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WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections1

by Cathy Daub PT, CCE and CD(BWI) and Horatio Daub, MD, MPH                       

 

Just 40 years ago when I first gave birth, a cesarean was still considered an operation done only for specific life-threatening conditions as well as when having had a prior cesarean.   Today, it has become an accepted, if not almost routine, way of giving birth.  What has caused this significant and disturbing trend?  Concerns about the sustained and unprecedented world-wide rise of cesarean section has prompted the World Health Organization to issue this report.  In the “WHO Recommendations Non-clinical Interventions to Reduce Unnecessary Caesarean Sections, they stated, “This is a major public health concern. There is an urgent need for evidence-based guidance to address the trend.” Their report was based on evidence of the effectiveness of interventions from an updated Cochrane review of 29 studies.

The importance of this WHO report is that it represents the first global guidelines of a clinical encounter between a health-care provider and pregnant woman in the context of patient care. The purpose of the study is to “provide evidence-based recommendations on non-clinical interventions that are designed to reduce cesarean section rates.” Their report acknowledges that a cesarean is a surgical procedure that when necessary can prevent maternal and newborn mortality when medically indicated.  However, beyond a certain threshold at risk, may result in increased maternal and perinatal morbidity along with both short and long-term health risks that may extend for decades beyond.  This in turn results in substantial increases in health-care costs, morbidity, and mortality for mothers and babies.

In the USA, about one in three births result in a cesarean, having increased dramatically from 5% in 1970 to over 32% in 2016. Today.  it seems to matter what country you are born in and in the USA, which state you live in. In the USA it is better to be born in Utah (22.3%), Idaho (21.9%), New Mexico (24.8%),  Alaska (23%) or Hawaii (25.2%) versus Mississippi topping the list at 38.2% or Louisiana (37.5%), Florida (37.4%), West Virginia (34.9%), NJ (36.2%) or Connecticut (35.4%).

Internationally, Finland has a low cesarean rate of about 16% of births and the UK’s rate is about 24%. Brazil tops the list at more than 50% with even higher rates in private sectors.  Latin America and the Caribbean follow with high cesarean birth rates at 40.5% and North America (32.3%) ranging down to Asia (19.2%) and the lowest in Africa (7.3%).

When cesarean rates vary to this degree, it must be due in part to how birth is managed rather than birth itself. The international health-care community has considered the ideal rate for caesarean section to be between 10% and 15%.  WHO concluded that “at the (global) population level, cesarean rates above 10% were not associated with reductions in rates of maternal and newborn mortality.”

The WHO report acknowledges that although societal changes such as increases in obesity, multiple pregnancies and older pregnant women have contributed to the increased cesarean rate, these are unlikely to explain the variance  of cesarean section rates between various countries or states.  Other non-clinical factors such as women wanting to plan their birth dates, physician factors, malpractice fears, and other economic and social factors are also implicated in the high variability of cesarean rates.

We know today that there are many non-clinical interventions that have proven to be successful in labor and birth but which are underutilized by most women, birth professionals, and facilitators.  These include warm water, optimal pelvic positioning,  the presence of a birth companion or doula, massage, speaking encouraging words, and keeping a positive and private environment.   On the contrary, medical intervention rates are very high with for example a 75% rate of epidural anesthesia and other obstetrical drugs to control pain.

In the WHO report, recommendations to reduce cesarean targeted women, health care professionals, and health organizations, facilities, or systems.

For women

  • Education that addresses fear of pain, advantages and disadvantages of cesarean sections and vaginal birth, risks and benefits of pain relief techniques and obstetrical drugs, and guidelines for indications and contraindications of cesarean sections.
  • Relaxation training and stress reduction programs conducted by nurses
  • Couple-based prevention programs that are inclusive and provide problem solving suggestions, mutual support strategies, and conflict management.
  • Psycho-education for women who fear childbirth itself and that address topics such as normalization of individual reactions, stages of labor, hospital routines, birth process, and pain relief.

For Health-Care Professionals

  • Implement “evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section” in settings with adequate resources and senior clinicians.
  • Implement “evidence-based clinical practice guidelines, cesarean section audits and timely feedback to health-care professionals.”

Health Organizations, Facilities or Systems

  • Establish a collaborative midwifery-obstetrician model of care where the model of staffing is based on care provided primarily by midwives with 24-hour back-up from an obstetrician who provides in-house labor and delivery coverage.
  • Establish financial strategies such equalizing physician fees for cesarean and vaginal births.

The highest level of certainty evidence was the recommendations for health-care professionals where accountability was required.  Interventions in labor and birth need to be guided by the basic premise that if the harms clearly outweigh the benefits for valued outcomes, they should not be used.

The WHO report stated that women find learning new information about birth to be empowering  but it should not provoke anxiety.  Women want emotional support alongside the communication of facts and figures about birth. But interestingly, there seemed to be no differences in cesarean rates based on computer-based decision aids, booklets, role play vs lecture for women with fear of childbirth, or educational brochures in spite of the fact that women seemed to want such things.

They did not see differences among various ways to present the childbirth information, but none of the discussed formats for learning included an experiential and emotional preparation for birth that is based on basic human values as is available in BirthWorks.

BirthWorks childbirth preparation is designed to build confidence for birth.  We offer a broader systems approach to childbirth that is based on a foundation of human values where optimal pelvic positioning is key.  Women learn how to work with their bodies in labor, knowing that the knowledge about how to give birth is already born within every woman.  Included are also identifying beliefs and releasing fears thus re-framing them to a positive experience,  the role of hormones and the value of the microbiome as well as the importance of mother-baby skin-to-skin contact, mother-daughter relationships, the value of doulas, and grieving and healing.  Classes are interactive and a place of joy and learning which is what the experience of birth can be.  BirthWorks childbirth preparation builds confidence and decreases fear through the integration of mind, body, and spirit.

Reference:

  1. World Health Organization 2018. This report is available under the Creative Commons Attribution –NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO, https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
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Reflections From A Mom With Multiples

by Cristin Tighe CCE(BWI)  (and Sienna Morrow)          

Taking care of one baby is a lot of work.  New moms often say they were busy all day but don’t exactly remember what they did!  Just imagine taking care of newborn twins or triplets!  I am a BirthWorks Mentor and one of my students, Sienna Morrow, who is in the BirthWorks Postpartum Doula Program sent a response to the question below that brought me to tears as it made me remember my own experience with my twins.

Question:  When is a baby considered to be premature?  List five main concerns a new mother with multiples might have in the first few months at home and how you would address them.

She wrote:

  • A baby is considered premature if born before 37 weeks.
  • A mother with multiples might be concerned with getting adequate sleep, breastfeeding two babies (tandem), creating a routine that works for both babies, bonding with each baby, and having enough support.
  • I would encourage the mother to tune into the babies and create a routine that works for all of them together by helping her process how things go throughout the days and areas where she is struggling.
  • I would help her connect to groups of moms of multiples in her area and give her time to have conversations with her partner about how they can support one another.
  • I would address any breastfeeding concerns that she has and build up her confidence with praise and words of wisdom.
  • I would also help her explore her own resources and discover things she can do to build a support network in her current situation.”

I, myself, gave birth to my twin boys at 38 weeks and 6 days so they were not premies. I breastfed my boys 21 of 24 hours the first day, and then it was like 16 hours a day until we all learned to tandem feed. I felt stuck in my primal brain for weeks, almost like having no awareness of being human most of the time.  As I reflect back on the experience, I am laughing, remembering some of my chimpanzee robotic-like thoughts that were running through my head during that time:

  • Feed next baby, get other one, feed other….fall down and sleep…are they both safe? …zzz…wake up! Baby must eat…
  • I starving, ravenous, soooo thirsty, give me water
  • Bladder bursting, need to pee
  • Need shower, crusty, smelly, sweaty, sticky
  • Where is Annalissa? (That’s my daughter who just turned four.  This thought would come with adrenaline as I was falling asleep feeding some baby boy – not sure who it was half the time, didn’t care, trusted my husband who rotated them.

These thoughts just repeated over and over, like the film “Groundhog Day”, until around four months.  Then, I woke up, like from a dream, checked we were all alive and when we were, I sighed deeply.