|Care in Normal Birth (WHO, 1996, 60 p.)|
Despite considerable debate and research over many years the concept of normality in labour and delivery is not standardised or universal. Recent decades have seen a rapid expansion in the development and use of a range of practices designed to start, augment, accelerate, regulate or monitor the physiological process of labour, with the aim of improving outcomes for mothers and babies, and sometimes of rationalising work patterns in institutional birth. In developed countries where such activity has become generalised questions are increasingly raised as to the value or desirability of such high levels of intervention. In the mean time, developing countries are seeking to make safe, affordable delivery care accessible to all women. The uncritical adoption of a range of unhelpful, untimely, inappropriate and/or unnecessary interventions, all too frequently poorly evaluated, is a risk run by many who try to improve the maternity services. After establishing a working definition of normal birth this report identifies the commonest practices used throughout labour and attempts to establish some norms of good practice for the conduct of non-complicated labour and delivery.
The report addresses issues of care in normal birth irrespective of the setting or level of care. Its recommendations on those interventions which are or should be used to support the processes of normal birth are neither country nor region specific. Enormous variations exist worldwide as to the place and level of care, the sophistication of services available and the status of the caregiver for normal birth. This report aims simply to examine the evidence for or against some of the commonest practices and to establish recommendations, based on the soundest available evidence, for their place in normal birth care. In 1985 a meeting of the World Health Organization (WHO) European region, the regional office of the Americas, together with the Pan American Health Organization in Fortaleza, Brazil, made a number of recommendations based on a similar range of practices (WHO 1985). Despite this, and despite the rapidly increased emphasis on the use of evidence-based medicine, many of these practices remain common, without due consideration of their value to women or their newborns. This is the first time that a meeting involving childbirth experts from each of the WHO regions worldwide has had the opportunity to clarify, in the light of current knowledge, what they consider to be the place of such practices in normal birth care.
After debating the evidence, the working group classified its recommendations on practices related to normal birth into four categories:
A. Practices which are demonstrably useful and should be encouraged
B. Practices which are clearly harmful or ineffective and should be eliminated
C. Practices for which insufficient evidence exists to support a clear recommendation and which should be used with caution while further research clarifies the issue
D. Practices which are frequently used inappropriately
The first issue to be clarified is the sense in which the expression normal birth is used throughout this paper (see 1.4 below). It is vital to be specific on this if misinterpretation is to be avoided. A frequently cited statement concludes that childbirth can only be declared normal in retrospect. This widespread notion led obstetricians in many countries to conclude that care during normal childbirth should be similar to the care in complicated deliveries. This concept has several disadvantages: it has the potential to turn a normal physiological event into a medical procedure; it interferes with the freedom of women to experience the birth of their children in their own way, in the place of their own choice; it leads to unnecessary interventions; and, because of the need for economies of scale, its application requires a concentration of large numbers of labouring women in technically well-equipped hospitals with the concomitant costs.
With the global phenomenon of increasing urbanisation many more women are delivering in obstetric facilities, whether they are having normal or complicated births. There is a temptation to treat all births routinely with the same high level of intervention required by those who experience complications. This, unfortunately, has a wide range of negative effects, some of them with serious implications. They range from the sheer cost of time, training and equipment demanded by many of the methods used, to the fact that many women may be deterred from seeking the care they need because they are concerned about the high level of intervention. Women and their babies can be harmed by unnecessary practices. Staff in referral facilities can become dysfunctional if their capacity to care for very sick women who need all their attention and expertise is swamped by the sheer number of normal births which present themselves. In their turn, such normal births are frequently managed with standardised protocols which only find their justification in the care of women with childbirth complications.
This report is not a plea for any particular setting for birth, for it recognises the reality of a range of appropriate places, from home to tertiary referral centre, depending on availability and need. It simply aims to identify what constitutes sound care for normal birth, wherever that birth takes place. The point of departure for the safe achievement of any birth, the assessment of risk, requires a special study of its own, but a brief introduction to the concept is needed here before the components of care in labour are discussed.
An assessment of need and of what might be called birthing potential is the foundation of good decision making for birth, the beginning of all good care. What is known as the risk approach has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as at risk, with a concomitant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as high risk go on to have perfectly normal, uneventful births. Nonetheless, some form of initial and ongoing evaluation of a womans likelihood of giving birth normally is critical to preventing and/or identifying the onset of complications and the decisions which have to be made about providing appropriate care.
This report therefore starts with the question of the assessment of the woman embarking on labour. The assessment of risk factors starts during prenatal care. This can be attained in a relatively simple way by determining maternal age, height and parity, asking for complications in obstetric history such as previous stillbirth or caesarean section, and searching for abnormalities in the present pregnancy, such as pre-eclampsia, multiple pregnancy, ante partum haemorrhage, abnormal lie or severe anaemia (De Groot et al 1993). The risk assessment can also differentiate more extensively between individual risk factors and levels of care (Nasah 1994). In the Netherlands a list of medical indications for specialist care has been devised, distinguishing between low, medium and high risk (Treffers 1993). In many countries and institutions where a distinction is made between low-risk and high-risk pregnancies, comparable lists are in use.
The effectiveness of a risk scoring system is measured by its ability to discriminate between women at high and low risk, that is by its sensitivity, specificity, positive and negative predictive value (Rooney 1992). Exact figures about the discriminatory performance of these risk scoring systems are difficult to obtain, but from the available reports we may conclude that a reasonable distinction between low and high risk pregnancies can be made in developed and developing countries (Van Alten et al 1989, De Groot et al 1993). Defining obstetric risk by demographic factors such as parity and maternal height has a low specificity and therefore results in many uncomplicated deliveries being labelled as high risk. The specificity of complications in the obstetric history or in the present pregnancy is much higher. However, even high quality antenatal care and risk assessment cannot be a substitute for adequate surveillance of mother and fetus during labour.
Risk assessment is not a only-once measure, but a procedure continuing throughout pregnancy and labour. At any moment early complications may become apparent and may induce the decision to refer the woman to a higher level of care.
During prenatal care a plan should be made, in the light of the assessment, which identifies where and by whom labour will be attended. This plan should be prepared with the pregnant woman, and made known to her husband/partner. In many countries it is also advisable that the plan is known to the family, because they ultimately take the important decisions. In societies where confidentiality is practised other rules prevail: the family can only be informed by the woman herself. The plan should be available when labour starts. At that moment a reevaluation of the risk status takes place, including a physical examination to assess maternal and fetal well-being, fetal lie and presentation and the presenting signs of labour. If no prenatal care has been provided, an assessment of risk should be made at the time of the first contact with the caregiver during labour. Low-risk labour starts between 37 and 42 completed weeks. If no risk factors are identified labour can be considered as low-risk.
In defining normal birth two factors must be taken into consideration: the risk status of the pregnancy, and the course of labour and delivery. As already discussed, the predictive value of risk scoring is far from being 100% - a pregnant woman who is at low risk when labour starts may eventually have a complicated delivery. On the other hand, many high-risk pregnant women ultimately have an uncomplicated course of labour and delivery. In this report our primary target is the large group of low-risk pregnancies.
We define normal birth as: spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
However, as the labour and delivery of many high-risk pregnant women have a normal course, a number of the recommendations in this paper also apply to the care of this women.
According to this definition how many births can be considered normal? This will largely depend on regional and local risk assessment and referral rates. Studies on alternative birthing care in developed countries show an average referral rate during labour of 20%, while an equal number of women have been referred during pregnancy. In multiparous women the referral rates are much lower than in nulliparae (MacVicar et al 1993, Hundley et al 1994, Waldenstrt al 1996). In these studies risk assessment usually is painstaking, which means that many women are referred who will eventually end up with a normal course of labour. In other settings the number of referrals might be lower. In Kenya it was found that 84.8% of all labours were uncomplicated (Mati et al 1983). Generally, between 70 and 80% of all pregnant women may be considered as low-risk at the start of labour.
The aim of the care is to achieve a healthy mother and child with the least possible level of intervention that is compatible with safety. This approach implies that:
In normal birth there should be a valid reason to interfere with the natural process.
The tasks of the caregiver are fourfold:
· support of the woman, her partner and family during labour, at the moment of childbirth and in the period thereafter.
· observation of the labouring woman; monitoring of the fetal condition and of the condition of the infant after birth; assessment of risk factors; early detection of problems.
· performing minor interventions, if necessary, such as amniotomy and episiotomy; care of the infant after birth.
· referral to a higher level of care, if risk factors become apparent or complications develop that justify such referral.
This description assumes that referral to a higher level of care can be easily realized. In many countries that is not the case; special regulations are then necessary to enable primary caregivers to perform life saving tasks. This implies additional training, and adaptation of legislation to support the caregiver in these tasks. It also implies agreement amongst caregivers regarding their responsibilities (Kwast 1992, Fathalla 1992).
The birth attendant should be able to fulfil the tasks of the caregiver, as formulated earlier. He or she should have a proper training and a range of midwifery skills appropriate to the level of service. At the least, these should permit the caregiver to assess risk factors, recognise the onset of complications, perform observations of the mother and monitor the condition of the fetus and the infant after birth. The birth attendant must be able to perform essential basic interventions and to take care of the infant after birth. He or she should be able to refer the woman or the baby to a higher level of care if complications arise which require interventions which are beyond the caregivers competence. Last but not least, the birth attendant should have the patience and empathetic attitude needed to support the woman and her family. Where possible, the caregiver should aim at providing continuity of care during pregnancy, childbirth and post partum period, if not in person then by the way that care is organised. Various professionals can be considered to fulfil these tasks:
· The obstetrician-gynaecologist: these professionals are certainly able to deal with the technical aspects of the various tasks of the caregiver. Hopefully they also have the required empathetic attitude. Generally obstetricians have to devote their attention to high-risk women and the treatment of serious complications. They are normally responsible for obstetric surgery. By training and by professional attitude they may be inclined and indeed, are often required by the situation, to intervene more frequently than the midwife. In many countries, especially in the developing world, the number of obstetricians is limited and they are unequally distributed, with the majority practising in big cities. Their responsibilities for the management of major complications are unlikely to leave them much time to assist and support the woman and her family for the duration of normal labour and delivery.
· The general physician and the general practitioner: the theoretical and practical training in obstetrics of these professionals varies widely. Certainly there are well-trained practitioners who are able to fulfil the tasks of the caregiver in primary care obstetrics and thus in normal birth. However, for general practitioners obstetrics is usually only a small part of their training and daily duty, and therefore it is difficult to keep up the skill and to remain up-to-date. General physicians working in developing countries often devote much of their time to obstetrics and are thus quite experienced, but may have to give more attention to obstetric pathology than to normal childbirth.
· The midwife: the international definition of the midwife, according to WHO, ICM (International Confederation of Midwives) and FIGO (the International Federation of Obstetricians and Gynaecologists) is quite simple: if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife (Peters 1995). Generally she or he is a competent caregiver in obstetrics, especially trained in the care during normal birth. However, there are wide variations between countries with respect to training and tasks of midwives. In many industrialized countries midwives function in hospitals under supervision of obstetricians. Usually this means that the care in normal birth is part of the care in the whole obstetric department, and thus subject to the same rules and arrangements, with little distinction between high-risk and low-risk pregnancies.
The effect of the International Definition of the Midwife is to acknowledge that different midwifery education programmes exist. These include the possibility of training as a midwife without any previous nursing qualification, or direct entry as it is widely known. This form of training exists in many countries, and is experiencing a new wave of popularity, both with governments and with aspiring midwives (Radford and Thompson 1987). Direct entry to a midwifery programme, with comprehensive training in obstetrics and related subjects such as paediatrics, family planning, epidemiology etc. has been acknowledged as both cost-effective and specifically focused on the needs of childbearing women and their newborn. More important than the type of preparation for practice offered by any government is the midwifes competence and ability to act decisively and independently. For these reasons it is vital to ensure that any programme of midwifery education safeguards and promotes the midwives ability to conduct most births, to ascertain risk and, where local need dictates, to manage complications of childbirth as they arise (Kwast 1995b, Peters 1995, Treffers 1995). In many developing countries midwives function in the community and health centres as well as in hospitals, often with little or no supervisory support. Efforts are being made to promote an expanded role of midwives, including life-saving skills in several countries in many parts of the world (Kwast 1992, OHeir 1996).
· Auxiliary personnel and trained TBAs (traditional birth attendants): in developing countries which have a shortage of well-trained health care personnel the care in villages and health centres is often committed to auxiliary personnel, such as auxiliary nurse/midwives, village midwives or trained TBAs (Ibrahim 1992, Alisjahbana 1995). Under certain circumstances this may prove inevitable. These persons have at least some training and frequently provide the backbone of maternity services at the periphery. The outcome of pregnancy and labour can be improved by making use of their services, especially if they are supervised by well-trained midwives (Kwast 1992). However, for the fulfilment of the complete set of tasks of the caregiver as described above their education is frequently insufficient, and their background may mean that their practice is conditioned by strong cultural and traditional norms which may impede the effectiveness of their training. Nonetheless, it should be acknowledged that it is precisely this close cultural identification which often makes many women prefer them as caregivers for birth, especially in rural settings (Okafor and Rizzuto 1994, Jaffre and Prual 1994).
From the above account, the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications. Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:
· To make it more accessible to women in greatest need, each function of maternity care should be carried out at the most peripheral level at which it is feasible and safe.
· To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively.
· In many countries, midwives and assistant nurse-midwives, located in small health centres, require a higher level of support if maternity care is to be effectively provided for and with the community.
These recommendations point to the midwife as the basic health care provider in obstetrics delivering care in small health centres, in villages and at home, and perhaps also in hospitals (WHO 1994). Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth. However, in many developed and developing countries midwives are either absent or are present only in large hospitals where they may serve as assistants to the obstetricians.
In 1992 the House of Commons Health Committee report on maternity services was published in the United Kingdom. Among other things, it recommended that midwives should carry their own caseload and take full responsibility for the women in their care; midwives should also be given the opportunity to establish and run midwife-managed maternity units within and outside hospitals (House of Commons 1992). The report was followed by the Expert Maternity Group report Changing Childbirth (Department of Health 1993) with comparable recommendations. These documents are first steps towards increased professional independence for midwives in Britain. In a few European countries midwives are fully responsible for the care of normal pregnancy and childbirth, either at home or in hospital. But in many other European countries and in the USA almost all midwives (if present) practise in hospital under the supervision of the obstetrician.
In many developing countries the midwife is considered the key person in the provision of maternity care (Mad 1994, Chintu and Susu 1994). However, that is not the case in all: some face a shortage of midwives. Especially in Latin America, schools of midwifery have been closed down, on the assumption that physicians would cover the tasks. In some countries the number of midwives is declining, and those that are present are maldistributed: the majority work in hospitals in towns, and not in the rural areas where 80% of the population lives and consequently most of the problems lie (Kwast and Bentley 1991, Kwast 1995b). It is recommended that more midwives be trained, and that consideration be given to the location of the training schools so that they are easily accessible to women and men from rural areas who are thus more likely to stay in the community they come from. The training should be such that midwives can meet the needs of the communities they are going to serve. They should be able to identify complications which require referral, but if referral to a higher level of care is difficult they should be able to perform life saving interventions.