Clinical Controversies: Problems and System Goals

Problems

Overreliance on maternity interventions and limited access to primary maternity care providers and settings provide the context for clinical controversies

Controversial clinical scenarios in maternity care include VBAC, vaginal breech and vaginal twin birth, cesarean section without indication, elective induction of labor, and home birth. Conflict about these forms of care occurs in the context of the current maternity care delivery system, which generally provides an intervention-intensive, specialty-oriented style of care. The system fosters liberal use of elective procedures and perverse financial incentives that favor overuse of services, including an overreliance on cesarean section versus skill-based and time-intensive approaches to facilitating labor and birth. Care is poorly coordinated and does not reliably ensure appropriate practice based on an individual woman’s clinical circumstances and personal preferences.

Primary maternity care with a focus on support and prevention is optimal for the majority of women and newborns who are essentially healthy and at low risk for complications. Yet, most U.S. births are attended by specialists trained in high-risk pregnancy and disease management, a large number of whom have little training or experience in protecting, promoting and supporting physiologic childbirth—the most appropriate form of care for most of the population. Other providers, specifically midwives and family physicians, often have a different focus and emphasis in their training and experience in maternity care, such that their skills may be better suited for providing this style of care. However, these caregivers attend relatively few births in the United States. Similarly, the freestanding birth center more consistently provides such care to healthy, low-risk women than acute care hospitals, yet just a fraction of women have access to that care setting.

Inconsistent adherence to evidence, lack of consensus, and wide variability in the care of women with controversial clinical scenarios

Childbearing women with controversial clinical situations face mixed professional messages and disagreement about appropriate care and care options. Gaps between evidence and practice, uncertainty about effects of inadequately assessed practices, and diminished access to many forms of care pit many women and their preferences against the maternity care available in their communities. This conflict is magnified during health care transitions, when women’s care may be managed very differently, often with inadequate coordination of care, by their various providers and settings.

Reduced access to essential practices and loss of provider skills that foster safe, physiologic childbirth

Women increasingly lack access to essential practices that foster vaginal birth and reduce the likelihood of cesarean section. Best current evidence supports providing carefully screened women access to practices such as planned VBAC, vaginal breech birth (Goffinet et al., 2006; Hannah et al., 2004; Hogle et al., 2003; Kotaska et al., 2009; Whyte et al., 2004), and vaginal twin birth; external version to turn fetuses to a head-first position; nonpharmacologic methods of labor pain relief and management; intermittent auscultation for fetal monitoring; and skillful judicious use of vacuum extraction and forceps. However, decreased use of these practices is leading to loss of skills and unsupportive environments.

Liability concerns

Liability concerns impact the care of women with controversial clinical scenarios. Perceived pressure pushes some clinicians and systems of care to make decisions with the primary aim of avoiding liability rather than supporting a healthy physiologic childbirth and honoring women’s informed choices.

System Goals

  • Primary maternity care is the standard of care for the majority of women and newborns who are at low risk for complications.
  • Focused attention is given to resolving clinical controversies, which adversely affect childbearing women, caregivers, and the maternity care system.
  • Care for childbearing women and newborns is provided within an integrated system that ensures respect and support for women’s informed choices while responding appropriately to unexpected needs.

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References

Goffinet, F., Carayol, M., Foidart, J.M., Alexander, S., Uzan, S., Subtil, D., et al. PREMODA Study Group. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observation prospective survey in France and Belgium. American Journal of Obstetrics & Gynecology. 2006, 194, 1002–1011.

Hannah, M.E., Whyte, H., Hannah, W.J., Hewson, S., Amankwah, K., Cheng, M., et al. (2004). Term Breech Trial Collaborative Group. Maternal outcomes at 2 years after planned Cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. American Journal of Obstetrics & Gynecology, 191, 917–927.

Hogle, K.L., Hutton, E.K., McBrien, K.A., Barrett, J.F., & Hannah, M.E. (2003). Cesarean delivery for twins: A systematic review and meta-analysis. American Journal of Obstetrics & Gynecology, 2003, 188, 220–227.

Kotaska, A., Menticoglou, S., Gagnon, R., Farine, D., Basso, M., Bos, H., et al., Maternal Fetal Medicine Committee; Society of Obstetricians and Gynaecologists of Canada. (2009). Vaginal delivery of breech presentation. Journal of Obstetrics & Gynaecology of Canada, 31, 557–566, 567–578.

Whyte, H., Hannah, M.E., Saigal, S., Hannah, W.J., Hewson, S., Amankwah, K., et al. Term Breech Trial Collaborative Group. (2004). Outcomes of children at 2 years after planned Cesarean birth versus planned vaginal birth for breech presentation at term: The International Randomized Term Breech Trial. American Journal of Obstetrics & Gynecology, 2004, 191, 864–871.