6/9/2018 Disclosures: None Minimizing Unhelpful Interventions in Obstetrics Robyn Lamar, MD, MPH AIM 2018, UCSF San Francisco, California Outline Maternal Mortality: US historic ● Historical & global perspectives on intrapartum care ● “Too little too late, too much too soon” ● Recent guidelines from WHO ● Case studies ○ Continuous cardiotocography ○ Active management of labor ○ Induction of labor ● Making the case for de-escalation of care FIGURE 3-5 Maternal Mortality Ratio per 100,000 Live Births over Time and Interventions That Contributed to Decline, United States. SOURCE: Robert L. Goldenberg, adapted from Johnson (2001). 1 6/9/2018 What reduced maternal mortality? http://publichealthlegacy.americashealthrankings.org/top-causes-of-maternal-mortality/ Medicalization of Childbirth Sorting it out Joseph DeLee, 1920 Childbirth moved to facilities and became dramatically more medicalized ● Sedation with scopolamine during 1st stage Maternal & neonatal mortality plummeted and ether during 2nd stage So where’s the problem with our interventions? ● Prophylactic episiotomy ● Prophylactic forceps ● Manual extraction of the placenta ● Ergot to prevent hemorrhage ● Suturing of episiotomy site Walzer Leavitt J. Joseph B. DeLee and the practice of preventive obstetrics. Am J Public Health. 1988 Oct;78(10):1353-61. 2 6/9/2018 C-section: International comparisons Too little too late, too much too soon Miller S et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016 Oct 29;388(10056):2176-2192. Too Little Too Late, Too Much Too Soon What’s the desired outcome? To determine the sweet spot, you need to know: 1. Your desired outcome 2. Strategies to maximize this desired outcome 3 6/9/2018 What’s the desired outcome? What strategies maximize the desired outcome? Overconfidence in the importance of a package of interventions to achieve “healthy mom, healthy baby” can lead to paternalistic or coercive approach toward laboring women Overemphasis on outcomes, as opposed to process, leads to undervaluing the experience of women during childbirth 4 6/9/2018 US Women’s attitudes towards birth are changing Listening to Mothers Survey III: “Giving birth is a process that should not be interfered with unless medically necessary” 2000-2002 2005 2011-2012 Disagree 31% 24% 16% Agree 45% 50% 58% http://transform.childbirthconnection.org/reports/listeningtomothers/ 5 6/9/2018 Many US Women report being pressured in labor Case Studies ● Active management of labor ● Continuous cardiotocography ● Induction of labor WHO RECOMMENDATION 27 Active Management of Labor A package of care for active management of labour for prevention of delay in labour is not recommended. Dublin National Maternity hospital Stated goal: to decrease maternal suffering. Package of delaying admission until diagnosis of labor; close monitoring of labor progress; proceeding quickly to amniotomy & then high-dose pitocin if steady dilation not seen; and c-section if delivery not achieved in 12 hours Reported excellent outcomes O'Driscoll K et al. Active management of labour. Br Med J. 1973 Jul 21;3(5872):135-7 O'Driscoil K, Meagher D. Active management of labour. W. B. Saunders, London, 1987. 6 6/9/2018 Active Management of Labor However, stellar results not replicated in other studies RCTs (and cochrane meta-analyses of these) failed to support: ● Amniotomy for augmentation of spontaneous labor ● High dose instead of low dose pitocin ● Pitocin augmentation of slow labor to prevent c-section What Worked in Dublin National Maternity Hospital? In favor of “fuzzy” interventions “A personal nurse is the basis of good intranatal care.” WHO: “non-clinical intrapartum Women received a “prior guarantee of continuous personal attention during labour.” practices, such as provision of emotional support through labour companionship, effective communication and respectful care, which may be fairly inexpensive to implement, are not regarded as priorities in many settings” 7 6/9/2018 WHO RECOMMENDATION 17 Continuous fetal monitoring: why it matters Continuous cardiotocography is not recommended for ● Continuous electronic fetal monitoring (EFM) quickly & widely adopted: assessment of fetal well-being in healthy pregnant women ○ 1980: used in 45% of US births undergoing spontaneous labour. ○ 2002: used in 85% of US birth ● Essentially rolled out as a national screening program for adverse fetal and neonatal outcomes before sufficient data collected to evaluate its efficacy Continuous fetal monitoring: the data Continuous fetal monitoring: interpreting the data ● Epidemiologic: CP rates have not changed in the past 4 decades ● Weighing cesarean risk versus neonatal seizures ● Cochrane review of continuous EFM versus IA; 13 RCTs, 37,000+ women ○ C-section: assuming a 15% risk of c-section in IA group, NNH = 11 ○ No difference in risk of ○ Seizures: assuming a 0.3% risk of seizures in IA group, NNT = 667 ■ CP RR 1.75 (CI 0.84 to 3.63) ■ Perinatal death RR 0.86 (CI 0.59 to 1.23) ■ Cord blood acidosis RR 0.92 (CI 0.27 to 3.11) ○ Lower risk of ● WHO conclusions ■ Neonatal seizures RR 0.50 (CI 0.31 to 0.80) ○ Increases the c-section rate ○ Higher risk of ○ Doesn’t prevent cerebral palsy ■ Cesarean delivery RR 1.63 (CI 1.29 to 2.07) ○ May be seen as a substitute for providing bedside, ■ Op vaginal delivery RR 1.15 (CI 1.01 to 1.33) supportive care ○ May restrict freedom of position/movement ○ May be stressful for women (and their companions) Alfirevic Z et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD006066. 8 6/9/2018 Labor Induction Incredibly useful intervention in some circumstances Use varies widely worldwide Threshold for “routine” induction continues to drop: 42 weeks > 41 weeks > 39 weeks? ARRIVE trial Induction at 39wk versus expectant management C-section rates decreased with induction: 22.2% > 18.6% Labor Induction Induction Research: What’s your comparison group? Thought experiment: What if we recommended 39wk induction of labor routinely? ● Comparing women being induced to women in spontaneous labor at same gestational age (favors spontaneous labor) How many inductions would this entail? 65% vs 6.5% of women haven’t delivered ● Comparing women being induced to women being expectantly managed (favors induction of labor) Do we have the resources for this? But women being expectantly managed are planning delivery at US hospitals, with Would this shift the standard of care? our usual intervention-intensive approach to labor What if we compare induction to women planning to deliver in low-intervention Would you be considered noncompliant if you declined? settings? 9 6/9/2018 Low versus High intervention approaches to care No RCTs Birth Place Study Prospective cohort study of 64,000 low risk births in England, 2008-2010 North American planned home birth data Stratified by intended place of birth: home, midwifery led unit, or hospital Included almost all trusts providing home birth (97%) and most midwifery units (90%) in England Collected both maternal & neonatal outcomes Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011 Nov 23;343:d7400. Birthplace Study: UK prospective cohort study Birthplace Study: UK prospective cohort study Composite adverse neonatal outcome for low risk women (N=63,827) Likelihood of intrapartum c-section Place of birth Percent (aOR) Place of birth per 1,000 deliveries (aOR) Hospital 11.1% (1.0) Hospital 4.4 (1.0) Alongside midwifery unit 4.4% (0.39) Alongside midwifery unit 3.6 (0.92) Freestanding midwifery unit 3.5% (0.32) Freestanding midwifery unit 3.5 (0.92) Home 2.8% (0.31) Home 4.2 (1.16) 10 6/9/2018 North American Data: needed! Induction of Labor: Summary MANA Statistics Project, 2004-2009, over 16,000 births If you are a low risk nullipara planning to ● Cesarean rate: 5.2% deliver in a US hospital, you may lower your ● Transfer rate: 11% risk of cesarean by inducing labor at 39wk ● Maternal death: 1 (embolism 3 days postpartum) from 22% to 19% ● Perinatal death: 2.0 per 1000 ○ Higher rates for small group with risk factors such as breech, twins, VBAC, etc But are these the numbers we are going for in a low risk nulliparas with a vertex singleton at term? Could de-escalation of Cheyney M et al. Outcomes of care for 16,924 planned home births in the United States: the Midwives care offer more? Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014 Jan- Feb;59(1):17-27. Conclusions “Progress requires the ability to normalise birth for most women, with integrated services available if complications develop.” Shaw D et al. Drivers of maternity care in high-income countries: can health systems support woman-centred care? Lancet. 2016 Nov 5;388(10057):2282-2295. 11 6/9/2018 Thank you! 12.