Over-medicalisation of childbirth - "too much, too soon"
In Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide, and Drivers of maternity care in high-income countries: can health systems support woman-centred care? Suellen Miller and colleagues1 and Dorothy Shaw and colleagues2 highlight the issue of over-intervention in maternity care.
What is “too much, too soon” in maternal health care?
“Too much, too soon” describes over-intervention in uncomplicated pregnancy and birth. “Too much, too soon” includes using non-evidence-based interventions, and interventions that may be life-saving when used appropriately, but harmful when applied routinely or overused. For example, induction and augmentation can be beneficial - and even life-saving - procedures when indicated. However, their overuse without a clear medical indication is associated with uterine rupture, perineal lacerations, anal sphincter injury, and uterine prolapse.3’ 4 In Brazil, both labour inductions and caesarean-sections increased over time from 3% to 43% and from 28% to 43% respectively. These increases were associated in time with increased preterm birth rates - from 6% to 16% - without any improvement in neonatal mortality.5
As facility births increase, so does the recognition that “too much, too soon” care is unnecessary, potentially harmful, increases health costs, and can be a sign of disrespect and abuse. We have described in the previous step that “too little, too late” care, remains a global public health problem. Care that is “too much, too soon” is typically attributed to high-income countries, but in fact also exists in low- and middle-income countries, and co-exists with care that is “too little, too late”. Settings with large social and health inequities and poor oversight and accountability are particularly susceptible.
The rapid increases in facility births in low- and middle-income countries are bringing the issue to the fore. This is because, as Shaw and colleagues2 describe, hospitals are “well optimised for high-risk women, with technology and staffing for close monitoring and expeditious access to interventions. Conversely, these facilities might not be optimised for low-risk women, and staff monitor and intervene more than is necessary for the overwhelming majority of women.” Excessive medicalisation for women whose births would have been uncomplicated might even offset the gains resulting from greater access to healthcare services and beneficial interventions.
When is “too much, too soon”?
In an earlier step this week, we highlighted guidelines indicating interventions that are based in evidence. The Cochrane Collaboration is a good source for understanding the research evidence behind specific interventions. Table 1 gives examples of interventions that are performed routinely in some settings, but that should not be.
Table 1 Perceived Benefits & Evidence-Base for Specific Maternity Care Procedures
|Procedure||Why people thought procedure should be done (not evidence based)||Evidence why procedure should not be done routinely|
|Continuous cardiotocography6||Monitoring the baby’s heartbeat during labour is used to identify those who are becoming short of oxygen and may benefit from an early delivery e.g. by caesarean-section.||Compared to intermittent monitoring, there was no difference in numbers of babies who died or had cerebral palsy; more women have caesarean-sections or instrumental deliveries. Fits in babies were rare (0.2%), but occurred less often with continuous monitoring.|
|Routine episiotomy7||Normal birth can tear the vagina; these sometimes extend to the rectum. To avoid such severe tears, health care providers recommend making a surgical cut to the perineum (episiotomy). Both tears and episiotomies need sutures, and can result in severe pain, bleeding, infection, pain with sex, and urinary incontinence.||Women in settings with routine episiotomy have 43% more severe perineal trauma at birth compared with women in settings with selective episiotomy.|
|Routine enema8||Women occasionally leak faeces while delivering. Enemas would reduce embarrassment, give more room for the baby to be born, reduce the length of labour and reduce infection for both the mother and the baby. Disadvantages were that enema is unpleasant and causes increased pain for women during labour.||Four studies found no significant differences in any of the outcomes assessed either for the woman or the baby, though none assessed pain for the woman.|
|Doppler ultrasound in normal pregnancy9||Doppler ultrasound uses sound waves to study blood circulation in the baby, uterus and placenta, and helps identify compromised fetuses in ‘high-risk’ pregnancies. Since it works in ‘high-risk’ cases, it might also work as a screening test in ‘low-risk’ pregnancies.||There were differences in perinatal death or neonatal morbidity, or in rates of antenatal, obstetric or neonatal interventions.|
Unnecessary use of such interventions can be costly for health systems - a particular problem where resources for maternal health are scarce. For example, in two provinces in Argentina alone, over US$250,000 per year would have been saved by adopting a policy of selective episiotomy, rather than routine episiotomy.10 The high costs of childbirth in the United States compared to other high-income countries, and cost increases over time are largely attributed to the high use of interventions.2 Costs can be compounded as overused interventions cause harm or increases the need for additional interventions. For example, electronic fetal monitoring and ultrasound during pregnancy are major drivers of further intervention in maternity care.
Who experiences “too much, too soon”?
Growing numbers of low- and middle-income countries are passing through an obstetric transition - shifting from high to lower maternal mortality.11 This is often achieved by having women come into health facilities to give birth, so skilled health professionals can attend them and manage their complications appropriately if they arise. However, the large majority of women deliver without complications, even if they receive no intervention at all. By coming into facilities that use unnecessary obstetric interventions, these women are potentially being exposed to harm, and few are in a position to give fully informed consent or are told of the risks of these interventions.12
Substantial variation in practices across settings that are not accounted for by size and type of facility raise concerns intervention rates are driven by clinical practice patterns, rather than medical indications.
In some cases, for example with frequent unindicated ultrasound, women ask for the interventions themselves.13 We also know that women in high-income countries can drive over-intervention because they have high expectations for a positive birth experience and a healthy baby. Fear of pregnancy and childbirth is common, affecting up to one-quarter of women in high-income countries.14 Over 70% of women interviewed in one study supported high-tech hospital birth, including use of electronic fetal monitoring. 15
With the exception of caesarean-section, there is not much work characterising women who experience ”too much, too soon” care. High-income countries generally have high caesarean-section rates, however we see the highest caesarean-section rates globally in middle-income countries. Figure 1 shows caesarean-section rates in India by wealth quintile and by public/private sector, indicating that the wealthiest women and those using the private sector have the higher caesarean-section rates.
Figure 1 Caesarean-Section Rate by Public/Private Sector or Wealth Quintile, in India Over All (1992-2016) & in Various Indian States (2015-2016)
Source: Campbell O. 2017. Data prepared for a presentation to MacArthur Foundation. Sources include: National Family Health Survey (DHS) 1992-1993; 1998-1999; 2005-2006 and 2015-2016 and Rapid Survey on Children, 2013-2014
How can “too much, too soon” be reduced?
“Too much, too soon”, historically associated with high-income countries, is rapidly increasing everywhere, especially in the private sector. This reflects weak regulatory capacity, as well as a lack of accountability and adherence to evidence-based guidelines.
Strategies to address over-intervention include:
Increase reliance on midwives rather than doctors for uncomplicated births, and seek locations for births that reduce over-medicalisation.2 Midwives can attend low-risk women at home, in freestanding birthing centres or in health centres2. Hospital-sited alongside midwifery-led birthing units can also optimise care for low-risk women2. Labourists and obstetricians who only provide care for labour and delivery have substantially reduced risks of caesarean-section among their patients.2
There is a shortage of clear, clinical guidelines and little adherence to existing guidelines1. Quality clinical practice guidelines need to be developed that reflect consensus among guideline developers, using similar language, similar strengths of recommendation, and agreement on direction of recommendations1. Strategies for enhanced implementation and adherence to guidelines need multi-sectorial input and rigorous implementation science.
Efforts to generate revenue and convenience can increase intervention rates. Financing and other approaches, such as second opinion, have been used in Brazil and China to tackle over-reliance on caesarean-section for example.16, 17
Birth is increasingly medicalised due to domination of fear2. Obstetric providers are often sued, usually because of a neurologically compromised infant, and practice defensive medicine that includes high levels of intervention . Medical liability reforms such as a no-fault system-at least for neurologically impaired infants - may help reduce caesarean-section rates.2
Women may demand interventions because they are perceived as desirable, modern, and resulting in more favourable outcomes. We need to ensure women are better informed on the benefits and risks of interventions.
A global approach that supports effective and sustained implementation of respectful, evidence-based care for routine antenatal, intrapartum, and postnatal care is urgently needed. Ultimately, health-care providers and health systems need to ensure that all women receive high quality, evidence-based, equitable, and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.
© The London School of Hygiene & Tropical Medicine