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The current global effort to prevent postpartum haemorrhage: how likely is it to be effective?

Abstract

This paper outlines the global effort by health professional agencies to reduce maternal deaths by managing the third stage of labour actively. It explores the tensions in the way midwifery and obstetric practice changes evolve, and are implemented, within developing and developed worlds. It questions the effectiveness of introducing the Western birth management practice of actively intervening in the third stage of every woman's birth when that intervention relies on certainty of access to pharmaceuticals.

It argues that complex problems require complex solutions, and that the midwifery profession should have a clear rationale for its decisions in relation to any intervention in labour and birth before promulgating major change.

Introduction

New Zealand midwives continue to have some reservations about the joint campaign of the United States Agency for International Development (USAID)), the International Federation of Gynaecologists and Obstetricians (FIGO), and the International Confederation of Midwives (ICM) to promote the use of uterotonic drug intervention in third stage of labour as the primary way to prevent postpartum haemorrhage (PPH), and reduce the maternal mortality rate. The original joint Statement promoting active management of third stage was drafted by FIGO with assistance from ICM Head Office in 2003, as part of the Safe Motherhood program, to try and reduce the numbers of maternal deaths in the developing world (International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians, 2003). In 2004 USAID funded FIGO and ICM to distribute the Statement worldwide. Called the Prevention of Post Partum Haemorrhage Initiative (POPPHI), the task force was led by FIGO/USAID and assisted by the ICM Head Office and the College of American Nurse/Midwives. The Statement, despite not having had the input of the ICM Council nor the support of the official Asia Pacific Region of ICM, was launched jointly with FIGO at the ICM Asia Pacific Regional Conference in Hong Kong in November 2003. The statement was then belatedly presented for official ratification of the ICM Congress meeting in Brisbane 2006. In the meantime it has been actively promoted by these joint agencies throughout the world.

There is no doubt something has to be done to help reduce the maternal mortality rates of the developing world. There is abundant literature on maternal mortality and the part PPH has in contributing to these deaths (United Nations Fund for Population Activites, 2005). There is simply not the space to elaborate here. This mostly preventable loss of lives is completely unacceptable.

Neither is there any doubt that those responsible for the active management movement are good and well meaning in their effort to provide answers. All midwives empathise with those who have to face the tragedy of maternal death. The fact that we often feel helpless in the face of such tragedy means we are desperate for ways to prevent and treat obstetric emergencies.

What is the issue?

The use of uterotonic drugs to prevent serious PPH for at-risk women has the potential to reduce maternal mortality. Women who are denied the basic human rights of access to health services, adequate food and water supplies, shelter and family planning, or who are physically unwell, are likely to benefit the most from the use of active management of the third stage of labour. However drugs alone do not carry guarantees. Although the consistent and skilful application of active management may help women in developing countries, there are multiple obstacles to its being successfully implemented. Not removing these obstacles, but instead teaching active management, as the only approach, to midwives and birth attendants in developing countries, could actually increase the rates of PPH and maternal mortality. Further, applying routine active management of third stage to healthy women seems to actually increase the rate of PPH.

Why is the New Zealand midwifery profession concerned?

Some of the New Zealand midwives concerns about the development of the USAID/FIGO/ ICM Joint Statement on active management of the third stage of labour were allayed when it was redrafted following challenging discussion at the 2006 ICM Council Meeting and Congress in Brisbane. There was a good number of NZ midwives present including myself as one of the two ICM Asia Pacific Representatives. This discussion centered on the invisibility of the women's context in the statement and the practical realities of midwives trying to implement a guideline that relied on drug administration. More significant however was that the often heated discussion illustrated the wide diversity of midwifery views on what components constituted the 'proper' management of third stage, both active and physiological. This diversity of practice amongst the highly motivated and well informed ICM Council Members is evidence, in New Zealand's view, that the PPH prevention program faces major hurdles in the training and implementation of effective active management at the workface in developing worlds where the level of education and skilled midwifery attendance can be inadequate or even absent (ibid; personal communication).

However the discussion did result in a consensus that the knowledge and teaching of physiological management is as important as that of active management in any guidelines relating to the prevention of PPH. ICM set up a working party and changes were made to the Joint Statement which reflected that view. ICM Board was directed to recommend to FIGO that the Statement include and emphasise the principle that educating all midwives regarding the correct physiological management of third stage, must always accompany the teaching of active management. It also noted that the Statement was primarily based on evidence in relation to women in resource-poor countries and that the guideline should be clear that its primary purpose was its application to resource-poor countries (ICM, 2006a). There is no evidence that the same level of routine intervention is necessary with healthy low-risk women, especially in the domiciliary setting (Elbourne, Prendiville, Carroli, Wood & McDonald, 2001; Cotter, Ness & Tolosa, 2005). If FIGO was unwilling to change its position, the ICM Board was directed to draft a separate statement to reflect and clarify the international midwifery position. As a result of this, FIGO agreed with the overall principles behind ICM's views, and changes were made. The new follow-up Statement is entitled "Prevention and Treatment of PPH: New Advances for Low Resource Settings" (ICM, 2006a).

It is concerning therefore to read ICM/FIGO reports of the workshops held so far (ICM, 2006b). International Midwifery, the journal of the ICM, published a supplement in volume 19 which was produced jointly by FIGO and POPPHI on Prevention of Post Partum Haemorrhage (ibid). It reported on the launch of the follow-up Joint Statement at the FIGO World Congress in 2006. There is little evidence, from ICM reporting, that the new Statement is being actioned to promote and teach both the physiological and active methods of management of third stage. The activities are all in relation to teaching active management and not one mentions the importance of both methods being understood. Furthermore the FIGO/ICM Declaration of Support on the back page of the same report (which can be viewed on www.figo.org/docs/PPH%20Joint%20Statement. pdf) ignores the role of physiological management completely. The declaration also appears to promote active management for all women, not just for those living in developing countries.

The implications for midwives

Midwives from some Asia Pacific countries have expressed their reservations about the wisdom of expecting a reliable supply of pharmaceuticals in countries where women have little, if any, status and therefore are unlikely to be prioritised for treatment. Given the abortificant effects of uterotonics, the drug itself attracts an alternative market, one where the price it can command for this use may well overwhelm the likelihood of the women receiving it as a treatment. (Personal communication from Asia Pacific midwives, ICM Congress, Brisbane, 2006). These midwives' experience is that they cannot get basic items such as gloves let alone a reliable source of uterotonic drugs. In the absence of the active management drugs, midwives must know the physiological management of the third stage if mothers are to have the best chance of safely progressing through third stage.

The experience of colonising Western cultures, which try to introduce new and 'better' knowledge into resource-strapped countries, is that the knowledge can be distorted and inappropriately applied. An example comes from a midwife reporting from Egypt (Pett, 2004) noting a worrying trend that an increasing proportion of maternal deaths in Egypt are due to medical intervention, in particular the inappropriate use of uterotonics in labour, although she does not indicate if this is related to management of the third stage.

Promoting active management in the evangelistic manner currently reported (ICM, 2006b) can distort the importance and relevance of physiological management. For example, the pressure on midwives to use the active management method of controlled cord traction (CCT) is quite relentless and is therefore likely to be the chosen method whether the prerequisite uterotonics (ecbolics/ oxytocins) are available or not. CCT applied in the absence of these drugs may well cause PPH, not prevent it.

Unplanned effects, of the unwarranted intervention or the introduction of poorly researched practices, can be illustrated in a number of other ways. The Term Breech Trial (Hannah, Hannah, & Hewson, 2000), indicating caesarean section was safer for all breech presenting babies, changed practice internationally over a very short time. Many midwives were highly critical and new data collected in 2006 has overturned the initial findings (Glezerman, 2006). Kotaska (2004) criticised the term breech trial methodology and drew attention to the limitations of applying randomisation methodologies inappropriately to complex phenomena. He cautioned about underestimating the impact of clinical judgement and skill required for complex populations and procedures.

What little we do know about the active versus expectant (physiological) management of third stage also fits into this category. Most of the proactive method evidence arose from a small number of randomised trials. Most of these were carried out in obstetric base hospitals where active third stage management was the norm (Prendiville, Elbourne & MacDonald, 2005; Rogers, Wood, McCandlish et al, 1998). Given the complexity of those hospital environments maybe we are still only seeing the results of entrenched obstetric and midwifery management behaviour, rather than an illustration of the failure of physiological birth. Many midwives and medical practitioners over the years have examined the management of third stage practices and some have questioned how appropriate the hospital-based environment is for making judgements about outcomes. Gyte (1994), Wickham (1999), Featherstone (1999), Enkin, Keirse, Renfrew, & Neilson, 2000), and Buckley (2005) have all offered extensive comment and review of third stage management and the available research literature.

However obstetrics has a history of introducing new practices without any sort of trial, randomised or not. The Western world's alarmingly high rate of caesarean section is also a reflection of non-evidence based intervention taking over from the physiological process. As with active management of third stage, there is no doubt that caesarean section is lifesaving when it is required and when carried out appropriately. Unfortunately Western cultures have increasingly applied this intervention inappropriately to well women and well babies. Often this is because it has become such a common intervention that many doctors and midwives are more comfortable with this surgical knowledge than they are with normal birth (Althabe et al, 2006). Some recent research warns us about the dangers of applying emergency measures routinely (Villar et al, 2006). Caesarean section is an intervention which, when applied to all women regardless of their risk, can cause harm to both mothers and babies (MacDorman, Declercq, Menacker & Molloy, 2006).

The ecological study from South America by Althabe and colleagues, concludes that, where women are healthy and live in medium to high-income countries, there is no correlation between mortality and the caesarean section rates (Althabe et al, 2006). That is, the operation does not reduce the rate of mortality. On the other hand in low-income countries, where women can have access to caesarean section, it does lower mortality rates. Once again, as with the prevention of PPH, well women do not require the same level of intervention as unhealthy women do. Healthy eating/lifestyle, family planning, good hygiene, one-on-one labour support and skilled midwifery care offer women more chance of a positive maternity experience than inappropriately applied medicalised intervention.

An editorial in The New England Journal of Medicine by Michael Green MD (2006) suggested that intrapartum electronic fetal heart monitoring is another example of obstetric services underestimating the pitfalls of intervening in labour inappropriately. Green states:

"More than 30 years ago the new technology of electronic fetal heart monitoring was introduced with the noble aspiration to eliminate cerebral palsy. We now find ourselves in a far less noble position of seeking new technology to mitigate the unintended and undesirable consequences of our last ineffective, but nonetheless persistent, technologic innovation". (Green, 2006, p.2248).

Another editorial, this time in Birth, records Murray Enkin (2006) saying the same sort of thing.

"The fundamental mistake of evidence based medicine is to treat complex problems as if they were merely complicated.... Naive efforts to simplify the management of pregnancy and childbirth through standardised formulas, evidence based protocols, are failing, and we are beginning to recognise anew the complexity of pregnancy and birth as life events to be experienced rather than diseases to be managed" (Enkin, 2006,p. 268).

The observations of Green and Enkin should be kept in mind when evaluating the possible consequences of the wide scale introduction of the intervention of active management of the third stage in the developing world. There is not one single answer to the prevention of maternal death and neither is there one only to the prevention of PPH. Women and midwives live in a complicated, individual and cultural contexts. This effectively negates a 'one size fits all' approach.

However, even if we consider the context, there is still missing evidence around the effectiveness of the active management method itself. No clinical trial has identified the relative importance of each of the active management components (Diaz-Rossello, 2006). Debate on the identification and development of the knowledge base around management of the third stage is still in progress (Long, 2003). As a result during the course of the prevention of PPH campaign, the components of the Joint Statement active management action plan have changed. For example early cord clamping, still thought of as an essential element in most countries practising active management, is now no longer included in the definition (ICM, 2006b).

The argument is that when women are dying there is no choice but to intervene. The real question in this instance is: intervene how? The intervention being promoted carries its own dangers besides those related to haemorrhage. For example, active management of third stage may increase the risk of anaemia for neonates by denying them their physiologically defined blood volumes. Badly executed active management is likely to expose the neonate to even further risk (MacLean, 2007). The ideal timing of drug administration for active management and cord clamping is still poorly understood and as such its use may have as much adverse impact on the neonate as her/his mother (Mercer, 2001).

The reasons for PPH are complex and it will take complex solutions to change the environment that is behind the causes of haemorrhage. One solution is to provide some women and some midwives with uterotonic drugs to actively manage the birth of the placenta. Current evidence would suggest this is particularly useful if those women and midwives are in the obstetric base hospital setting (Enkin et al, 2000).

Another solution is enhanced education of midwives around good practice in relation to third stage, but this cannot be in isolation from other midwifery competencies, or from the social, education, economic context of the woman and her family (Harris, 2001). Early cord clamping and the timing of administrating uterotonics were introduced largely without supporting evidence, yet, as is the case with fetal electronic monitoring, the intervention remains routine in many Western countries. We are left with the ironic situation of having to prove the value of normal birth. It would seem we know more about birth as it is medically managed than we do about birth when it is 'allowed' to progress normally. Unless we really understand the consequences of active management and of introducing drugs into every woman's labour, regardless of the woman's risk, the setting, or the education level of the attending midwives, we may be promoting pointless innovation and risking the failure of the intervention. As a result more women may suffer and more may die. Are we generating "an unintended and undesirable consequence" (Green, 2006, p. 2248)?

The implications of routine active management when women are healthy and well

It is the application of solutions intended for at-risk women (particularly those women in the developing world) to healthy, well women that also concerns NZ midwives. The biggest risk to healthy New Zealand women, and this is the same in many Western cultures, is that the majority are giving birth in high-risk hospital settings. Birthing at home or in the community setting, with a midwife providing continuity of care, is more likely to reduce the woman and baby's risk of poor outcomes and unnecessary intervention than setting rigid protocols (Benjamin, Walsh & Taub, 2001; Roberts, Tracey & Peat, 2000; Johnson & Daviss, 2005; NZCOM, 2007).

In New Zealand about 30% of all the women, with a midwife lead maternity carer (LMC) who is a member of the New Zealand College of Midwives' Maternity Provider Organisation (MMPO), have physiological management of third stage of labour (NZCOM, 2007). The women choose this option as a result of the informed consent culture in New Zealand. This allows them to assess their own risk and make their own decisions about care.

Out of a total cohort of 12,061 women cared for by 369 midwives in 2004, the rate of PPH in those 30% of healthy women (who chose physiological management) was lower than that of the healthy women who chose active management (ibid).

In NZ most women start their pregnancy with an LMC and some 78% in 2003 had a midwife LMC. (Ministry of Health, 2006). It is common therefore for midwife LMCs to have a mixed caseload of low to moderate risk women. They either provide care for these women on their own responsibility or they work in consultation with specialists.

The incidence overall of PPH following vaginal birth in the MMPO 2004 cohort of mixed low to moderate risk status women was 8.3%. Of the women who chose an actively managed third stage, some 6% had a PPH of between 500 and 999mLs, compared to 3% of women who chose a physiologically managed third stage. Some 1% of women in the actively managed group had a PPH over 1000mLs. No women in the physiologically managed group had a PPH over 1000mLs. Manual removal of the placenta was required for 0.4% of the women, and this was the same rate in both groups. The main incidence of PPH in this cohort, and in New Zealand in general, was not following spontaneous vaginal birth but was predominantly associated with operative birth, both forceps and caesarean section (Women's Hospitals Australasia, 2005).

The USAID/FIGO/ICM campaign to promote active management of third stage has also hit New Zealand. Obstetricians, previously accepting of women's right to choose and make their own decisions on these matters of complexity, are now trying to impose active management for all women. Midwives report several hospitals have introduced active management protocols recently, quoting the Joint Statement as the driver (personal communication, Midwifery Advisor, NZCOM, 2007).

Conclusion

These observations are offered in the hope that we can continue to discuss the most appropriate way of helping more women and babies survive childbirth without losing sight of the power of the normal birth process and the midwifery wisdom that helps them achieve this, thus enabling us to use all our knowledge, both midwifery and medical, to increase women's confidence and safety in giving birth. Even in resource-poor countries not all women are unhealthy, and in resource-rich countries we do not always provide the best level of care necessary to keep mothers and babies well.

We have not had adequate debate about these issues in a holistic, women-centred way. The response so far has largely been from the medical community, and is based on current management ideologies and limited science. It is not based on the understanding of physiology or normal birth mechanisms. Pregnancy and childbirth must always be examined in light of the social, economic, cultural, physical and emotional context in which women live if we are to save lives. To not do so is to let women down and we are likely to do further harm. We will only progress if we continue to debate our concerns honestly and openly. ICM must take an informed midwifery position on this issue in order to provide leadership to midwives, and reliable information to women and their families.

Accepted for publication: March 2007

Guilliland, K. (2007). The Current Global Effort to Prevent Post Partum Haemorrhage: How likely is it to be effective? New Zealand College of Midwives Journal, 36, 28-31.

References

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Johnson, K., & Daviss, B. (2005). Outcomes of planned home births with certified professional midwives; large prospective study in North America. British Medical Journal, 330, 1416.

Kotaska, A. (2004). Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. British Medical Journal, 329, 1039-1042.

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Villar, J., Valladares, E., Wojdyla, D., Zavaleta, N., Carroli, G., Velazco, A., Shah, A., Campodonico, L., Bataglia, V., Faundes, A., Langer, A., Narvaez, A., Donner, A., Romero, M., Reynoso, S., Simonia de Padua, K., Giordano, D., Kublickas, M., & Acosta, A. (2006). Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America, The Lancet, 367, 1819-1829.

Personal communications:

Asia Pacific Midwives, personal communication, ICM Congress, Brisbane, 2006.

N. Campbell, Midwifery Advisor, NZCOM, personal communication, 2007.

Karen Guilliland

RGON RM ADN (Maternal and Child Health) MA MNZM

Karen is currently the Chief Executive Officer for the New Zealand College of Midwives (NZCOM), and is one of two Asia Pacific representatives on the International Confederation Midwives executive committee. She is a member of the Canterbury District Health Board and PHARMAC, the Pharmaceutical Management Agency for New Zealand. She has had a working interest in global health systems for many years.

Contact for correspondence: nzcom@nzcom.org.nz
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Title Annotation:DISCUSSION ARTICLE ON A PRACTICE ISSUE
Author:Guilliland, Karen
Publication:New Zealand College of Midwives Journal
Article Type:Clinical report
Geographic Code:8NEWZ
Date:Apr 1, 2007
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