Sunday, April 5, 2009

Two great lectures! Lecture 1: OB care in the UK

Sometimes being a student is a drag. Like today - it's a beautiful day, the birds are chirping, the sun is shining, and all I should be doing is writing papers and working on group projects (well, with a little break to write a blog post). But sometimes I'm so grateful for the chance to be exposed to, and connect with, people doing amazing work in maternal and child health.

I went to two great lectures recently (I'll cover the second one in the next post). The first was by Holly Powell Kennedy, incoming president of the American College of Nurse Midwives, presenting on her recent research as a Fulbright Distinguished Scholar in the UK. Her research was an ethnographic study that included interviews and participant observation in a hospital birth center. She was interested in both how the health care practitioners defined "normal birth" and "optimal birth", as well as what the system of care looked like.

She did her research at a hospital in London considered "the best of the best" of the UK maternity care system, and I will say - it sounded incredible. Here are the things I was most impressed by:

One-to-one care: In this birth center, they used a combination of midwifery care (over 50% of births), doctors in training, and obstetricians. With the midwifery care at least, it is all one-on-one. There are no obstetric nurses - the midwife does all the nursing and midwifery care and is with the patient more or less continuously. Powell Kennedy pointed out in her pictures how empty the corridors were - because everyone's in the rooms with the patients! The two reasons she gave for this are the one-on-one care, and also...

No central monitoring, and no routine continuous monitoring: Go into a hospital and you get very familiar with the nurses' station full of people keeping their eye on 2-3 patients via computer screen. In this hospital there is no electronic fetal monitoring unless there is a clinical indication - it's intermittent auscultation using a doppler or even a fetoscope/pinard horn - and no way to watch even the continuous monitoring if you're out of the room. (There's also no strip on admission!) When it's time for the birth, the midwife only pages for help if she (or he) needs it - there's no flood of 2-5 people suddenly in the room staring at your crotch!

Hands-on, and hands-off skills: She never saw midwives or OBs doing ultrasound for position - they were confident in their skills to tell by feel, and she never saw any misses. They also had a strong belief and skills in observing external signs of labor, and did few vaginal checks.

Does any of this sound like homebirth midwives you know? It's so similar to that ideal midwifery model of care! But what struck me most was how in this hospital system, when they embraced homebirth, they were able to have such seamless and better care. Powell Kennedy highlighted one midwifery practice that cares for a very poor population but that has excellent outcomes. One of their standards is to have the 36-week visit at home, with the mom and her planned support people. They give her a home birth kit and say "Don't decide now where you want to give birth. When it's time, we'll come here and labor with you as long as you want to stay home. If you want to go to the hospital (or need to), we'll go. If you want to stay here, we'll stay." Imagine!

Powell Kennedy really remarked on some fundamental differences in belief in this sytem: they trust in women and give women the authority. Women carry their own records - bringing them to their appointments, bringing them to the hospital at birth. Let me make that clear: the office keeps no records on them. They carry their own records, lab tests, the whole thing. There's also a strong focus on spontaneous labor and birth, as a normal physiologic event, and the idea that health care providers should master the art of doing "nothing" well.

I was sitting one row in front of the midwives from the hospital practice where I've volunteered as a doula. You should have heard them whispering to each other and sighing with delight during this whole presentation! But Powell Kennedy really emphasized that this hospital was not necessarily typical of the UK system - only, it seems, what is possible within that system (and so far impossible in ours, with rare exceptions). Even within this hospital, things aren't perfect - there isn't necessarily continuity even across midwifery teams in all these practices. Still, it was so impressive - more or less like a vision of heaven! I was pleased that it was part of grand rounds for the hospital, so there were some OBs/residents/med students there able to hear that this isn't just hippie crazytalk - other health systems actually use these standards of care.

Two final notes that I don't know much about but would like to learn more: Powell Kennedy commented on the use of nitrous oxide as a pain reliever during birth. She said it was as ubiquitous as oxygen - available at the bedside, at home births, even in the labor room bathrooms! They had a very low epidural rate (10%) but almost 50% of the births she observed, the moms used nitrous oxide. I know almost nothing about it and its use for pain relief, but now I'm curious.

She also referred us to this website, Birth Choice UK, which is supposed to have statistics for every maternity care practice in the country! Not all the statistics are complete, and I haven't had much chance to investigate it, but imagine if we had that here?

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