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

Miller, Suellen; Ábalos, Edgardo; Chamillard, Mónica; Ciapponi, Agustín; Colaci, Daniela; Comandé, Daniel; Díaz, Virginia; Geller, Stacie E.; Hanson, Claudia; Langer, Ana; Manuelli, Victoria; Millar, Kathryn; Morhason-Bello, Imran O.; Castro, Cynthia Pileggi; Pileggi, Vicky Nogueira; Robinson, Nuriya; Skaer, Michelle; Souza, João Paulo; Vogel, Joshua P.; Althabe, Fernando

doi:10.1016/s0140-6736(16)31472-6

Cited by 805 publications

(812 citation statements)

References 110 publications

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“…These results support the “Too little too late, too much too soon debate” in maternal care, in which Miller et al40 argued that unnecessary use of nonevidence‐based interventions can be harmful for healthy women and infants, as much as a lack of lifesaving interventions is damaging for those that need them. Our results should make consumers and maternal health care professionals aware of the potential harm that birth interventions may have in the longer term, encouraging a “precautionary principle” approach that weighs the possible benefits of the intervention against its potential detrimental effects for each mother and child 41.…”

Section: Discussionsupporting

confidence: 71%

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population‐based cohort study

Peters

Thornton

Jonge

et al. 2018

Birth

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BackgroundSpontaneous vaginal birth rates are decreasing worldwide, while cesarean delivery, instrumental births, and medical birth interventions are increasing. Emerging evidence suggests that birth interventions may have an effect on children's health. Therefore, the aim of our study was to examine the association between operative and medical birth interventions on the child's health during the first 28 days and up to 5 years of age.MethodsIn New South Wales (Australia), population‐linked data sets were analyzed, including data on maternal characteristics, child characteristics, mode of birth, interventions during labor and birth, and adverse health outcomes of the children (ie, jaundice, feeding problems, hypothermia, asthma, respiratory infections, gastrointestinal disorders, other infections, metabolic disorder, and eczema) registered with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes. Logistic regression analyses were performed for each adverse health outcome.ResultsOur analyses included 491 590 women and their children; of those 38% experienced a spontaneous vaginal birth. Infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, adjusted odds ratio (aOR) 2.75 (95% confidence interval [CI] 2.61‐2.91) compared with spontaneous vaginal birth. Children born by cesarean delivery were particularly at statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery showed the highest association for metabolic disorder, aOR 2.63 (95% CI 2.26‐3.07).ConclusionChildren born by spontaneous vaginal birth had fewer short‐ and longer‐term health problems, compared with those born after birth interventions.

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Section: Discussionsupporting

confidence: 71%

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population‐based cohort study

Peters

Thornton

Jonge

et al. 2018

Birth

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“…Conversely, any overestimation of the risk of complications and over‐medicalisation of care during labour and childbirth may lead to iatrogenic complications, avoidable suffering, and a waste of limited resources 24. In an attempt to optimise intrapartum care, several organisations recommend the use of the WHO partograph to guide labour monitoring and management 24. The ‘one‐centimetre per hour rule’, as illustrated by the partograph alert line, has also (formally or informally) been used to prompt labour interventions in many settings around the world 4, 25.…”

Section: Discussionmentioning

confidence: 99%

Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study

Souza

Oladapo

Fawole

et al. 2018

BJOG

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ObjectiveTo assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes.DesignA facility‐based, multicentre, prospective cohort study.SettingThirteen maternity hospitals located in Nigeria and Uganda.PopulationA total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour.MethodsResearch assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic.OutcomesSevere adverse birth outcomes.ResultsThe rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty‐nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves.ConclusionsOur findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the ‘one‐centimetre per hour’ rule should be re‐evaluated.FundingBill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879).Tweetable abstractThe alert line in check: results from a WHO study.

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“…Recent studies suggest that the benchmark for assessing normal labour progression, which was derived from studies conducted over 60 years ago, may not be appropriate for clinical decision making for individual women 7, 8. Although unnecessary labour interventions are generally more common in middle‐ and high‐income settings,9 the routine use of ineffective and potentially harmful labour practices are also widespread in resource‐limited settings, with the consequent misallocation of scarce resources and a further widening of the equity gap 10, 11, 12. On the other hand, failure to employ effective labour interventions when needed is also a recognised contributor to health inequities and poor quality of care during childbirth 9…”

Section: Why Do We Need To Revisit Intrapartum Care?mentioning

confidence: 99%

WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing

Oladapo

Tunçalp

Bonet

et al. 2018

BJOG

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

Cited by 805 publications

References 110 publications

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population‐based cohort study

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population‐based cohort study

Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study

WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing

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