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August 2013

Reducing the Medicalization of Maternal and Newborn Care. August 2013. Session Objectives. The objectives of this session are to: Introduce the concept of “ medicalized ” care Provide examples of maternal and newborn health (MNH) care practices that may be harmful or life-saving

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August 2013

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  1. Reducing the Medicalization of Maternal and Newborn Care August 2013

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

  3. 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

  4. 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

  5. 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

  6. Symbols of a Medicalized Model: Woman without Companion

  7. Symbols of a Medicalized Model:Family Unit Separated During Labor & Delivery

  8. 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

  9. 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

  10. Unnecessary/Uncontrolled Labor Induction& Augmentation Labor induction has been associated with: • More maternal interventions (epidural analgesia and cesarean section) • Increased PPH • Longer length of stay • Higher likelihood of non-reassuring fetal heart rate tracings; need for neonatal resuscitation (Glantz 2010, 2012)

  11. 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 Unnecessary /Unsafe Cesarean Sections (Gibbons 2012)

  12. 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% (Haberman 2013; Shah 2009; Boyle 2012; Villar 2006)

  13. 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 (Galyean 2009)

  14. 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) (Rodriquez 2008)

  15. 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 (Bulletin of ACNM 2008; Singata 2012)

  16. Restricting Ambulation &Choice of Birth Position • 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

  17. 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

  18. 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

  19. 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 (Cochrane 2013; ACOG 2009)

  20. 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 (Beilin 2005; Jordan 2005; Lieberman 2002; Mardirosoff 2002; Radzyminski 2003, 2005)

  21. 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-Somuah2006; 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-Somuah2006; Liu 2004)

  22. 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)

  23. 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)

  24. Unnecessary Suctioning of Newborn Literature search of 41 articles found no benefit from routine suctioning • Search 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 (Velaphi 2008)

  25. 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 (McDonald 2008)

  26. 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) (Rabe 2012)

  27. Respectful Maternal & Newborn Care Respectful care demonstrates: • Respect for a woman’s rights, choices, and dignity • Care that “does no harm” • Care that promotes positive parenting and improves birth outcomes • Care that is culturally sensitive and valued by the woman and her community

  28. 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 equitably

  29. Campaign for ‘Normal Birth’:Top 10 Tips for Providers • Wait and see • Build her a nest • Get her off the bed • Justify intervention • Listen to her • Keep a diary • Trust your intuition • Be a role model • Be Positive • Promote skin-to-skin contact (http://www.rcmnormalbirth.org.uk/practice/ten-top-tips)

  30. WE ALL HAVE A ROLE IN ASSURING THAT WOMEN HAVE RESPECTFUL MATERNITY CARE! THANKS!

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