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Changing Obstetric and Midwifery Practice. Managing Complications in Pregnancy and Childbirth. 2000. 1600. Latin America. Asia. Africa. 1200. Maternal Deaths per 100'000 Live Births. 800. 400. 0. AbouZahr and Wardlaw 2001.

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Changing obstetric and midwifery practice l.jpg

Changing Obstetric and Midwifery Practice

Managing Complications in Pregnancy and Childbirth


Maternal mortality ratios by country in latin america asia and africa l.jpg

2000

1600

Latin America

Asia

Africa

1200

Maternal Deaths per 100'000 Live Births

800

400

0

AbouZahr and Wardlaw 2001.

Maternal Mortality Ratios by Country in Latin America, Asia and Africa

Obstetric and Midwifery Practice


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Maternal Mortality: Scope of Problem

  • 180–200 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 death=30 maternal morbidities

1 Sadik 1997.

2 WHO 1998.

Obstetric and Midwifery Practice


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Newborn Mortality: Scope of Problem

  • 3 million newborn deaths (first week of life)

  • 3 million stillbirths

Obstetric and Midwifery Practice


Causes of maternal death l.jpg

Hemorrhage

24.8%

Infection

14.9%

Indirect

causes

19.8%

Eclampsia

12.9%

Other direct

causes

Obstructed labor

Unsafe

abortion

6.9%

7.9%

12.9%

Causes of Maternal Death

Obstetric and Midwifery Practice


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Interventions to Reduce Maternal Mortality

Historical review

  • Traditional birth attendants

  • Antenatal care

  • Risk screening

    Current approach

  • Skilled provider at childbirth

Obstetric and Midwifery Practice


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Interventions: Antenatal Care

  • Antenatal care clinics started in US, Australia, Scotland between 1910–1915

  • New concept—screening 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

Obstetric and Midwifery Practice


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Interventions: Risk Screening

  • Disadvantages

  • Very poorly predictive

  • Costly—removes woman to maternity waiting homes

  • If risk-negative, gives false security

  • Conclusion: Cannot identify those at risk of maternal mortality—every pregnancy is at risk

Obstetric and Midwifery Practice


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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

Obstetric and Midwifery Practice


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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”

Obstetric and Midwifery Practice


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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

Obstetric and Midwifery Practice


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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

Interventions: Traditional Birth Attendants

Obstetric and Midwifery Practice


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Maternal Mortality ReductionSri Lanka, 1940–1985

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

Obstetric and Midwifery Practice


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Maternal Mortality ReductionSri Lanka, 1940–1985

85% births attended by trained personnel

Obstetric and Midwifery Practice


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Maternal Mortality: UK 1840–1960

Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements

Antenatal care

Maine 1999.

Obstetric and Midwifery Practice


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Relationship between Skilled Attendant at Delivery and MMR for countries with MMR<500

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.

Obstetric and Midwifery Practice


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Relationship between Skilled Attendant at Delivery and MMR for countries with MMR>500

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.

Obstetric and Midwifery Practice


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Good Quality Maternity Services Will Save the Lives of Newborns

AbouZahr and Wardlaw 2001.

Obstetric and Midwifery Practice


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Care During Pregnancy and Childbirth in Asia, Africa and Latin America (selected countries)

Obstetric and Midwifery Practice


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Interventions: Latin America 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.

Obstetric and Midwifery Practice


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Interventions: Latin America 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)

Obstetric and Midwifery Practice


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Delay in decision to seek care Latin America

Lack of understanding of complications

Acceptance of maternal death

Low status of women

Sociocultural barriers to seeking care

Delay in reaching care

Mountains, islands, rivers—poor 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

Solutions for Maternal and Newborn Survival

Identifying the problem: Maternal and newborn death

Embracing the solution: Maternal and newborn survival

Obstetric and Midwifery Practice


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Changing Established Practices Latin America

  • Experience

  • Expert opinion

  • Evidence

  • Expectation

Obstetric and Midwifery Practice


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Evidence-Based Medicine Latin America

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

Obstetric and Midwifery Practice


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So What Has Changed? Latin America

  • 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

Obstetric and Midwifery Practice


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Levels of Evidence and Grades of Recommendations Latin America

Obstetric and Midwifery Practice


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Treatment Latin America

Prevention

Diagnostic method

A

Patient with desired

characteristics

SORTED

Alternative treatment, prevention

or diagnostic method vs. placebo

B

Obstetric and Midwifery Practice


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Final Result Latin America

Number or % without morbidity

Number or % with collateral effects

Group

A

Number or % without morbidity

Number or % with collateral effects

Group

B

Obstetric and Midwifery Practice


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Interpretation of Results Latin America Calcium Supplementation to Prevent Gestational Hypertension

Calcium

57 / 5799.8%

Placebo

87 / 58814.8%

RR = 0.67 (0.49–0.91)

Reduction in prevalence by 33%

(variable effect between 51%–9%)

Obstetric and Midwifery Practice


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Graphic Expression Latin America

Relative Risk

Protective Effect

Deleterious Effect

.1

.2

1

5

10

Obstetric and Midwifery Practice


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.05 Latin America

.2

1

5

20

Antenatal Fetal Monitoring

4 studies 1,579 patients

Relative risk (95%CI)

Cesarean section rates

Detection of fetal cardiac abnormalities

Apgar

Signs of neurological abnormalities

Perinatal interventions

Perinatal mortality

Obstetric and Midwifery Practice


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.1 Latin America

.2

1

5

10

External Cephalic Version More Than 37 Weeks

6 studies 712 women

Relative risk (95% CI)

Vaginal breech deliveries

Cesarean sections

Apgar <7 at 1 min.

Apgar <7 at 5 min.

Umbilical vein pH <7.20

Newborn admissions

Perinatal mortality

Obstetric and Midwifery Practice


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Beneficial Forms of Care Latin America

  • 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)

Obstetric and Midwifery Practice


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Beneficial Forms of Care (cont’d) Latin America

  • 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)

Obstetric and Midwifery Practice


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Management of Hypertension in Pregnancy Latin America

Obstetric and Midwifery Practice


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Magnesium Sulfate vs. Diazepam: Recurrence of Convulsions Latin America

RR 0.45

95% CI 0.35–0.58

No differences in maternal morbidity and borderline decrease in maternal mortality

Duley and Henderson-Smart 2000.

Obstetric and Midwifery Practice


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Active vs. Physiological Management: Postpartum Hemorrhage Latin America

Obstetric and Midwifery Practice

Prendiville et al 1988,

Rogers et al 1998.


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Active vs. Physiological Management: Results Latin America

Obstetric and Midwifery Practice


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Forms of Care of Unknown Effectiveness Latin America

  • 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

Obstetric and Midwifery Practice


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Forms of Care Likely to Be Ineffective Latin America

  • 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

Obstetric and Midwifery Practice


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Forms of Care Likely to Be Harmful Latin America

  • 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

Obstetric and Midwifery Practice


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Practices not recommended Latin America

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

Antenatal Care Practices

Obstetric and Midwifery Practice


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Essential Care Series Latin America

Obstetric and Midwifery Practice


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Promoting a Culture of Quality Care Latin America

  • Good quality care saves time and money

    • Partograph

    • Manual vacuum aspiration/postabortion care

    • Active management of third stage

  • Team responsibility:

    • Providers

    • Supervisors

    • Community

Obstetric and Midwifery Practice


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References Latin America

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: 1295–1300.

Obstetric and Midwifery Practice


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References (cont’d) Latin America

Rogers J et al. 1998. Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351 (9104): 693–699.

Sadik N. 1997. Reproductive health/family planning and the health of infants, girls and women. Indian J Pediatr 64(6): 739–744.

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.

Obstetric and Midwifery Practice


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