August 2013

Reducing theMedicalization of

Maternal andNewborn Care

Session Objectives

The objectives of this session are to: Introduce the concept of “medicalized” care Provide examples of maternal and newborn health (MNH) care practicesthat may be harmful or life-saving Provide examples of MNH care practices that are harmful Provide evidence to support the harmfulness of these examples

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What is Medicalized MNH Care?

The routine use of practices during labor and childbirth that:

Are not evidence-based Are unnecessary or unwarranted Do not improve the health

outcomes for mother or baby and may do harm

Prioritize needs of providers over needs of women

Encourage technology or interventions without proven benefit

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Symbols of a Medicalized Model:Technology

The body as a machine Separation between the body and the mind Pregnancy is a medical condition that needs to be controlled

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Symbols of a Medicalized Model:Centered on the Professional Care

Giver

Centered on the provider’s needs and preferences: Ease Speed Comfort Habit/Tradition

Results in woman’s discomfort and disempowerment

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Symbols of a Medicalized Model: Woman without Companion

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Symbols of a Medicalized Model:Family Unit Separated During

Labor & Delivery

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Practices that May Be Harmfulor Life-Saving

Induction or augmentation of labor Cesarean section Episiotomy Restricting food and fluids Electronic fetal monitoring Oro-pharnygeal suctioning of newborn

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Practices That Are Harmful

Restricting ambulation/different positions during labor and choice of birth position

Lack of companion/family during labor Over-use of anesthesia/analgesia Separation of mother and baby Early cord clamping Routine enema and/or perineal shaving

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Unnecessary/Uncontrolled Labor Induction

& Augmentation

Labor induction has been associated with:More maternal interventions (epidural analgesia and cesarean section)Increased PPHLonger length of stayHigher likelihood of non-reassuring fetal heart rate tracings; need for neonatal resuscitation

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(Glantz 2010, 2012)

Unnecessary /Unsafe Cesarean Sections

WHO standard is 5-15% of all deliveries

Data from 137 countries: 54 countries had CS rates of ˂10%; 69 countries showed rates of ≥15%

Global saving by reduction of CS rates to 15% was ±$2.32 billion; the cost to attain 10% CS rate was $432 million. Overuse of global resources

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(Gibbons 2012)

Unnecessary /Unsafe Cesarean Sections (cont.)

Increasingly indications are subjective and non-clinical May be performed without adequate

anesthesia/access to blood Data for 106,546 births found rate of CS delivery was

positively associated with: Postpartum antibiotic treatment Severe maternal morbidity and mortality Increase in perinatal mortality rates Increase in babies admitted to neonatal intensive care Rates of preterm delivery and neonatal mortality both

rose at rates of C-S between 10% and 20%

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(Haberman 2013; Shah 2009; Boyle 2012; Villar 2006)

Unnecessary /Unsafe Cesarean Sections (cont.)

Detrimental to births following C-section Study: 10,684 women – 2,680 had prior C-S; 7,974

had prior vaginal birth Patients having a prior C-S:

• Had more than a 2.5-fold risk of requiring blood transfusion

• Had nearly a 4-fold higher risk of admission to the ICU• Were 1.5 times more likely to be readmitted to the

hospital than those with a prior vaginal birth

Future pregnancies and births need special care

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(Galyean 2009)

Unnecessary/Routine Episiotomies Episiotomies can reduce maternal and neonatal

morbidity if they are restricted to evidence-based indications

RCT of 2,606 births in 8 maternities found: Anterior perineal trauma more common in the selective

group Severe perineal trauma, perineal pain, healing

complications, and wound dehiscence were all less frequent in the selective group

In another study 14.3% of routine group had third- or fourth-degree perineal lacerations, compared to 6.8% in selective group (RR, 2.12; 95% confidence interval, 1.18-3.81)

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(Rodriquez 2008)

Restricting Food or Fluids in Labor

Unproven fear of aspiration if oral intake allowed

Allowing self-regulated intake of oral hydration and nutrition has been shown to help prevent ketosis and dehydration, and to reduce stress levels

Cochrane review (3,130 women) found no justification for restricting oral fluid or food during labor

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(Bulletin of ACNM 2008; Singata 2012)

Little data to show significant effect of positions on birth outcomes

Choice of labor and birth positions encourages a woman’s sense of control and reduces need for analgesia

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Restricting Ambulation &Choice of Birth Position

Restricting Ambulation &Choice of Birth Position (cont.)

Women who assumed a nonsupine position for birth: had fewer perineal injuries (Shorten

2002; Soong 2005; Terry 2006)

had less vulvar edema, and had less blood loss (Terry 2006)

Women choosing nonsupine position for birth: had shorter second stages required less pain relief medication,

and had fewer abnormal FHRs (Simkin

2002)

Alternate Positions

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Unnecessary Electronic Fetal Monitoring (EFM)

Issues associated with using EFM: Technology, maintenance and costs Training – how to use, how to interpret

High inter- and intra-observer variability in interpretation of FHR tracing (ACOG 2009)

Lack of proven benefit of continuous EFM over intermittent auscultation in low-risk pregnancy (Cochrane 2013; ACOG 2009)

May restrict ambulation and positions during labor

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Unnecessary EFM (cont.)

Continuous EFM vs. intermittent auscultation associated with:

Increased rates of operative delivery (C-S, vacuum) With resulting increased risks to mother

Reduction in neonatal seizures by 50%, but….

No reduction in neonatal death, cerebral palsy, other significant neonatal morbidity

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(Cochrane 2013; ACOG 2009)

Over-Use of Anesthesia/Analgesia

Epidural/Intrathecal anesthesia is associated with increased rates of transient fetal heart rate abnormalities (even higher when intrathecal opioids/narcotics used)

Newborns of women who receive intrathecal opioids/narcotics experience more difficulties initiating breastfeeding

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(Beilin 2005; Jordan 2005; Lieberman 2002; Mardirosoff 2002; Radzyminski

2003, 2005)

Over-Use of Anesthesia/Analgesia (cont.)

Compared with women using no pain medication or exclusively opioid pain medication during labor, women having epidurals have increased risk for:Longer first-stage labor (Alexander 2002; Lieberman 2002; Sharma 2004)

Longer second-stage labor (Alexander 2002; Anim-Somuah 2006; Feinstein 2002; Lieberman 2002; Liu 2004; Sharma 2004)

Third- and fourth-degree tears associated with the increased incidence of instrumental vaginal deliveries (Lieberman 2002)

Fetal distress (Anim-Somuah 2006; Liu 2004)

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Separation of Mother & Baby

Eliminating or minimizing separation for procedures whenever possible reduces distress in healthy infants and mothers (Anderson 2003; Gray 2000; Klaus 1998)

Minimizing separation during the hospital stay increases breastfeeding initiation and duration in mothers with healthy infants (Anderson 2003; Klaus 1998)

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Separation of Mother & Baby (cont.)

Touching, holding, and caring for healthy, sick or premature infants or infants with congenital problems enhances attachment between mothers and babies (Charpak 2001; DiMatteo 1996; Feldman 1999; Klaus 1998; Rowe-Murray 2001; Schroeder 2006; Tessier 1998)

Eliminating or minimizing separation for procedures whenever possible reduces distress in sick or premature infants, infants with congenital problems, and mothers (Feldman 1999; Klaus 1998)

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Unnecessary Suctioning of Newborn

Literature search of 41 articles found no benefit from routine suctioningSearch found suctioning was associated with:

Perturbations in heart rate

Apnea Delays in achieving

normal oxygen saturations

Based on currently available literature, routine suctioning is more likely to cause harm than good

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(Velaphi 2008)

Early Cord Clamping:Term Infant

Evidence has problems with definitions, i.e. “early” vs. “late” In 11 trials of 2,989 mothers and their babies, Cochrane

review found: No significant differences for PPH (CI 0.96 to 1.55) Increased need in infants for phototherapy for jaundice (CI 0.38

to 0.92 in the late compared with early clamping group) Increase in newborn hemoglobin levels in the late cord

clamping group compared with early cord clamping (CI 0.28 to 4.06), although this effect did not persist past 6 months

Infant ferritin levels remained higher in the late clamping group than the early clamping group at 6 months

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(McDonald 2008)

Early Cord Clamping:Premature Infants

In premature infants, Cochrane review found that early (within seconds) vs. delayed (30-180 seconds) was associated with: Fewer infants requiring transfusions for anemia (RR 0.61, 95%

confidence interval (CI) 0.46 to 0.81) Less intraventricular hemorrhage (RR 0.59, 95% CI 0.41 to

0.85) Lower risk for necrotising enterocolitis (RR 0.62, 95% CI 0.43

to 0.90) compared with immediate clamping Peak bilirubin concentration was higher for infants allocated

to delayed cord clamping compared with immediate clamping (95% CI 5.62 to 24.40)

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(Rabe 2012)

Respectful Maternal & Newborn Care

Respectful care demonstrates:Respect for a woman’s rights, choices, and dignityCare that “does no harm”Care that promotes positive parenting and improves birth outcomesCare that is culturally sensitive and valued by the woman and her community

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Reversing the Trend:Partnership in Care

Aim to provide respectful maternity care – that is woman centered, empowering and supportive

Care which permits free communication and full expression of trust and commitment

Be careful with language – use ‘birth’ and not ‘delivery’

Ensure all women are treated equitably28

Campaign for ‘Normal Birth’:Top 10 Tips for Providers

1. Wait and see2. Build her a nest3. Get her off the bed4. Justify intervention5. Listen to her6. Keep a diary7. Trust your intuition8. Be a role model9. Be Positive10. Promote skin-to-skin contact

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(http://www.rcmnormalbirth.org.uk/practice/ten-top-tips)

WE ALL HAVE A ROLE IN ASSURING THAT WOMEN HAVE RESPECTFUL

MATERNITY CARE!

THANKS!