Tuesday, July 21, 2009

WHO Statistics & ACOG Guidelines Published

The World Health Organization has issued the World Health Statistics 2009, which is a compilation of data from the 193 member states with summaries of progress towards the health-related goals and targets.

In addition to the myriad of statistical data in the report, the ranking of nations by maternal mortality rate (per 100,000 live births). The listing below indicates how many deaths/100,000 live births.

1. Ireland
2. Sweden
3. Switzerland, Bosnia/Herzegovina, Denmark
4. Spain, Germany, Iceland, Israel, Kuwait, Australia, Austria, Czech Republic
5. Slovakia, Slovenia
6. Netherlands, Hungary, Japan
7. Norway, Finland, Canada, Croatia
8. Poland, United Kingdom, Malta, Belgium
9. New Zealand
10. Former Yugoslav Republic of Macedonia, Cyprus
11. USA, Portugal, Lithuania, Bulgaria

With a national cesarean rate of 33%, high induction rates (22%), and routines that are meant to ensure healthy pregnancy outcomes for all, none of these technologies seem to be making a dent in the maternal mortality rate. The fact is that 30 countries (including Hungary, Croatia, and Malta) appear to be handling obstetrics better than the good ol’ USA.

Ironically on the heals of the WHO report, is the new American College of Obstetricians & Gynecologists (ACOG) practice bulletin #107 scheduled to be published in the August 2009 issue of Obstetrics & Gynecology. Noting that the nation’s induction rate has more than doubled in the last 19 years, ACOG states that “the risks must be weighed against the benefits to the woman and the fetus.”

“Cervical ripening is the first component to labor induction. If the cervix is not sufficiently dilated, then drugs or mechanical cervical dilators should be used to ripen the cervix before labor is induced. Once the cervix is dilated, labor can be induced with oxytocin, membrane stripping, rupture of amniotic membrane, or nipple stimulation. Misoprostol (bloggers note: Cytotec), a medication for peptic ulcers is a commonly used off-label drug that both ripens the cervix and induces labor. The ACOG guidelines indicate that inducing labor with misoprostol should be avoided in women who have had even one prior cesarean delivery due to the possibility of uterine rupture (which can be catastrophic).”

The Guidelines go on to itemize out the examples in which “labor induction is indicated (but are not limited to) gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth retardation and postterm pregnancy.”

Take a look at how induction of labor can not only affect the woman’s mind/body/spirit during labor but also afterwards PLUS the effect such practices have on the newly born. According to the March of Dimes, oxytocin that makes the contractions stronger may also lower the baby’s heart rate necessitating the need for continuous fetal monitoring, which can restrict movement by the mother and hinder completion of the cardinal movements which facilitates labor. Women who have inductions and their babies are at increased risk of infection and the baby’s may experience a decrease in oxygen due to cord compression (March of Dimes). The effects of an induced labor on initiation of breastfeeding are innumberable.

It is not impossible to change protocols and policies and see dramatic changes in statistics AND improve pregnancy outcomes. In the late 1990’s a certain Midwestern hospital created a pilot program to reduce that hospitals’ cesarean section rate (then 27%). In this program were two vital parts: a Cesarean Section Review Committee (CSRC) and a Hospital Based Doula Program. The CSRC was comprised of physicians, nurses, childbirth educators and doulas. On a monthly basis, the committee would review all of the cesareans performed at that hospital. If the committee deemed a cesarean questionable or unnecessary, a letter would be sent to the physician. In Hospital Based Doula Program, doulas were hired directly by the expectant parents and had 1-2 prenatal visits, plus 1-2 postpartum visits and the doula during the entire labor. The results? Within 18 months, this hospital reduced its cesarean section rate to 11%. Patient satisfaction was astronomically positive.

How much more plainly do the statistics need to be

Technology (and policy arrogance) is not working.

No comments: