On 24 April 2017, providers, advocates, researchers and policymakers gathered at the Wilson Center to discuss the growing trend of overuse of medical interventions in global maternal health care. The event, titled, “Too Much Too Soon: Addressing Over-Intervention in Maternity Care,” was part of the Advancing Dialogue in Maternal Health Series.
After welcoming remarks from Roger-Mark De Souza of the Wilson Center, Anneka Knutsson, Chief of Sexual and Reproductive Health at the United Nations Population Fund, began the discussion with an observation that while the maternal health community has made progress in terms of improving access to care and understanding the causes of maternal mortality and morbidity, poor quality remains a major challenge. “We have to get it right for women. This is very much about the status of women,” she stated, noting that poor maternal health care quality can come in the form of both under-intervention and over-intervention— “too little, too late” and “too much, too soon.”
Achieving equitable, accessible and respectful maternity care
Suellen Miller, Director of the Safe Motherhood Program and Professor of Obstetrics, Gynecology and Reproductive Health Sciences at the University of California, San Francisco, summarized key findings from a paper that she co-authored in The Lancet Maternal Health Series titled, “Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide.” Miller and colleagues systematically reviewed evidence-based guidelines for antenatal, intrapartum and postpartum care and offered recommendations. They also estimated coverage rates of recommended practices that can be harmful if overused and found large disparities across countries.
Miller noted that the global health community has traditionally focused on care that is too little, too late, but stakeholders are becoming increasingly concerned about care that is too much, too soon. In many middle-income countries, for example, cesarean rates have risen exponentially within the last few decades. However, Miller emphasized that issues of inadequate care and over-intervention can coexist simultaneously within countries or populations, using cesarean rates to illustrate her point. In China, India, the United States and many other countries, cesarean rates vary widely based on social determinants such as socioeconomic status, race and place of residence.
While high rates of cesarean section and induction in many countries indicate overuse, other evidence-based practices such as continuous labor support and skin-to-skin contact following delivery are often underutilized. Miller suggested that midwifery-led care yields the best outcomes with the fewest interventions and lowest costs. Providing care that is neither too little, too late nor too much, too soon is essential to achieving equitable, accessible and respectful maternity care for all women.
India’s “dual maternity care burden”
Myriam Vuckovic, Assistant Professor in the International Health Department at Georgetown University discussed what she calls the “dual maternity care burden” of India. Maternal mortality ratios, antenatal care attendance and other key indicators vary dramatically across states. While some women cannot access the basic maternal health care they need, others undergo unnecessary obstetric interventions such as episiotomy, antibiotic use and induction and augmentation of labor.
In 2011, roughly 80% of deliveries involved the use of uterotonics for labor augmentation. This widespread practice occurs in public and private hospitals as well as in home birth settings. One contributing factor is the high value placed on labor pain in Indian culture. Additionally, uterotonics typically expedite the labor process, thereby incentivizing overcrowded facilities to use them as a method of increasing patient flow. The use of uterotonics in home birth settings can be quite dangerous: In India, researchers have observed that inadequately trained traditional birth attendants often store and administer these drugs incorrectly and do not have the proper equipment to monitor women afterwards. Vuckovic proposed education, training, health governance strengthening, research and regulation as strategies to address the overuse of uterotonics in India. Improving the quality of maternity care in India will require attention to both under-intervention and over-intervention.
Autonomy and respect
Saraswathi Vedam, Associate Professor at the Midwifery Program of the University of British Columbia, presented findings from several community-based participatory research studies that she has led to explore women’s preferences for and experiences with maternity care in Canada, Hungary and the United States. Her work has focused on women’s autonomy: “We need to know who’s making the decisions and what’s driving those decisions,” she said.
Vedam noted that women generally want to lead the decision-making process about their care with guidance from their medical provider. Unfortunately, many women reported feeling pressured by their provider to undergo obstetric interventions such as cesareans, inductions and episiotomies, resulting in experiences of less respect and autonomy. Vedam and colleagues designed new measures to quantify these experiences, the Mother’s Autonomy in Decision Making (MADM) scale and the Mothers on Respect (MOR) index. Based on data from an online survey conducted in the United States, women of color who were poor and covered by Medicaid were most likely to have low scores on these respect and autonomy scales. The researchers also found that women who delivered with midwives tended to have higher respect and autonomy scores compared to their counterparts.
Women’s experiences of disrespect during childbirth are a global issue, Vedam pointed out, and respectful maternity care is essential for improving outcomes. Addressing the shortage of health workers as well as their daily struggles with stress and exhaustion is another key component. Perhaps most of all, “women need time,” Vedam stated. All women have a right to consider their options and make informed choices about their maternal health care without feeling pressured into a decision.
Watch the webcast of this dialogue.
Read a summary of The Lancet Maternal Health Series article, “Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide.”