ADDRESSING RESPECTFUL MATERNITY CARE: Reducing the medicalisation of maternal and

1. ADDRESSING RESPECTFUL MATERNITY CARE: Reducing the medicalisation of maternal and newborn care

2. Session Objectives The objectives of this session are to: • Review the concept of ‘medicalised’care • Provide examples of care that can reduce harmful practices • Share examples of evidence-based interventions • Share suggestions on how to keep birth ‘normal’

3. What Is Medicalised Maternaland Newborn Care? The routine use of practices during labor and childbirth that: • Are not evidence-based • Are unnecessary or unwarranted • Are unfamiliar and often undesirable to women • 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. What Drives Medicalised Maternaland Newborn Care? • Medico-legal pressures • Profit • Non-evidence-based beliefs within the medical community, established practices • Convenience for providers • Perception/illusion of safety • Fear: the desire to control birth and reduce risk • Desire to use technology

5. What Drives Medicalised Maternaland Newborn Care? • What drives medicalised maternal and newborn care in your practice/place of work? • Consider the origins of the practice – Do you know if it is evidence-based? Take 10 minutes to think about the following questions:

6. Why Does Medicalisation Matter? • Cost can be higher • Can reduce access to interventions for those who really need them • Can lead to poorer health outcomes • Does not involve woman fully in decision making, results in her discomfort and disempowerment = disrespectful care • Evidence suggests that higher rates of normal births are linked to provider beliefs about birth, implementation of evidence-based practice, and team working (BMJ 2002)

7. For more information on themedicalisation of childbirth… http://www.k4health.org/ toolkits/rmc/powerpoint-medicalization-mnh-care

8. Respectful Maternal and 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

9. Reversing the Trend: Partnership in Care Aim to provide respectful maternity care that: • is woman-centered, empowering and supportive • is evidence-based and shown to be beneficial • permits free communication and full expression of trust and commitment • ensures all women are treated equitably

10. ASK: What do Women Want? For example… Respectful maternity care – kindness, respect, information Availability of drugs and medical equipment in clean facilities Support persons in labor and birth Culturally appropriate services

11. Finding Evidence How do you know if one treatment will work better than another, or if it will do more harm than good? • Cochrane Reviewshttp://www.cochrane.org/cochrane-reviews

12. Common Medicalised PracticesThat Are Harmful • Restricting ambulation/different positions during labor and choice of birth position • Lack of companion/family during labor • Over-use of anesthesia/analgesia • Administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled • Restricting food and fluids • Separation of mother and baby • Early cord clamping • Routine episiotomy

13. Unnecessary/Routine Episiotomies • Episiotomies can reduce maternal and neonatal morbidity if they are restricted to evidence-based indications (WHO 2006) • Associated morbidity includes perineal damage by tears, pain and dyspareunia

14. Restrictive Episiotomy vs.Routine Episiotomy Restrictive episiotomy policies found that women experienced: • less severe perineal trauma • less posterior perineal trauma • less suturing and fewer healing complications at seven days • with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth • Overall, women experienced more anterior perineal damage with restrictive episiotomy http://summaries.cochrane.org/CD000081/ episiotomy-for-vaginal-birth#sthash.DHo9cyUN.dpuf

15. Choice of Birth Position Gravity is our greatest aid in giving birth, but for historical and cultural reasons we make women give birth on their backs. • Choice of positions for labor and birth encourages a woman’s sense of control and reduces need for analgesia

16. Choice of Birth Position (cont.) • Women who assumed a nonsupine position for birth: • had fewer perineal injuries • had less vulvar edema • had less blood loss • Women choosing nonsupine position for birth: • had shorter second stages • required less pain relief medication • had fewer abnormal fetal heart rates Alternate Positions

17. Midwife-Led Care Linked to Less Medicalisation: Sandal 2013 Women who had midwife-led continuity models of care were… …more likely to experience: • no intrapartum analgesia/anaesthesia • spontaneous vaginal birth • attendance at birth by a known midwife • a longer mean length of labour (hours) • satisfaction with services OUTCOMES …less likely to experience: • preterm birth • fetal loss before 24 weeks' gestation There were no differences between groups for caesarean births. …less likely to experience: • regional analgesia • episiotomy • instrumental birth http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD004667.pub3/abstract

18. Campaign for ‘Normal Birth’:Tips for Providers • Wait and see • Get her off the bed • Justify intervention • Listen to her • Be a role model • Be positive • Promote ‘skin-to-skin’ contact http://www.rcmnormalbirth.org.uk/practice/ten-top-tips

19. Support Persons • The presence of a birth companion improves birth outcomes and the overall birth experience • Continuous empathetic and physical support is associated with shorter labour, less medication and fewer operative deliveries. http://summaries.cochrane.org/CD003766/continuous-support-for-women-during-childbirth

20. Keep Mother and Baby Together The day of birth is the most dangerous day for mother and babyState of the World’s Mothers Report, SC 2013 • Promote warming with ‘skin-to-skin’ after birth • Promote early and exclusive breastfeeding • Ensure mother counselled on danger signs

21. Cord Clamping World Health Organization (2012) recommends delayed cord clamping • Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.

22. Cord Clamping (cont.) Benefits include: • Increased iron stores at birth and less infant anemia • Decreased intraventricularhemorrhage • Less necrotizing enterocolitis • Less infant sepsis • Fewer blood transfusions needed

23. Be Accountable! • Take responsibility for your own actions • Provide care that is evidence-based and shown to be beneficial • Do no harm • Record and report • Communicate • Be the woman’s advocate • Explore opportunities for collaborative working and team building to improve respectful quality of care

24. We all have a role in assuring that women have respectful maternity care! THANKS!