Wijmenga S M I 1984 Home confinement: the positive results in Holland. Journal of the Royal College of General Practitioners 34:425-30 Donnison J 1977 Midwives and Medical Men Heineman, London, pp 11, 12, 32-35, 58 Duncan J M 1870 Mortality of Childbed, quoted by DonnisonJ, op. at, p 94 Fairbairn J S c1930 quoted by Donnison J, op. cit, p 190 Gibbs D M F, Cardozo L D, Studd J W W, Cooper D J 1982 Prolonged pregnancy: is induction of labour indicated? British Journal of Obstetrics and Gynaecology 89, 292 5 Hall M H, Chng P K, Macgillivray I 1980 Is routine antenatal care worth while? Lancet 2, 78-80 Hansard 1936 Fifth Series vot 311 (Commons) cols 111719; quoted by Donnison J, op. cit, p 189 Inch S 1982 Birthrights. Hutchinson, London Klein M, Lloyd I, Redman C, Bull M, Turnbull A C 1983 A comparison of low-risk pregnant women booked for delivery in two systems of care: shared care (consultant) and integrated general practice unit. I. Obstetrica procedures and newborn outcomes and II Labour and

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delivery management and neonatal outcome. British Journal of Obstetrics and Gynaecology, 90:118-22 and 123-8

Kloosterman G J 1978 Organisation of obstetric care in the Netherlands. Ned Tijdschr Genieskunde 1161-71 Macfarlane A 1978 Variations in numbers of births and perinatal mortality by day of week in England and Wales. British Medical Journal, 2:1670-3 Mangay-Maglacas A, Pizurki J 1981 T h e Traditional Birth Attendant in Seven Countries: Case studies in Utilization and Training. W H O Public Health Papers 75 Maternity Statistics (1978) Office of Population Censuses and Surveys Monitor MB4-81 1 H M S O , London Ministry of Health 1937 Report on an Investigation into Maternal Mortality; quoted by DonnisonJ, op. cit. p 190 Odent M 1984 How to help women in labour. In Pregnancy Care for the 1980s eds Zander L, and Chamberlain G. 'The Royal Society of Medicine and Macmillan Press, London O'Driscoll K, Carroll C J, Coughlan M 1975 Selective induction of labour British Medical Journal 2:727-9

Registrar General Statistical Reviews of England and Wales (Annual to 1973). H M S O London Tew M 1978 The case against hospital deliveries: the statistical evidence. In The Place of Birth, eds Kitzinger S and Davis J A. Oxford University Press, Oxford pp 56-65 Tew M 1985a Safety in intranatal carc--thc statistics. In Modern General Practitioner Obstetrics, ed Marsh G N. Oxford University Press, Oxford pp 203-23 Tew M 1986 Do intranatal interventions make birth safer? British Journal of Obstetrics and Gynaecology, in press. Tew M 1985b Place of birth and perinatal mortality. Journal of Royal College of General Practitioners 35 (August) Williams R, Studd J 1980 Induction of labour. J M a t Child Health 5, 1, 16 2? Yudkin P, Frumar A M, Anderson A M B, Turnbull A C 1979 A retrospective study of induction of labour. British Journal of Obstetrics and Gynaecology, 86, 257-65