This blog was originally posted as an editorial in the International Journal of Gynecology and Obstetrics here.
In this issue of the International Journal of Gynecology and Obstetrics (IJGO), you will find among others six papers from the FIGO Safe Motherhood and Newborn Health (SMNH) Committee. The papers deal with the issues of labor and delivery as well as promotion of a framework for safe delivery. The additional paper on “12 steps to safe and respectful Mother Baby–Family maternity care” fits well in this context. The messages from these papers represent a call to action not only by healthcare professionals, but also by governments and healthcare officials. The involvement and commitment of these bodies is essential for the improvement of maternal and perinatal outcomes.
In many low‐ and middle‐income countries (LMICs), intrapartum losses account for almost half of all stillbirths, whereas in high‐income countries they account for only 10%–15% of all stillbirths.1 The reasons for this disparity include inadequate assessment at admission, insufficient staffing, and a lack of appropriate tools to monitor labor and delivery. Indeed, in many LMICs, labor wards are generally understaffed, resulting in a high burnout rate of healthcare workers. Between 1990 and 2012 the global skilled birth attendance rate increased from 57% to 69%.2 However, if this is not accompanied by an increase in the number of healthcare workers, then no obvious improvements can be anticipated. Against this context, FIGO’s SMNH Committee has tried to establish the minimal requirements for labor ward staffing, taking into account the number of births and presence or otherwise of operating room facilities.3 Since previous guidelines at health facility level have been lacking, the SMNH recommendations must be regarded as “authority’’‐based. However, they may provide governments with an instrument to assess the minimal (and optimal) requirements for the presence of skilled birth attendants. Moreover, they should encourage real‐world clinical and implementation research, especially in those LMICs with particularly challenging human resource gaps, to assess the accuracy of these recommendations. Such confirmative and concomitant studies may be necessary to convince local governments to provide serious investment to address labor ward staffing.
Given the high rate of intrapartum fetal deaths in LMICs, the Delphi consensus statement on fetal monitoring during labor4 concludes that the use of intrapartum cardiotocography (CTG) should be encouraged. However, the authors promote the use of cardiotocography only for those with high‐risk conditions and during the second stage of labor. This reflects: the absence of clear benefits from trials in high‐income countries; limited or absent access to training in CTG interpretation; well‐placed fear of increases in (unnecessary) cesarean deliveries; fear of HIV infection; and lack of time. Following the guidelines of this paper on intermittent fetal heart rate, recording and monitoring of contractions is profoundly difficult. It may already be almost impossible in most LMICs, given the lack of time and skilled birth attendants. The road to prevention of intrapartum stillbirths is likely to be a long one, but the two aforementioned papers represent a vital step, along with an emphasis on the re‐introduction of vaginal instrumental deliveries in many LICs, as shown in a 2018 paper published in IJGO.5
Affordable and low‐maintenance obstetric devices are essential in LMICs. The devices, as showcased in the paper published in this issue,6 may help practitioners to choose the appropriate instruments for the relevant procedures.
Regarding the care of critically ill pregnant women, the paper by Escobar, Langenegger et al.7 discusses the establishment of obstetric critical care units (OCCUs) in limited‐resource environments in regional centers large enough to provide facilities and acquire sufficient expertise. Based on previous experiences in both South Africa and Colombia, the authors present a blueprint for the establishment of obstetric critical care units. This paper should prompt governments to assess the quality and needs of their local facilities in order to take appropriate actions to meet established criteria.
In 2018, the SMNH Committee published a position paper on how to stop the cesarean section epidemic.8 Worldwide cesarean section (CS) rates show linear growth without any evidence of improved maternal and perinatal outcomes. In fact, increasing CS rates are associated with short‐ and long‐term maternal and perinatal consequences and with higher rates of autoimmune and obesity‐related problems in offspring. Consequences for future pregnancies include an increase in spontaneous preterm birth, uterine rupture, and abnormal placentation, which may result in excessive maternal bleeding, need for hysterectomy, and maternal mortality. In some African countries, cesarean deliveries are associated with a very high maternal and neonatal mortality and morbidity. This is due to the absence of facilities for instrumental vaginal delivery, delayed performance of CSs, and inadequate facilities/skills.9 In these countries the situation is even more complicated, since rural areas exhibit insufficiently low CS rates while urban areas exhibit exceedingly high CS rates. The worldwide increase in cesarean deliveries needs to be stopped. Obstetricians cannot do this alone. The engagement of government bodies, United Nations partners, professional organizations, women’s groups and other stakeholders is necessary to reduce unnecessary CSs. This can be achieved by creating awareness about the benefits and risks of CS, and by investing resources in better care during labor through effective midwifery staffing and adequate pain relief. Practical skills training for doctors and midwives is necessary, and reintroduction of vaginal instrumental deliveries should be promoted. Moreover, financial incentives for doctors and hospitals favoring CSs should be discouraged, especially in private practice settings. Professional organizations and governments should re‐examine their medico‐legal systems and current fears of litigation following a vaginal delivery.
“Too many CSs, too many episiotomies.” A restrictive approach to the use of episiotomies is the dictum that the SMNH Committee promotes in this issue of IJGO.10 Figures of 70%–90% as found in some Asian countries are far too high. It will be difficult to define an optimal episiotomy rate, but this may well be in the range of 15%–25%.
The final paper published in this issue under the responsibility of the SMNH Committee is the FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders.11 This is a follow‐up paper from the IJGO special issue on placenta accreta published in 2018.12 The increase in placenta accreta disorders is largely a consequence of increasing CS rates. Lowering the CS rate is the only rational option. In the meantime, adequate diagnosis and treatment are essential to decrease severe rates of maternal morbidity and mortality.