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

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 2

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 3

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 4

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 5

6. Symbols of a Medicalized Model: Woman without Companion 6

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

8. Practices that May Be Harmful or Life-Saving  Induction or augmentation of labor  Cesarean section  Episiotomy  Restricting food and fluids  Electronic fetal monitoring  Oro-pharnygeal suctioning of newborn 8

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 9

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 10 (Glantz 2010, 2012)

11. 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 11 (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% 12 (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 13 (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) 14 (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 15 (Bulletin of ACNM 2008; Singata 2012)

16.  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 16 Restricting Ambulation & Choice of Birth Position

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 17

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 18

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 19 (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 20 (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-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) 21

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) 22

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) 23

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 24 (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 25 (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) 26 (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 27

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 28

29. Campaign for ‘Normal Birth’: Top 10 Tips for Providers 1.Wait and see 2.Build her a nest 3.Get her off the bed 4.Justify intervention 5.Listen to her 6.Keep a diary 7.Trust your intuition 8.Be a role model 9.Be Positive 10.Promote skin-to-skin contact 29 (http://www.rcmnormalbirth.org.uk/practice/ten-top-tips)

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

31. References  Ajeet S & K Nandkishore (2013): The Boom in Unnecessary Caesarean Surgeries Is Jeopardizing Women's Health, Health Care for Women International, 34:6, 513-521  Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD006066. DOI:10.1002/14651858.CD006066.pub2  American College of Obstetricians & Gynecologists (2009). ACOG Practice Bulletin No. 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles (Reaffirmed 2013). Obstet Gynecol. 2009; 114:192-202  Anderson, G., Moore, E., Hepworth, J., & Bergman, N. (2003). Early skin-to-skin contact for mothers and their healthy newborn infants. The Cochrane Database of Systematic Reviews, (2). Art No: CD003519. DOI:10.1002/14651858. D003519  Boyle A and Reddy UM. The epidemiology of cesarean: the scope of the problem. Seminars in Perinatology. 2012; 36(5):308-314.  Charpak, N., Ruiz-Pelaez, J., Figueroa de, C. Z., & Charpak, Y. (2001). A randomized, controlled trial of kangaroo mother care: Results of follow-up at 1 year of corrected age. Pediatrics, 108(5), 1072–1079. 18

32. References (cont.)  DiMatteo, M. R., Morton, S., Lepper, H., Damush, T. M., Carney,M. F., Pearson, M., et al. (1996).Cesarean childbirth and psychosocial outcomes: A meta-analysis. Health Psychology, 15(4), 303–314.  Feldman, R.,Weller, A., Leckman, J., Kuint, J., & Eidelman, A. I. (1999). The nature of the mother’s tie to her infant: Maternal bonding under conditions of proximity, separation and potential loss. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 40(6), 929–939.  Galyean AM, Lagrew DC, Bush MC, and Kurtzman JT. Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies. Journal of Perinatology, (29) 726-730.  Gibbons L, Belizan JM, Lauer JA, Betran AP,Merialdi M, Althabe F. (2012). Inequities in the use of cesarean section deliveries in the world. American Journal of Obstetrics & Gynecology, (206) 4:331.e1-331.e19  Glantz JC. Term labor induction compared with expectant management. Obstet Gynecol 2010;115(1):70–76.  Glantz JC. Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less. Birth 2012; 39(4);286-290. 18

33. References (cont.)  Gray, L.,Watt, L., & Blass, E. (2000). Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 105(1), 38–46  Gulmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2012;6(4):CD004945.  Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub3  Haberman S. et.al. Nonclinical parameters affecting primary Cesarean rates in the United States. American Journal of Perinatology 13 May 2013 [epub ahead of print]  Jordan, S., Emery, S., Bradshaw, C., Watkins, A., & Friswell, W. (2005). The impact of intrapartum analgesia on infant feeding. BJOG, 112, 927–934  Klaus, M. (1998). Mother and infant: Emotional ties. Pediatrics, 102, 1244–1246  Lieberman, E., & O’Donoghue, C. (2002). Unintended effects of epidural analgesia during labor: A systematic review. American Journal of Obstetrics and Gynecology, 186(5), S31–S68 18

34. References (cont.)  Liu, E., & Sia, A. (2004). Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: Systematic review. British Medical Journal, 328, 1410–1416.  Mardirosoff, C., Dumont, L., Boulvain, C., & Tramer, M. (2002). Fetal bradycardia due to intrathecal opioids for labour analgesia: A systematic review. BJOG, 109, 274–281  McDonald SJ,Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2.  Nieuwenhuijze MJ. et.al. Influence on birth positions affects women’s sense of control in second stage of labor. Midwifery. doi:pii: S0266-6138(12)00248-3. 10.1016/j.midw.2012.12.007. [Epub ahead of print]  Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3 - See more at: http://summaries.cochrane.org/CD003248/early-cord-clamping-versus-delayed-cord- clamping-or-cord-milking-for-preterm-babies#sthash.AtnLnll5.dpuf 18

35. References (cont.)  Radzyminski, S. (2003). The effect of ultra low dose epidural analgesia on newborn breastfeeding behaviors. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23(3), 322–331.  Rodriquez A. et.al. Selective vs routine midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women. American Journal of Gynecology & Obstetrics. 2008. 198(3): 285.e.1-4.  Rowe-Murray, H., & Fisher, J. (2001). Operative intervention in delivery is associated with compromised early mother-infant interaction. British Journal of Obstetrics and Gynaecology, 108, 1068–1075.  Schroeder, M., & Pridham, K. (2006). Development of competencies through guided participation for mothers of preterm infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(3), 358–368.  Shah A, et al, Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa, Int J Gynecol Obstet (2009), doi:10.1016/j.ijgo.2009.08.013 18

36. References (cont.)  Sharma, S., McIntire, D., Wiley, J., & Leveno, K. (2004). Labor analgesia and cesarean delivery: An individual patient meta-analysis of nulliparous women. Anesthesiology, 100, 142–148  Shorten, A., Donsante, J., & Shorten, B. (2002). Birth position, accoucheur and perineal outcomes: Informing women about choices for vaginal birth. Birth, 29(1),18–27.  Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186, S131–S159.  Soong, B., & Barnes, M. (2005). Maternal position at midwife attended birth and perineal trauma: Is there an association? Birth, 32(3), 164–169.  Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2010, Issue 1. (update 2012), Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub2  Taljaard M. et al. Understanding the factors associated with differences in caesarean section rates at hospital level: The case of Latin America. Paediatr Perinat Epidemiol, 23 (2009), pp. 574–581 18

37. References (cont.)  Terry, R., Wescott, J., O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199–202.  Tessier,R., Cristo,M., Velez, S.,Giron,M., Calume, de Z. F., Ruiz-Palaez, J. G., et al. (1998). Kangaroo mother care and the bonding hypothesis. Pediatrics, 102(2), 17–25.  Vardo JH, Thornburg LL, Glantz JC. Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor. J Reprod Med 2011;2:25–30.  Velaphi S and Vidyasagar D. The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. Seminars in Fetal & Neonatal Medicine 2008; 13: 375-382.  Villar J et.al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367:1819- 1829. 37