Changing Obstetric and Midwifery Practice

1. Changing Obstetric and Midwifery Practice Managing Complications in Pregnancy and Childbirth

2. 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

3. 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

4. Newborn Mortality: Scope of Problem • 3 million newborn deaths (first week of life) • 3 million stillbirths Obstetric and Midwifery Practice

5. 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

6. Interventions to Reduce Maternal Mortality Historical review • Traditional birth attendants • Antenatal care • Risk screening Current approach • Skilled provider at childbirth Obstetric and Midwifery Practice

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Maternal Mortality ReductionSri Lanka, 1940–1985 85% births attended by trained personnel Obstetric and Midwifery Practice

15. Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999. Obstetric and Midwifery Practice

16. 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

17. 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

18. Good Quality Maternity Services Will Save the Lives of Newborns AbouZahr and Wardlaw 2001. Obstetric and Midwifery Practice

19. Care During Pregnancy and Childbirth in Asia, Africa and Latin America (selected countries) Obstetric and Midwifery Practice

20. 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. Obstetric and Midwifery Practice

21. 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) Obstetric and Midwifery Practice

22. 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, 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

23. Changing Established Practices • Experience • Expert opinion • Evidence • Expectation Obstetric and Midwifery Practice

24. Evidence-Based Medicine Systematic, scientific and explicit use of current best evidence in making decisions about the care of individual patients Obstetric and Midwifery Practice

25. 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 Obstetric and Midwifery Practice

26. Levels of Evidence and Grades of Recommendations Obstetric and Midwifery Practice

27. Treatment Prevention Diagnostic method A Patient with desired characteristics SORTED Alternative treatment, prevention or diagnostic method vs. placebo B Obstetric and Midwifery Practice

28. Final Result 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

29. Interpretation of ResultsCalcium 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

30. Graphic Expression Relative Risk Protective Effect Deleterious Effect .1 .2 1 5 10 Obstetric and Midwifery Practice

31. .05 .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

32. .1 .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

33. 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) Obstetric and Midwifery Practice

34. Beneficial Forms of Care (cont’d) • 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

35. Management of Hypertension in Pregnancy Obstetric and Midwifery Practice

36. Magnesium Sulfate vs. Diazepam: Recurrence of Convulsions 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

37. Active vs. Physiological Management: Postpartum Hemorrhage Obstetric and Midwifery Practice Prendiville et al 1988, Rogers et al 1998.

38. Active vs. Physiological Management: Results Obstetric and Midwifery Practice

39. 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 Obstetric and Midwifery Practice

40. 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 Obstetric and Midwifery Practice

41. 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 Obstetric and Midwifery Practice

42. 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 Antenatal Care Practices Obstetric and Midwifery Practice

43. Essential Care Series Obstetric and Midwifery Practice

44. 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 Obstetric and Midwifery Practice

45. 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: 1295–1300. Obstetric and Midwifery Practice

46. References (cont’d) 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