Reducing the Medicalization of
Maternal and Newborn Care
July 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
 Provide examples of MNH care
practices that are harmful
 Provide evidence to support the
harmfulness of these examples
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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
 Shift power from woman to provider
 Encourage technology or
interventions without proven benefit
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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
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Symbols of a Medicalized Model:
Centered on the Professional Care Giver
 Centered on the
professional
 Disempowerment
of the woman
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Symbols of a Medicalized Model:
Woman without Companion
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Symbols of a Medicalized Model:
Family Unit Separated During Labor & Delivery
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Practices that May Be Harmful or Life-Saving
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Induction or augmentation of labor
Cesarean section
Episiotomy
Restricting food and fluid
Electronic fetal monitoring
Routine nasal suctioning of newborn
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Practices That Are Harmful
 Restricting ambulation/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 or shaving
9
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)
10
Unnecessary Cesarean Sections
 WHO standard is 5-15%
 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
 Local and national savings
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(Gibbons 2012)
Unnecessary C-Sections (cont.)
 Increasingly indications are subjective and non-clinical
 Data for 106,546 births found rate of cesarean
delivery was positively associated with:
 Postpartum antibiotic treatment
 Severe maternal morbidity and mortality
 Increase in fetal 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)
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Unnecessary C-Sections (cont.)
 Detrimental to births following C-section
 Study: 10,684 women – 2,680 had prior C-S; 7,974
had prior VD
 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 VD
(Galyean 2009)
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Unnecessary/Routine Episiotomies
 Episiotomies can reduce maternal morbidity if they are
restricted to specific indications rather than routinely
 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 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, 1.183.81)
(Belizan 1993; Rodriquez 2008)
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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)
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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
 Women who ambulated during the first stage of
labor were less likely to have C-S, forceps or
vacuum extraction (Albers, 1997)
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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), less vulvar edema, and 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)
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Unnecessary Electronic Fetal Monitoring
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
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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)
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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)
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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)
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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)
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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; RoweMurray, 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)
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Unnecessary Nasal 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, and
 delays in achieving normal oxygen saturations.
Based on the currently available literature, routine
suctioning is more likely to cause harm than good
Velaphi 2008
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Early Cord Clamping – Term Infant
 Evidence has problems with definitions, i.e. “early” vs “late”
 In 11 trials of 2989 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 haemoglobin 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 six months.
 Infant ferritin levels remained higher in the late clamping
group than the early clamping group at six months
McDonald 2008
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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 anaemia (RR
0.61, 95% confidence interval (CI) 0.46 to 0.81),
 less intraventricular haemorrhage (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
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Respectful Maternal & Newborn Care
Respectful care demonstrates:
 Respect for a woman’s rights, choices, and
dignity
 Care that “does no harm”
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WE ALL HAVE A ROLE IN ASSURING THAT
WOMEN HAVE RMC!
THANKS!