Low-risk pregnant women urged to avoid hospital births

 NHS guidance from National Institute for Health and Care Excellence suggests 45% of births ‘unsuitable’ for labour wards Pregnancy Low-risk pregnancy cases are being urged to avoid hospital birth under new NHS guidelines
Women with low-risk pregnancies are to be encouraged to have non-hospital births under new NHS guidelines, which could see almost half of mothers-to-be planning to deliver their baby away from traditional labour wards. Guidance from National Institute for Health and Care Excellence (Nice) says that midwife-led care has been shown to be safer for women and recommends that all women with low-risk pregnancies – 45% of the total – should be advised that giving birth in a midwifery-led unit, whether attached to a hospital or not, is “particularly suitable”. The changes, published on Wednesday , have been made because women who give birth under midwife-led care have less chance of being asked to undergo medical interventions such as episiotomies, caesareans and use of forceps or ventouse. 

 Susan Bewley, professor of complex obstetrics at King’s College, London, and chair of the Nice advisory group, added that infections were more common on hospital wards. “We’re supporting an individual calm conversation about what is right for each individual in her circumstances,” Bewley said. “They may choose any birth setting and they should be supported in those choices as that’s their right.”

 The NHS body also advised midwives not to clamp and cut a baby’s umbilical cord until at least a minute after birth in the absence of complications, and generally within five minutes. The announcement reverses decades of NHS policy and its own advice from 2007 recommending “early clamping and cutting of the cord”. Research suggests that early clamping and cutting may leave newborn babies deprived of vital blood from the placenta, risking anaemia. 

  In separate guidance on postnatal care, Nice said parents should also be informed about the association between falling asleep with their baby on a bed, sofa or chair and sudden infant death syndrome until the baby is 12 months old. The change represents another significant change to the guidelines, issued in 2006, which only applied to babies up to the age of six to eight weeks. Parents should also be informed that the association may be greater if parents use drugs or have recently drunk alcohol, or if the baby was of low birth weight or premature.

 Nine out of 10 of the 700,000 babies born in England and Wales each year are currently delivered in hospital under the supervision of obstetricians. Nice added that commissioners should ensure that women have all four possible options for giving birth available to them: hospital care, midwifery units in hospitals, midwifery units based in the community and at home. Professor Mark Baker, Nice’s clinical practice director, said: “It’s very difficult to explain why this is happening but the closer you are to hospital, and indeed if you are in hospital, the more likely you are to receive hospital care and surgical interventions. “Surgical interventions can be very costly, so midwifery-led care is value for money while putting the mother in control and delivering healthy babies.” The outcome for the baby is the same in different settings except in the case of first-time mothers giving birth at home, where there is a “small increase” in risk of serious complications – nine in every 1,000 compared with five in every 1,000 in the other settings – which the guidance says mothers should be advised about. Home births are the cheapest, followed by midwife-led units and then hospitals but Bewley said costs did not come into the equation. Cathy Warwick, chief executive of the Royal College of Midwives (RCM), said: “For low-risk women, giving birth in a midwife-led unit or at home is safe and reduces medical interventions. “We hope this will focus commissioners’ and providers’ of maternity services attention on ensuring that women have a real choice about where they give birth.” The RCM has been campaigning for about 5,000 extra midwives to be recruited. Warwick said the new guidance would not stretch existing medical staff further but ensure they were better employed, as more women would have births without interventions, which require more resources. Elizabeth Duff, senior policy adviser for the NCT (National Childbirth Trust), welcomed the advice and urged the NHS to “put these guidelines into practice as soon as possible and make home and community birth, a real, not just theoretical, option”. Community midwife units have lower medical intervention rates and rates of transfer to obstetric wards than those in hospitals but many have been closing recently. For women not giving birth for the first time they also have a lower rate of transfer to an obstetric ward than mothers who planned to give birth at home.

Midwives, not medicine, rule pregnancy in Sweden, with enduring success

AFP RELAX NEWS Monday, October 7, 2013, 11:14 AM


Only one ultrasound in nine months and no need to see the doctor or obstetrician: at first glance, Sweden's pregnancy care appears rather simplistic.


But while it may be far from the medical approach to pregnancy seen in most Western countries, where mothers-to-be have loads of doctor's appointments and tests, the Swedish system, where midwives reign supreme, has proven its merits.


According to the organization Save the Children, Sweden is the second-best country in the world to become a mother, behind Finland.


Neonatal mortality is low, at 1.5 deaths per 1,000 — the second lowest in Europe behind Iceland — as is maternal death in childbirth, at 3.1 per 100,000 births, according to the European Perinatal Health Report from 2010.


In Sweden, midwives are entrusted with caring for the health of the expectant mother and the foetus. It is the only pregnancy care available to women, and is free for the patient, falling under state health care benefits.


"A doctor can be called in at the midwife's initiative as soon as she notices that something is not right," says Sofie Laaftman, a midwife in central Stockholm.


For those accustomed to intensive medical care during pregnancy, the Swedish way may seem rudimentary: a few blood and urine tests are done to detect vitamin deficiencies or anomalies, the mother's blood pressure and the heartbeat of the foetus are checked, and a little nutritional advice is doled out.


During a normal pregnancy without complications, just one ultrasound will be done over the whole nine months — and not a single gynaecological exam.


Meanwhile, in France for example, a 2011 report from the health ministry showed 20 percent of expectant mothers had more than six ultrasounds and four percent had more than 10 — without any obvious benefit.


"Pregnancy is a normal condition" and not an illness, says Marie Berg, professor in health and care sciences at Sahlgrenska Academy at Sweden's University of Gothenburg.


Laaftman echoed that notion, saying most women under 40 did not need more medicalised care since their bodies were healthy and capable of giving birth, which is after all a natural process.


A scientific study published in August by the Cochrane Collaboration, an organisation of health practitioners, concluded that "most women" — those who have no complications in pregnancy — would benefit from seeing a midwife during pregnancy rather than a doctor.


Care by a midwife can actually reduce the number of premature births, the study's authors say. In Sweden, only five percent of babies are born prematurely.


But the lack of contact during pregnancy can be tough for some expectant mothers.


Christina Singelman, a 31-year-old expecting her second child, recalls the sense of loneliness she felt during her first pregnancy: from the time she registered at the clinic until her first ultrasound, some 10 weeks went by without a single appointment.


But if the woman is under the age of 40, has no prior medical conditions and has fallen pregnant by natural methods, "there's no reason to have more frequent checks in the beginning," insists Laaftman, the Stockholm midwife, who cares for about 100 pregnant women at a time.


Adina Trunk, 33, saw two different midwives for her two pregnancies.


"They were both very competent but the system puts them in a very passive position. It's always up to the expectant mother to take the initiative, to ask questions and possibly ask to see a specialist," she says.


"And since this is a culture where people don't like to make a fuss, it keeps costs down," she adds.


Midwives also take care of the delivery, although that is with an entirely different team than the one that has followed the mother throughout her pregnancy.


A doctor will only intervene if there are complications during the delivery, or if the woman in labour asks for an epidural, which is the case in about half of all deliveries.


Entrusting pregnancy and delivery care to midwives to such an extent is unique in the world.


Midwives in Sweden have been in charge of pregnancy care since the 18th century.


While the rise of the modern medical profession meant midwives in much of Europe were forced to yield at least part of their responsibilities to doctors, Sweden's midwives held onto their traditional role thanks to doctors' consent and, in recent times, a strong union.


The system has never been called into question, owing primarily to its strong track record.


The number of Caesarian sections is relatively low in Sweden, at around 17 percent of births in 2011, and only 10 percent of women undergo episiotomy, an incision to widen the opening for delivery.


"It's an efficient system in terms of cost management," says University of Gothenburg professor Berg.


In countries where doctors care for pregnant women, she says, the number of "tests and ultrasounds often multiply, which opens the way to easy money."

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"Great Concern" over U.S. deaths in Pregnancy, Childbirth from CBS News

CBS News
Tavis Ukena

The number of U.S. women who die during or soon after pregnancy may be higher than previously thought -- and it's on the rise, according to a new study.

Between 2000 and 2014, the nation's maternal death rate rose by almost 27 percent, researchers found. However, over that time, reporting methods changed, the study authors noted.

For every 100,000 live births, nearly 24 women died during, or within 42 days after pregnancy in 2014. That was up from nearly 19 per 100,000 in 2000.

The numbers, published online Aug. 8 in Obstetrics & Gynecology, are worse than previous estimates. Federal health officials have already reported a spike in the nation's maternal mortality figures, but they estimated a rate of 16 per 100,000 as recently as 2010.

The new findings give a clearer picture of where the United States really stands, according to lead researcher Marian MacDorman, of the University of Maryland.

And it's not a good place, her team said: With the 2014 numbers, the United States would rank 30th on a list of 31 countries reporting data to the Organization for Economic Cooperation and Development -- beating out only Mexico.

A large share of the national increase does have to do with better reporting, MacDorman said. Since 2003, U.S. states have been slowly adopting a revised standard death certificate that includes several pregnancy "check boxes."

But, she said, about 20 percent of the increase reflected a "real" rise in women's deaths.

"Certainly, maternal death is still a rare event," MacDorman stressed. "But it's of great concern that the rate is not improving -- it's increasing."

The big question is, why?

"Our study couldn't get into the causes of death," MacDorman said. "We were just trying to get at the numbers."

But Dr. Nancy Chescheir, editor-in-chief of Obstetrics & Gynecology, speculated on some factors that could be driving the increase.

For one, she said, women in the United States are having babies at older ages, and they are also increasingly likely to be obese and have medical conditions such as diabetes and high blood pressure. So women are now going into pregnancy at greater risk of complications compared to years past.

There was a bright spot in the study findings, however: In contrast to other states, California showed a decrease in maternal deaths, reaching an estimated 15 per 100,000 in 2014.

That, according to Chescheir, may stem from a "massive public health effort" known as the California Maternal Quality Care Collaborative. State agencies, hospitals, health plans and other groups worked to identify two leading causes of maternal deaths in the state -- preeclampsia and hemorrhage during childbirth -- and took steps to address them.

Among other things, the group created online "toolkits" to help hospitals better manage preeclampsia and hemorrhaging, Chescheir said.

"They've done a fantastic job of rolling these resources out," she said.

MacDorman agreed, and said other states may be able to learn from California's experience.

But when U.S. women die during or soon after pregnancy, it often has nothing to do with obstetric complications, Chescheir pointed out. Violence and drug abuse are major causes.

A second study in the same issue of the journal looked at maternal deaths in Illinois between 2002 and 2011. More than one-third were the result of car accidents, homicide, substance abuse and suicide; 13 percent, in fact, were homicides.

Chescheir said doctors have a role to play in preventing those deaths, too -- by screening pregnant women for drug usle, domestic abuse and depression, then referring them for help.

Doctors should also talk to women about how to use seatbelts during pregnancy, Chescheir said. Some women, she noted, stop using seatbelts because they think they're unsafe during pregnancy.

The point is not to alarm women, both Chescheir and MacDorman stressed.

"For the vast majority of women, pregnancy goes well," Chescheir said.

But, she added, "it's important to remember that pregnancy is a time of some risk."

Ideally, Chescheir said, couples should plan ahead for pregnancy -- in part so the woman can get any health conditions under control, and lose weight if needed.

"Go into pregnancy in the best health possible," she advised. "That's the first step."