Changing Obstetric and Midwifery Practice

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

2. Obstetric and Midwifery Practice Maternal Mortality Ratios by Country in Latin America, Asia and Africa

3. Obstetric and Midwifery Practice 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 For each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy and childbirthFor each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy and childbirth

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

5. Obstetric and Midwifery Practice Causes of Maternal Death

6. Obstetric and Midwifery Practice Interventions to Reduce Maternal Mortality Historical review Traditional birth attendants Antenatal care Risk screening Current approach Skilled provider at childbirth Review of the past interventions: Traditional birth attendants and antenatal care still play a role, but the role needs clarification.Review of the past interventions: Traditional birth attendants and antenatal care still play a role, but the role needs clarification.

7. Obstetric and Midwifery Practice 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 Wide use of antenatal care in UK, US and Australia. Still, maternal mortality in US was 700/100.000 in 1940s.Wide use of antenatal care in UK, US and Australia. Still, maternal mortality in US was 700/100.000 in 1940s.

8. Obstetric and Midwifery Practice 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 Risk screening is another intervention that has been used. It is problematic because only about 10�15% of women who are thought to be �at risk� for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If �risk factors� are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.Risk screening is another intervention that has been used. It is problematic because only about 10�15% of women who are thought to be �at risk� for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If �risk factors� are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.

9. Obstetric and Midwifery Practice 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

10. Obstetric and Midwifery Practice 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�

11. Obstetric and Midwifery Practice 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

12. Obstetric and Midwifery Practice Interventions: Traditional Birth Attendants 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

13. Obstetric and Midwifery Practice 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 Midwifery skills: Provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.Midwifery skills: Provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.

14. Obstetric and Midwifery Practice Maternal Mortality ReductionSri Lanka, 1940�1985

15. Obstetric and Midwifery Practice Maternal Mortality: UK 1840�1960 Other interventions can make a difference, but not as substantial as skilled providers. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled providers who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and to be prepared to handle them.Other interventions can make a difference, but not as substantial as skilled providers. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled providers who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and to be prepared to handle them.

16. Obstetric and Midwifery Practice

17. Obstetric and Midwifery Practice

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

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

20. Obstetric and Midwifery Practice 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 A skilled provider should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.A skilled provider should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.

21. Obstetric and Midwifery Practice 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)

22. Obstetric and Midwifery Practice Solutions for Maternal and Newborn Survival 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

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

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

25. Obstetric and Midwifery Practice 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

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

27. Obstetric and Midwifery Practice

28. Obstetric and Midwifery Practice Final Result

29. Obstetric and Midwifery Practice Interpretation of ResultsCalcium Supplementation to Prevent Gestational Hypertension

30. Obstetric and Midwifery Practice Graphic Expression

31. Obstetric and Midwifery Practice Antenatal Fetal Monitoring

32. Obstetric and Midwifery Practice External Cephalic Version More Than 37 Weeks

33. Obstetric and Midwifery Practice 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)

34. Obstetric and Midwifery Practice 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)

35. Obstetric and Midwifery Practice Management of Hypertension in Pregnancy

36. Obstetric and Midwifery Practice Magnesium Sulfate vs. Diazepam: Recurrence of Convulsions Magnesium sulfate reduced convulsions by 55% compared to diazepam.Magnesium sulfate reduced convulsions by 55% compared to diazepam.

37. Obstetric and Midwifery Practice Active vs. Physiological Management: Postpartum Hemorrhage

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

39. Obstetric and Midwifery Practice 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

40. Obstetric and Midwifery Practice 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

41. Obstetric and Midwifery Practice 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

42. Obstetric and Midwifery Practice Antenatal Care Practices 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

43. Obstetric and Midwifery Practice Essential Care Series

44. Obstetric and Midwifery Practice 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

45. Obstetric and Midwifery Practice References

46. Obstetric and Midwifery Practice References (cont�d)