1. ADDRESSING
RESPECTFUL
MATERNITY CARE:
Reducing the
medicalisation of
maternal and
newborn care

2. Session Objectives The objectives of this session are to:
Review the concept of ‘medicalised’ care
Provide examples of care that can reduce harmful practices
Share examples of evidence-based interventions
Share suggestions on how to keep birth ‘normal’
MNH care practices that may be harmful or life-saving – depending on the context in which they are used

3. What Is Medicalised Maternal and Newborn Care?
The routine use of practices during labor and childbirth that:
Are not evidence-based
Are unnecessary or unwarranted
Are unfamiliar and often undesirable to women
Do not improve the health outcomes for mother or baby and may do harm
Prioritize needs of providers over needs of women
Encourage technology or interventions without proven benefit
Over the last three decades, care in pregnancy and labour has undergone significant changes. One consequence of these changes has been that midwives, doctors and childbearing women have become more dependent on technology in labour and birth. This is despite recommendations that a greater emphasis should be placed on the social context of childbirth and health. ACTIVITY – In small groups select an everyday practice in your setting. Discuss the origins of the practice. Do you know if it’s evidence-based…?

4. What Drives Medicalised Maternal and Newborn Care?
Medico-legal pressures
Profit
Non-evidence-based beliefs within the medical community, established practices
Convenience for providers
Perception/illusion of safety
Fear: the desire to control birth and reduce risk
Desire to use technology

5. What Drives Medicalised Maternal and Newborn Care?
Take 10 minutes to think about the following questions:
What drives medicalised maternal and newborn care in your practice/place of work?
Consider the origins of the practice – Do you know if it is evidence-based?

6. Why Does Medicalisation Matter?
Cost can be higher
Can reduce access to interventions for those who really need them
Can lead to poorer health outcomes
Does not involve woman fully in decision making, results in her discomfort and disempowerment = disrespectful care
Evidence suggests that higher rates of normal births are linked to provider beliefs about birth, implementation of evidence-based practice, and team working (BMJ 2002)

7. For more information on the medicalisation of childbirth…
toolkits/rmc/powerpoint-medicalization-mnh-care

8. Respectful Maternal and Newborn Care
Respectful care demonstrates:
Respect for a woman’s rights, choices and dignity
Care that “does no harm”
Care that promotes positive parenting and improves birth outcomes
Care that is culturally sensitive and valued by the woman and her community

9. Reversing the Trend: Partnership in Care
Aim to provide respectful maternity care that:
is woman-centered, empowering and supportive
is evidence-based and shown to be beneficial
permits free communication and full expression of trust and commitment
ensures all women are treated equitably

10. ASK: What do Women Want? For example…
Respectful maternity care – kindness, respect, information
Availability of drugs and medical equipment in clean facilities
Support persons in labor and birth
Culturally appropriate services

11. Finding Evidence
How do you know if one treatment will work better than another, or if it will do more harm than good?
Cochrane Reviews

12. Common Medicalised Practices That Are Harmful
Restricting ambulation/different positions during labor and choice of birth position
Lack of companion/family during labor
Over-use of anesthesia/analgesia
Administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled
Restricting food and fluids
Separation of mother and baby
Early cord clamping
Routine episiotomy
Ask, Can you name some others?
Enemas, shaving are some other examples.

13. Unnecessary/Routine Episiotomies
Episiotomies can reduce maternal and neonatal morbidity if they are restricted to evidence-based indications (WHO 2006)
Associated morbidity includes perineal damage by tears, pain and dyspareunia
Although routine episiotomies are not recommended, restricted episiotomies may be indicated for avoiding severe maternal perineal lacerations or expediting/facilitating difficult deliveries.

14. Restrictive Episiotomy vs. Routine Episiotomy
Restrictive episiotomy policies found that women experienced:
less severe perineal trauma
less posterior perineal trauma
less suturing and fewer healing complications at seven days
with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth
Overall, women experienced more anterior perineal damage with restrictive episiotomy
episiotomy-for-vaginal-birth#sthash.DHo9cyUN.dpuf

15. Choice of Birth Position
Gravity is our greatest aid in giving birth, but for historical and cultural reasons we make women give birth on their backs.
Choice of positions for labor and birth encourages a woman’s sense of control and reduces need for analgesia
Should always support a woman’s right to choice (Gupta 2012, Kemp 2013, Nieuwenhuijze 2013)

16. Choice of Birth Position (cont.)
Women who assumed a nonsupine position for birth:
had fewer perineal injuries
had less vulvar edema
had less blood loss
Women choosing nonsupine position for birth:
had shorter second stages
required less pain relief medication
had fewer abnormal fetal heart rates
Alternate Positions
“Supine position” is the position in which a woman lies flat on her back, often with feet in stirrups. Any position other than this is “nonsupine.”
Lithotomy position reduces blood flow to the fetus, adversely affecting the fetal heart rate, raises levels of maternal stress hormones, reducing uterine contractility and labor progress.

17. Midwife-Led Care Linked to Less Medicalisation: Sandal 2013
Women who had midwife-led continuity models of care were…
…more likely to experience:
no intrapartum analgesia/anaesthesia
spontaneous vaginal birth
attendance at birth by a known midwife
a longer mean length of labour (hours)
satisfaction with services
OUTCOMES
…less likely to experience:
preterm birth
fetal loss before 24 weeks' gestation
There were no differences between groups for caesarean births.
…less likely to experience:
regional analgesia
episiotomy
instrumental birth
CD pub3/abstract

18. Campaign for ‘Normal Birth’: Tips for Providers
Wait and see
Get her off the bed
Justify intervention
Listen to her
Be a role model
Be positive
Promote ‘skin-to-skin’ contact

19. Support Persons
The presence of a birth companion improves birth outcomes and the overall birth experience
Continuous empathetic and physical support is associated with shorter labour, less medication and fewer operative deliveries.

20. Keep Mother and Baby Together
The day of birth is the most dangerous day for mother and baby State of the World’s Mothers Report, SC 2013
Promote warming with ‘skin-to-skin’ after birth
Promote early and exclusive breastfeeding
Ensure mother counselled on danger signs

21. Cord Clamping World Health Organization (2012) recommends
delayed cord clamping
Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.

22. Cord Clamping (cont.) Benefits include:
Increased iron stores at birth and less infant anemia
Decreased intraventricular hemorrhage
Less necrotizing enterocolitis
Less infant sepsis
Fewer blood transfusions needed

23. Be Accountable! Take responsibility for your own actions
Provide care that is evidence-based and shown to be beneficial
Do no harm
Record and report
Communicate
Be the woman’s advocate
Explore opportunities for collaborative working and team building to improve respectful quality of care

24. We all have a role in assuring that women have respectful maternity care!
THANKS!