'Too much care' threatens maternal health

Whilst the major focus of international advocacy and policy for maternal health is on enabling women to have access to skilled care during pregnancy and childbirth, some women face severe morbidity, even death, from an excess of maternity care.

Excessive care and over reliance on unnecessary technology is common in developed countries. However, it is also a problem in countries with thriving private obstetric sectors and where obstetric and midwifery care does not follow recognised evidence-based guidelines, such as in India and Brazil. Unnecessary caesarean section, for example, although a life saving intervention for those who need it, can cause problems during current and future pregnancies and can divert scarce health system resources away from basic service provision.

Recent evidence shows that there has been a phenomenal increase in the rates of caesarean birth. With the exception of Africa, urban rates are now well above ten percent in most countries. Even in some rural areas rates of caesarean section have doubled over the last ten years. Irrational demand, commercial exploitation and medical malpractice are not uncommon, and the potential for unintended harm to both mother and child are significantly greater in the developing world. In poor countries, very high rates of caesarean section among the few women who can afford the intervention, often coexist with dangerously low rates among the larger rural and urban poor populations of childbearing women.

Overuse of caesarean section

Caesarean section is becoming widespread at the expense of the practice of normal birth. The development of appropriate health systems for maternal and newborn care is being undermined by the lack of midwifery training that focuses on care in normal birth. Exaggerating the risks of normal birth to women who are able to pay, or who can borrow the money, for both the convenience and the financial gain of medical institutions, is a damaging development in low-resource settings.

A recent study in Bangladesh found that women's distrust of medical facilities at birth is increasing due to some doctors inappropriately recommending caesarean section. The authors conclude that little progress will be made in increasing skilled attendance and reducing maternal death without addressing the fundamental health system elements that cause health care staff to undertake procedures without medical need.

This over-medicalisation of childbirth relates not only to caesarean sections but also to a range of other unnecessary, non-evidence based medical practices. For example, in some eastern European hospitals over 20 different drugs are given to women in normal labour, together with enemas, constant foetal monitoring and labouring and giving birth whilst in stirrups. Episiotomy, a surgical incision through the perineum to enlarge the vagina and assist childbirth, is often routinely practiced without strong evidence that it protects the perineum. It can cause an increased risk of HIV transmission, fetal distress, trauma, perineal tears and painful sexual intercourse.

Overuse of drugs

The drug oxytocin is useful during the third stage of labour (the delivery of the placenta) to reduce the risk of postpartum haemorrhage and also, in carefully controlled situations, to induce or enhance labour. But its use is becoming increasingly common in settings where medical supervision during childbirth is minimal. In some parts of India, Mali, Nepal and Senegal, one third of women have received oxytocin during childbirth. Inappropriate use of oxytocin, especially in settings without medical supervision, can lead to fetal distress, stillbirth, rupture of the uterus and maternal death.

The safe motherhood movement argues against harmful traditional practices, but it also needs to address harmful and unnecessary clinical practices and their consequences for women and health systems.

Gwyneth Lewis
National Clinical Lead for Maternal Health and Maternity Services, Room 202, Wellington House, 133-155 Waterloo Road, London SE1 8UG
Gwyneth.Lewis@dh.gsi.gov.uk

See also

'Levels and Trends in Caesarean Birth in the Developing World', Studies in Family Planning 37(1), pages 41-48, by Cynthia K Stanton and Sara A. Holtz, 2006

'Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America', The Lancet 367(9525), pages 1819-29, by JosŽ Villar et al, 2006
www.thelancet.com/journals/lancet/article/PIIS0140673606687047/fulltext

'Life Saving or Money Wasting? Perceptions of Caesarean Sections Among Users of Services in Rural Bangladesh', Health Policy 80, pages 392-401, by Justin Oliver Parkhurst and Syed Azizur Rahman, 2006
www.id21.org/health/h8jp2g2.html

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