Promoting evidence based practice in maternal care
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7343.928 (Published 20 April 2002) Cite this as: BMJ 2002;324:928All rapid responses
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Dear Ana and Jose:
I enjoyed reading your article and entirely agree in that informed
choices is the strategy to raise awareness in women and their families for
improving normalcy, thus safety, in birth.
I strongly believe that the implementation of non exisiting models,
specially those trained in the physiology of birth, such as holistic
midwifery should be established, as part of the resources in public health
teams. I specifically refer to the case of Mexico, where I work, and also
to other countries.
Last week, six midwives from Argentina, Chile, Urugay and Bolivia met
in our workplace. Together, South American and Mexican midwives discussed
a schema of why women are allowing themselves and their babies to have so
much technological intervention. The similarity of concepts was amazing.
Ana, we need people like you participating in a recent launching of a
national network for the Humanization of Birth: REMEXHUPAN, part of a
Latin American and Caribbean network RELACAHUPAN.
Thanks in advance for you contacting us at:
lauracao@att.net.mx or ticime@laneta.apc.org
Competing interests: No competing interests
Sir-Béhague and colleagues found that women want Caesarean sections
in developing countries partly to avoid pain (1). We have some data that
show severe pain during childbirth is common in developing country
institutional deliveries. We believe this is a large, unmet need.
In 1998, with Kassam Mahomed from the University of Zimbabwe, we
measured current practice at Harare Hospital. We extracted information on
use of enema, amniotomy, pethidine and episiotomy from 501 patient notes.
At this busy hospital where resources are limited, we found that pethidine
was given to 75/501 women during vaginal delivery; other forms of pain
relief were rarely provided because of shortage of anaesthetic and nursing
staff. We conducted exit interviews on a sample of women by visiting on
selected days. From the 62 postnatal women identified, we asked them to
categorise the severity of pain with these options: tolerable without pain
relief, tolerable with pain relief, not tolerable with pain relief, and
not tolerable and no pain relief given. Forty percent of women said the
pain during childbirth was not tolerable and no pain relief was available
for these women. (Mahomed K, Smith H, Garner P. Quality of childbirth care
in a government hospital in Harare. Unpublished report).
In 1999, with Qian Xu from Fudan University, we used a similar survey
in four hospitals in Shanghai. We used a structured interview with 150
postnatal women per hospital to document practices used during childbirth.
We asked women if pain relief was given during labour and to describe pain
using a scale of options: lumbago or slight discomfort, tolerable pain and
sleeping undisturbed, obvious pain and sleeping disturbed, and severe
intolerable pain. Acupuncture, epidural anaesthesia, abdominal massage,
diazepam and pethidine are the most commonly used methods. Pain relief was
provided for less than 27% of women at all four hospitals, yet over half
of the women who delivered vaginally (157/303) said they could not
tolerate labour pain and 34% (103/303) said they could not sleep because
of the pain. Episiotomy was used routinely, with rates above 85% in three
hospitals, and half the deliveries were by caesarean section (296/599).
Excluding the women who had clear medical indications for caesarean
section, in-depth interviews revealed that women frequently preferred a
caesarean section, and their reasons were for the good of the child, and
fear of pain during vaginal delivery (2).
Making childbirth less painful might include better quality health
services, which can be achieved by encouraging use of specific
interventions that are beneficial and assist women during childbirth.
Allowing lay companions to be present reduces the need for medication for
pain relief and the likelihood of caesarean section (3); where this is not
possible, ensuring access to an appropriate form of analgesia will help.
As Langer and Villar point out (4), promoting evidence-based practice
in maternal care is not easy. We have recently tried this by targeting a
few simple changes that will reduce pain and improve women’s experience.
Simply reducing the use of enemas, perineal shaving, and routine
episiotomies will do a lot to reduce unnecessary pain and discomfort
during childbirth. The Better Births Initiative (5) is proving successful
in pilot studies in South Africa; it helps improve the quality of
childbirth experience and hence may help reduce the demand for Caesarean
sections.
1. Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean
sections in Brazil: population based cohort study linking ethnographic and
epidemiological methods. BMJ 2002;324:942-5.
2. Qian X, Smith H, Zhou L, Liang J, Garner P. Evidence-based
obstetrics in four hospitals in China: An observational study to explore
clinical practice, women's preferences and provider's views. BMC Pregnancy
and Childbirth 2001, 1:1.
3. Hodnett ED. Caregiver support for women during childbirth
(Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software.
4. Langer A, Villar J. Promoting evidence based practice in maternal
care. BMJ 2002;324:928-9.
Competing interests: No competing interests
We are often reminded by the BMJ to loosen our paternalistic grip on
the patient, to put patients first and to encourage patients to make
informed decisions about their care. The editorial by Langer and Villar1
suggests that when women make decisions that do not conform to the
evidence as we perceive it that they must be making this decision for the
wrong reason - "to avoid negative side effects" rather than "from a
positive attitude based on accurate information...". They imply the
women's choice is therefore incorrect and we should attempt educate the
women to choose the correctly.
Perhaps in Brazil the quality of care for a caesarian section is
better than that for other methods of delivery and the women are making a
valid informed decision whether we like it or not. Of course this may not
be the case. In either scenario unfortunately the human mind does not
conform to the logic that given certain information we will all choose the
"right" answer, assuming there is a body of opinion that can decide
exactly what the "right" answer is!
When patients make the "wrong" informed choice then out of the
swirling mists of political correctness appears paternalism, it had never
left us.
Reference.
1. Langer A, Villar J. Promoting evidence based practice in maternal
care. BMJ 2002; 324: 928-929
Yours sincerely
Dr. Richard Seigne
Competing interests: No competing interests
Though it is a well noted fact that women's request for a caesarean
delivery is one of the contributing factors in the increasing caesarean
rates world over, it is definitely surprising to know about the underlying
reasons for such requests.
However in my own place of work we face a totally different kind of
problem. Here women insist on vaginal birth in the face of well
recognised medical or obstetric indications for ceasarean birth. There are
incidences where we were helpless in the face of a woman's consent for a
caesarean delivery with previous two caesarean deliveries , and had to be
mute observers of vaginal delivery, anticipating the dreaded complication
of a uterine rupture.
Most of these obsessive women belong to lower educational status and
grandmultiparity. Does it all go to emphasise that lack of education makes
them endanger their lives with dogmatic decisions, just as a higher
education too makes them take an irrational decision?
In the light of the above facts I feel the health care providers have a
great role in adequate counselling regarding the indications for caesarean
birth.
Competing interests: No competing interests
OVER YEARS IN URBAN INDIA THE CONFINEMENT HAS SHIFTED FROM HOME TO
THE HOSPITAL WHERE THE PREGNANT WOMAN WHO IS MIDDLE CLASS AND SOME TIMES
BELONGING TO UPPER ECONOMIC GROUP GENERALLY OPTS FOR ONE OR TWO CHILDERN,
IT IS EASY TO MOTIVATE THEM TO HAVE SESARIAN SECTIONS.
sUCH SUREGERIES EVEN IN WOMEN WHO WOULD HAVE DELIVERED NORMAL BABIES IS ON
THE INCREASE.In one recent study it is more than 40%
The reasons are obious apart from definite indications the main indication
is money.
The sad part of it IS THAT no body seem to protest much less the hapless
patienT. The community doctors have no say as these deliveries occur in
the institutions.
IT IS DIFFICULT TO REVERSE THIS TREND IN THE PREVAILING SOCIO ECONOMIC
SCENARIO AND FALLING ETHICAL STANDARDS IN THIS COUNTRY,
Competing interests: No competing interests
It is pertinent that there should be a continued effort to reduce
Caesarean section rates worldwide. It was surprising however to find the
authors had missed a key factor in reducing caesarean section rates-
something that was highlighted recently in the journal (Has the
Medicalization of birth gone too far? Johansson R Newburn M MacFarlane A
BMJ 2002 324 892-895).
That is the contribution of one-to-one support in labour- ideally a
relationship between caregivers that has developed during the antenatal
period. Of course if women have devloped this relationship with an
Obstetrician and built up trust she will listen to him when he sugggests
she pays for a caesarean section as well. Where women have bulit up
relationships with midwives they are more likely to end up with a normal
birth.
Competing interests: No competing interests
It is encouraging to see such reports are published to address true
challenges in maternity care. The misuse of power, authority and
knowledge by some health care providers are real issues which have not
even been considered as a problem in some developing countries.
All the issues raised in the above paper such as the social gap between
the consumers and providers, poor labour care (e.g. lack of access to
effective pain relief) leaves women to accept or even to choose the most
invasive methods of labor. Anecdotally, the caesarean section mode of
delivery is sold to women as a cosmetically superior option to the normal
labor! As sad as it looks in some countries, the choice of caesarean
section is followed as a fashion and in public belief it is used as a
measure of one’s wealth and fortune! The informed choice is not even an
option for many women attending overcrowded clinics. The financial gains
and convenience of an elective caesarean section as opposed to a
demanding, unpredictable sometimes sleep disturbing labor and delivery
care for some health professionals may outweigh a conscious and just
choice for mothers. This also highlights the inherited dangers of private
health system where the health care professionals directly benefit from
consumer’s choices of treatment and allows opportunities to exploit
vulnerable groups!
We welcome the authors’ suggestion in integrating developing countries
publications and introducing rigorous changes to improve women’s condition
and health worldwide. It certainly is time for World Health Organisation
to take a more proactive role in introducing more systematic approaches to
promote evidence based practice and informed choice globally.
Competing interests: No competing interests
I was also surprised by the assertion in the editorial that Béhague,
et al, "contradict" studies that indicate most cesareans are unwanted.
The way that I interpret Béhague, et al, is quite consistent with the
other studies.
Béhague, et al, show that in a social context in which rich woman
overwhelmingly have cesareans, poor women interpret cesareans as "better
medical care" and therefore actively seek it out. But this doesn't answer
why the prevalence of Cesarean sections is there in the first place.
Financial incentives are the most logical explanation for huge gaps
between private hospitals (with generally wealthier lower risk mothers)
and public hospitals (who admit mothers with less income and are
reimbursed less for Cesareans). Once patterns are established for the
wealthy, it is not surprising to see a shift in preferences in the rest of
the population.
Most of the literature on how financial incentives (and doctor's
convenience) affect cesarean rates comes from the United States and
Brazil. However, a recent study in Peru confirms that after controlling
for a variety of risk factors, hospital ownership and payment mechanisms
have a statistically significant impact on the decision to do a cesarean.
See Lorena Alcázar and Raúl Andrade "Induced Demand and Absenteeism in
Peruvian Hospitals", Ch. 5 in R. Di Tella and W. Savedoff, *Diagnosis
Corruption: Fraud in Latin America's Public Hospitals*, Inter-American
Development Bank, Washington, DC, 2002.
Competing interests: No competing interests
Any uterine incision that extends to interrupt the lateral
neurovascular bundle threatens the innervation of the anterior uterine
wall above this level. Recurrent, preterm and late Caesarean section may
be frequent causes. Focal, hyperechoic changes of the anterior uterine
wall may reflect disruption of the normal vascular patterns. Severe
adenomyosis is strongly associated with uterine denervation (1) and may
require hysterectomy in later life (another denervatory event).
Disruption of myofascial pelvic supports during labour inevitably
damages branches of the inferior hypogastric plexi (denervation) and may
create the conditions for reinnervation. Collateral sprouting and
chaotic, small-diameter nerve fibres have been identified in uterus,
vagina, vulva, uterosacral ligaments and bladder (2). Chronic pelvic
pain, menstrual dysfunction, dysmenorrhoea, dyspareunia, irritative
bladder and bowel symptoms are the contemporary labels for these
consequences.
Both abdominal and vaginal delivery carry clear though unquantified
threats to the pelvic innervation. The epidemic of teenage pregnancy is
bringing serious gynaecological problems to the clinic in women under the
age of twenty five. What happens to a woman during her first delivery
(abdominal or vaginal) may place her on a trajectory of pain and misery
for the rest of her life. If Brazilian women were aware of these concerns
would they submit themselves to Caesarean section in their present numbers
(3) ? Obstetric fashion needs to be replaced by robust facts about the
remote consequences of different patterns of labour and delivery.
Comprehensive and appropriate datasets are available; some better
questions may have to be asked ?
MJ Quinn, MD, MRCOG, Hinchingbrooke Hospital, Huntingdon, PE29 6NT.
martin.quinn@hbhc-tr.anglox.nhs.uk
(1) Differences in uterine innervation at hysterectomy.
MJ Quinn, N Kirk, MC Slack, MD Harris.
Presented at Society of Gynecological Surgeons, Dallas, March 2002.
(2) Obstetric denervation – Gynecologic reinnervation
MJ Quinn, N Kirk, MC Slack, MD Harris.
Am J Obstet Gynecol 2002;, Jan; 186(1):168.
(3) Consumer demand for caesarean sections in Brazil: population
based birth cohort study linking ethnographic and epidemiological methods.
Behague DP, Victora CG, Barros FC,
BMJ 2002; 324:942-945.
Competing interests: No competing interests
Spread of World Health Organization Reproductive Health Library Information to Doctors in India
In this article there is mention of health providers needing to
identify ways to make updated evidence available to practitioners in a
user-friendly format such as the World Health Organization's reproductive
health library.
Towards this we have established Recon Healthcare Bangalore Model
(RHBM) through which within a period of 7 months, 1346 doctors have been
given the information they need pertaining to women's heath care from WHO-
RHL in a cost ineffective manner. The expense incurred has been Rs. 46 per
doctor (0.604 GBP). The existing organisation infrastructure was used for
this purpose. This service has been offered to doctors free of cost. In a
country as vast as India, spread of communication regarding latest health
information to doctors is difficult. Through our RHBM it has been shown
this is possible and achievable by linking academia with the industry.
From an expected response of 3130, we have received 1346 responses
(43%) for one-time questionnaire. 88.87% of doctors found the write-up
useful and 83.73% stated that this helped in improving patient care.
To the best of our knowledge, such an activity has not been carried
out anywhere in the world. The WHO has a wonderful opportunity to take up
such models and spread the knowledge relating to women’s healthcare all
over the world very rapidly.
Competing interests:
None declared
Competing interests: No competing interests