Promoting evidence based practice in maternal care

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 Unpublished report).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.

5. http://www.liv.ac.uk/lstm/bbimainpage.html

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.

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.

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.