Changing Obstetric and Midwifery Practice

1
Changing Obstetric and Midwifery Practice

• Managing Complications in Pregnancy and Childbirth

2
Maternal Mortality Ratios by Country in Latin
America, Asia and Africa
3
Maternal Mortality Scope of Problem

• 180200 million pregnancies per year
• 75 million unwanted pregnancies1
• 50 million induced abortions2
• 20 million unsafe abortions (same as above)
• 600,000 maternal deaths (1 per min.)
• 1 maternal death30 maternal morbidities

1 Sadik 1997. 2 WHO 1998.
4
Newborn Mortality Scope of Problem

• 3 million newborn deaths (first week of life)
• 3 million stillbirths

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Causes of Maternal Death
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Interventions to Reduce Maternal Mortality

• Historical review
• Traditional birth attendants
• Antenatal care
• Risk screening
• Current approach
• Skilled provider at childbirth

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Interventions Antenatal Care

• Antenatal care clinics started in US, Australia,
  Scotland between 19101915
• New conceptscreening healthy women for signs of
  disease
• By 1930s large number (1,200) antenatal care
  clinics opened in UK
• No reduction in maternal mortality
• But, widely used as a maternal mortality
  reduction strategy in 1980s and early 1990s
• Is antenatal care important? YES!!
• Early detection of problems and birth preparation

8
Interventions Risk Screening

• Disadvantages
• Very poorly predictive
• Costlyremoves woman to maternity waiting homes
• If risk-negative, gives false security
• Conclusion Cannot identify those at risk of
  maternal mortalityevery pregnancy is at risk

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Why Change the Focus of Antenatal Care

• Every pregnancy faces risks
• It is almost impossible to predict accurately
  which woman will face life- threatening
  complications
• Antenatal risk assessment has not reduced
  maternal mortality
• Many antenatal routines have not been effective
  in preventing complications

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Risk Approach Does Not Work

• Large number of women classified as high risk
  never develop any complications
• Most women who develop complications do not have
  risk factors and were classified as low risk

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Implications of Risk Approach

• Women classified as low risk have a false sense
  of security
• Women classified as high risk undergo
  unnecessary inconvenience and cost
• Health systems overburdened by unnecessary
  management of high risk mothers and resources
  for dealing with actual emergencies reduced

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Interventions Traditional Birth Attendants

• Advantages
• Community-based
• Sought out by women
• Low tech
• Teach clean childbirth

• Disadvantages
• Technical skills limited
• May keep women away from life-saving
  interventions due to false reassurance

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Maternal Mortality ReductionSri Lanka, 19401985

• Health System Improvements
• Introduction of system of health facilities
• Expansion of midwifery skills
• Decreased use of home childbirth and births by
  untrained birth attendants
• Spread of family planning

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Maternal Mortality ReductionSri Lanka, 19401985
85 births attended by trained personnel
15
Maternal Mortality UK 18401960
Improvements in nutrition, sanitation
Antibiotics, banked blood, surgical improvements
Antenatal care
Maine 1999.
16
Relationship between Skilled Attendant at
Delivery and MMR for countries with MMRlt500
Maternal Mortality Ratio per 100,000 live births
Skilled Attendant at Delivery
Source Safe Motherhood Initiative website and
Maternal Mortality in 1995 Estimates developed
by WHO, UNICEF, UNFPA 2001.
17
Relationship between Skilled Attendant at
Delivery and MMR for countries with MMRgt500
Maternal Mortality Ratio per 100,000 live births
Skilled Attendant at Delivery
Source Safe Motherhood Initiative website and
Maternal Mortality in 1995 Estimates developed
by WHO, UNICEF, UNFPA 2001.
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Good Quality Maternity Services Will Save the
Lives of Newborns
AbouZahr and Wardlaw 2001.
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Care During Pregnancy and Childbirth in Asia,
Africa and Latin America (selected countries)
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Interventions Skilled Provider at Childbirth

• Has relevant training, range of skills
• Recognizes onset of complications
• Observes woman, monitors newborn
• Performs essential basic interventions
• Refers mother and newborn to higher level of care
  if complications arise requiring further
  interventions
• Has patience and empathy

WHO 1999.
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Interventions Skilled Provider at Childbirth

• Proven effective
• Malaysia basic maternity services, 320 ? 157
• Cuba national priority, 118 ? 31
• China facility-based childbirth 1,500 ? 50
• Malaysia vs. Indonesia
• Midwifery skills (2 years) vs. nursing and
  midwifery education (4 years)

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Solutions for Maternal and Newborn Survival

• Identifying the problem Maternal and newborn
  death

• Embracing the solution Maternal and newborn
  survival

• Delay in decision to seek care
• Lack of understanding of complications
• Acceptance of maternal death
• Low status of women
• Sociocultural barriers to seeking care
• Delay in reaching care
• Mountains, islands, riverspoor organization
• Delay in receiving care
• Supplies, personnel, finances
• Poorly trained personnel with punitive attitude

• Community involvement and social mobilization
• Mother-friendly services
• Community education
• Taking care to the community
• Skilled provider at every birth
• Innovative community programs
• Improved standards of care
• Developing guidelines
• Preservice training
• Performance improvement strategies
• Periodic audits, e.g., near miss audits

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Changing Established Practices

• Experience
• Expert opinion
• Evidence
• Expectation

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Evidence-Based Medicine

• Systematic, scientific and explicit use of
  current best evidence in making decisions about
  the care of individual patients

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So What Has Changed?

• Developments in clinical research
• Developments in methodology
• Meta-analysis
• Recognition of bias in traditional reviews and
  expert opinions
• Explosion in medical literature
• Methodological papers
• Electronic databases

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Levels of Evidence and Grades of Recommendations
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A
Patient with desired characteristics
SORTED
Alternative treatment, prevention or diagnostic
method vs. placebo
B
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Final Result
Number or without morbidity Number or with
collateral effects
Group A
Number or without morbidity Number or with
collateral effects
Group B
29
Interpretation of ResultsCalcium Supplementation
to Prevent Gestational Hypertension
Calcium 57 / 579 9.8 Placebo 87 / 588 14.8
RR 0.67 (0.490.91) Reduction in prevalence by
33 (variable effect between 519)
30
Graphic Expression
Relative Risk
Protective Effect
Deleterious Effect
.1
.2
1
5
10
31
Antenatal Fetal Monitoring
4 studies 1,579 patients
Relative risk (95CI)
Cesarean section rates Detection of fetal cardiac
abnormalities Apgar Signs of neurological
abnormalities Perinatal interventions Perinatal
mortality
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External Cephalic Version More Than 37 Weeks
6 studies 712 women
Relative risk (95 CI)
Vaginal breech deliveries Cesarean sections Apgar
lt7 at 1 min. Apgar lt7 at 5 min. Umbilical vein pH
lt7.20 Newborn admissions Perinatal mortality
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Beneficial Forms of Care

• Active management of the third stage of labor
  (decreases blood loss after childbirth)
• Antibiotic treatment of asymptomatic bacteriuria
  in pregnancy (prevents pyelonephritis and
  reduces the incidence of preterm childbirth)
• Antibiotic prophylaxis for women undergoing
  cesarean section (reduces postoperative
  infectious morbidity)

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Beneficial Forms of Care (contd)

• External cephalic version at term (decreases
  incidence of breech delivery and reduces cesarean
  section rates)
• Magnesium sulfate therapy for women with
  eclampsia (more effective than diazepam, etc.)
  for the control of convulsions
• Population-based iodine supplementation in
  severely iodine deficient areas (prevents
  cretinism and infant deaths due to iodine
  deficiency)
• Routine iron and folic acid supplementation
  (reduces the incidence of maternal anemia at
  childbirth or at 6 weeks postpartum)

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Management of Hypertension in Pregnancy
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Magnesium Sulfate vs. Diazepam Recurrence of
Convulsions

• RR 0.45
• 95 CI 0.350.58

No differences in maternal morbidity and
borderline decrease in maternal mortality
Duley and Henderson-Smart 2000.
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Active vs. Physiological Management Postpartum
Hemorrhage
Prendiville et al 1988, Rogers et al 1998.
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Active vs. Physiological Management Results
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Forms of Care of Unknown Effectiveness

• Antibiotic prophylaxis for uncomplicated
  incomplete abortion to reduce postabortion
  complications
• Anticonvulsant therapy to women with
  pre-eclampsia, the prevention of eclampsia
• Routine symphysio-fundal height measurements
  during pregnancy to help detect IUGR
• Routine topical antiseptic or antibiotic
  application to the umbilical cord to prevent
  sepsis and other illness in the neonate

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Forms of Care Likely to Be Ineffective

• Use of antibiotics in preterm labor with intact
  membranes in order to prolong pregnancy and
  reduce preterm birth
• Early amniotomy during labor to reduce cesarean
  section rates
• External cephalic version before term to reduce
  incidence of breech delivery
• Routine early pregnancy ultrasound to decrease
  perinatal mortality

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Forms of Care Likely to Be Harmful

• Routine episiotomy (compared to restricted use of
  episiotomy) to prevent perineal/vaginal tears
• Diazoxide for rapid lowering of blood pressure
  during pregnancy (associated with severe
  hypotension)
• Forceps extraction instead of vacuum extraction
  for assisted vaginal delivery when both are
  applicable forceps delivery is associated with
  increased incidence of maternal genital tract
  trauma
• Using diazepam or phenytoin to prevent further
  fits in women with eclampsia when magnesium
  sulfate is available

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Antenatal Care Practices

• Practices not recommended
• High risk approach
• Routine antenatal measurement
• Maternal height to screen for cephalopelvic
  disproportion
• Determining fetal position before 36 weeks
• Testing for ankle edema to detect pre-eclampsia
• Bed rest for threatened abortion, uncomplicated
  twins, mild pre-eclampsia
• External cephalic version before 37 weeks

• Recommended practices
• Birth preparedness counseling
• Complication readiness planning
• Iron and folate supplementation
• Tetanus immunization
• Reduced frequency of antenatal visits by skilled
  provider to maintain normal health and detect
  complications
• In selected populations
• Iodine supplementation in severely iodine
  deficient areas
• Intermittent presumptive treatment for malaria
• External cephalic version at term

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Essential Care Series
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Promoting a Culture of Quality Care

• Good quality care saves time and money
• Partograph
• Manual vacuum aspiration/postabortion care
• Active management of third stage
• Team responsibility
• Providers
• Supervisors
• Community

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References
AbouZahr C and T Wardlaw. 2001. Maternal
Mortality in 1995 Estimates Developed by WHO,
UNICEF, UNFPA. World Health Organization (WHO)
Geneva. Duley L and D Henderson-Smart. 2000.
Magnesium sulphate versus diazepam for eclampsia
(Cochrane Review), in The Cochrane Library. Issue
4. Update Software Oxford. Maine D. 1999.
What's So Special about Maternal Mortality?, in
Safe Motherhood Initiatives Critical Issues.
Berer M et al (eds). Blackwell Science Limited
London. Prendiville et al. 1988. The Bristol
third stage trial Active versus physiological
management of the third stage of labor. BMJ 297
12951300.
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References (contd)
Rogers J et al. 1998. Active versus expectant
management of third stage of labour The
Hinchingbrooke randomised controlled trial.
Lancet 351 (9104) 693699. Sadik N. 1997.
Reproductive health/family planning and the
health of infants, girls and women. Indian J
Pediatr 64(6) 739744. WHO. 1999. Care in
Normal Birth A Practical Guide. Report of a
Technical Working Group. WHO Geneva. WHO 1998.
Pospartum Care of the Mother and Newborn A
Practical Guide. Report of a Technical Working
Group. WHO Geneva.