Inconsistent definitions of labour progress and over-medicalisation cause unnecessary harm during birth

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Abstract

Nanna Maaløe and colleagues argue that resource challenges, unclear and outdated clinical practice guidelines, and lack of women’s perspectives lead to overdiagnosis and overtreatment of prolonged labour

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Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

Suellen Miller, Edgardo Abalos, Monica Chamillard … (2016)

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. 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.

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Continuous support for women during childbirth

Meghan Bohren, G Hofmeyr, Carol Sakala … (2017)

Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine.

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Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis

Oonagh E. Keag, Jane E. Norman, Sarah Stock (2018)

Background Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. Methods and findings Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution. Conclusions When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.

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Author and article information

Contributors

Nanna Maaløe: Role: assistant professor

Monica Lauridsen Kujabi: Role: doctor,

Nina Olsén Nathan: Role: midwife

Morten Skovdal: Role: professor

Brenda Sequeira Dmello: Role: doctor

Susan Wray: Role: professor

Thomas van den Akker: Role: professor

Natasha Housseine: Role: postdoctoral researcher

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): BMJ-UK

Journal ID (hwp): bmj

Title: The BMJ

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2023

Publication date (Electronic): 6 December 2023

Volume: 383

Electronic Location Identifier: e076515

Affiliations

[1 ]Global Health Section, Department of Public Health, University of Copenhagen, Denmark

[2 ]Department of Obstetrics and Gynaecology, Copenhagen University Hospital—Herlev Hospital, Copenhagen, Denmark

[3 ]Department of Obstetrics and Gynaecology, Aarhus University Hospital, Skejby, Denmark

[4 ]Department of Obstetrics, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark

[5 ]Section for Health Services Research, Department of Public Health, University of Copenhagen, Denmark

[6 ]CCBRT Hospital, Dar es Salaam, Tanzania, East Africa

[7 ]Women and Children’s Health, University of Liverpool, Liverpool, UK

[8 ]Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands

[9 ]Athena Institute, VU University, Amsterdam, Netherlands

[10 ]Department of Obstetrics and Gynaecology, Aga Khan University, Tanzania, East Africa

Author notes

Correspondence to: N Maaløe nannam@ 123456sund.ku.dk

Article

Publisher ID: BMJ-2023-076515.R3 Publisher ID: maan076515

DOI: 10.1136/bmj-2023-076515

PMC ID: 10726361

PubMed ID: 38084433

SO-VID: 29afa80f-5f04-4bba-9f95-8dc08a200b5e

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This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100001731, Danida Fellowship Centre;

Inconsistent definitions of labour progress and over-medicalisation cause unnecessary harm during birth

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Sex and gender-sensitive medicine

Most cited references 60

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

Continuous support for women during childbirth

Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis

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