The WHO on Birth: the “Fortaleza Declaration” and “Safe Motherhood: Care in Normal Birth”

Because I seem to be on a bit of a theme right now (Easter and birth? Why not!), I thought some of you might like a look at the recommendations on birthing care from the World Health Organisation.

The WHO, the health arm of the United Nations, is an organisation without a financial investment in developing a care monopoly, and without a financial interest in managed, scheduled birth. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

The Fortaleza Declaration (summarised in “Appropriate Technology For Birth“) was produced in 1985, and very little has changed, except that intervention rates have skyrocketed without any dramatic improvement in perinatal and maternal mortality.

Compare these recommendations to your birth experience, that of your friends, or your experiences as a healthcare provider. “Standard” obstetric care is a series of managed rituals and stopclocks, not an evidence-based or woman-centred journey.

Here are the recommendations:

These 16 recommendations are based on the principle that each woman has a fundamental right to receive proper prenatal care:

that the woman has a central role in all aspects of this care, including participation in the planning, carrying out and evaluation of the care:

and that social, emotional and psychological factors are decisive in the understanding and implementation of proper prenatal care.

* The whole community should be informed about the various procedures in birth care, to enable each woman to choose the type of birth care she prefers.

* The training of professional midwives or birth attendants should be promoted. Care during normal pregnancy and birth and following birth should be the duty of this profession.

* Information about birth practices in hospitals (rates of cesarean sections, etc.) should be given to the public served by the hospitals.

There is no justification in any specific geographic region to have more than 10-15% cesarean section births (the current US c-section rate is estimated to be about 23%).

[Ed: The current US rate now is over 30%, and the current WA rate over 34%. The UK, with a better developed but non-optimal midwifery system has 23%, the Netherlands, 14%. Canada 24%. In Chile, the overall rate is 40%, and the C section rate among women with private obstetricians is 57-83%.]

* There is no evidence that a cesarean section is required after a previous transverse low segment cesarean section birth. Vaginal deliveries after a cesarean should normally be encouraged wherever emergency surgical capacity is available.

* There is no evidence that routine electronic fetal monitoring during labor has a positive effect on the outcome of pregnancy.

* There is no indication for pubic shaving or a pre-delivery enema.

* Pregnant women should not be put in a lithotomy (flat on the back) position during labor or delivery. They should be encouraged to walk during labor and each woman must freely decide which position to adopt during delivery.

* The systematic use of episiotomy (incision to enlarge the vaginal opening) is not justified.

* Birth should not be induced (started artificially) for convenience and the induction of labor should be reserved for specific medical indications.

No geographic region should have rates of induced labor over 10%.

* During delivery, the routine administration of analgesic or anesthetic drugs, that are not specifically required to correct or prevent a complication in delivery, should be avoided.

* Artificial early rupture of the membranes, as a routine process, is not scientifically justified.

* The healthy newborn must remain with the mother whenever both their conditions permit it. No process of observation of the healthy newborn justifies a separation from the mother.

* The immediate beginning of breastfeeding should be promoted, even before the mother leaves the delivery room.

* Obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centers and to influence obstetrical views nationwide.

* Governments should consider developing regulations to permit the use of new birth technology only after adequate evaluation.

~~~~~~~~~

You can then read the 1997 “Safe Motherhood: Care in Normal Birth” here at the WHO. From the intro:

In 1985 a meeting of the World Health Organization (WHO) European region, the regional office of the Americas, together with the Pan American Health Organization in Fortaleza, Brazil, made a number of recommendations based on a similar range of practices (WHO 1985). Despite this, and despite the rapidly increased emphasis on the use of evidence-based medicine, many of these practices remain common, without due consideration of their value to women or their newborns.

The summary recommendations are here.

Practices which are Demonstrably Useful and Should be Encouraged

1.A personal plan determining where and by whom birth will be attended, made with the woman during pregnancy and made known to her husband/partner and, if applicable, to the family (1.3).

2.Risk assessment of pregnancy during prenatal care, reevaluated at each contact with the health system and at the time of the first contact with the caregiver during labour, and throughout labour (1.3).

3.Monitoring the woman’s physical and emotional well-being throughout labour and delivery, and at the conclusion of the birth process (2.1).

4.Offering oral fluids during labour and delivery (2.3).

5.Respecting women’s informed choice of place of birth (2.4).

6.Providing care in labour and delivery at the most peripheral level where birth is feasible and safe and where the woman feels safe and confident (2.4, 2.5).

7.Respecting the right of women to privacy in the birthing place (2.5).

8. Empathic support by caregivers during labour and birth (2.5).

9.Respecting women’s choice of companions during labour and birth (2.5).

10.Giving women as much information and explanation as they desire (2.5).

11.Non-invasive, non-pharmacological methods of pain relief during labour, such as massage and relaxation techniques (2.6).

12.Fetal monitoring with intermittent auscultation (2.7).

13.Single use of disposable materials and appropriate decontamination of reusable materials throughout labour and delivery (2.8).

14.Use of gloves in vaginal examination, during delivery of the baby and in handling the placenta (2.8).

15.Freedom in position and movement throughout labour (3.2).

16. Encouragement of non-supine position in labour (3.2, 4.6).

17.Careful monitoring of the progress of labour, for instance by the use of the WHO partograph (3.4).

18.Prophylactic oxytocin in the third stage of labour in women with a risk of postpartum haemorrhage, or endangered by even a small amount of blood loss (5.2, 5.4).

19.Sterility in the cutting of the cord (5.6).

20.Prevention of hypothermia of the baby (5.6).

21.Early skin-to-skin contact between mother and child and support of the initiation of breast-feeding within 1 hour postpartum in accordance with the WHO guidelines on breast-feeding (5.6).

22.Routine examination of the placenta and the membranes (5.7).

CATEGORY B: Practices which are Clearly Harmful or Ineffective and Should be Eliminated

1.Routine use of enema (2.2).

2.Routine use of pubic shaving (2.2).

3.Routine intravenous infusion in labour (2.3).

4.Routine prophylactic insertion of intravenous cannula (2.3).

5.Routine use of the supine position during labour (3.2, 4.6).

6.Rectal examination (3.3).

7.Use of X-ray pelvimetry (3.4).

8.Administration of oxytocics at any time before delivery in such a way that their effect cannot be controlled (3.5).

9.Routine use of lithotomy position with or without stirrups during labour (4.6).

10.Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4).

11.Massaging and stretching the perineum during the second stage of labour (4.7).

12.Use of oral tablets of ergometrine in the third stage of labour to prevent or control haemorrhage (5.2, 5.4).

13.Routine use of parenteral ergometrine in the third stage of labour (5.2).

14.Routine lavage of the uterus after delivery (5.7).

15. Routine revision (manual exploration) of the uterus after delivery (5.7).

CATEGORY C: Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue

1. Non-pharmacological methods of pain relief during labour, such as herbs, immersion in water and nerve stimulation (2.6).

2. Routine early amniotomy in the first stage of labour (3.5).

3. Fundal pressure during labour (4.4).

4.Manoeuvres related to protecting the perineum and the management of the fetal head at the moment of birth (4.7).

5. Active manipulation of the fetus at the moment of birth (4.7).

6. Routine oxytocin, controlled cord traction, or combination of the two during the third stage of labour (5.2, 5.3, 5.4).

7. Early clamping of the umbilical cord (5.5).

8. Nipple stimulation to increase uterine contractions during the third stage of labour (5.6).

CATEGORY D: Practices which are Frequently Used Inappropriately

1. Restriction of food and fluids during labour (2.3).

2. Pain control by systemic agents (2.6).

3. Pain control by epidural analgesia (2.6).

4. Electronic fetal monitoring (2.7).

5. Wearing masks and sterile gowns during labour attendance (2.8).

6. Repeated or frequent vaginal examinations especially by more than one caregiver (3.3).

7. Oxytocin augmentation (3.5).

8. Routinely moving the labouring woman to a different room at the onset of the second stage (4.2).

9.Bladder catheterization (4.3).

10. Encouraging the woman to push when full dilatation or nearly full dilatation of the cervix has been diagnosed, before the woman feels the urge to bear down herself (4.3).

11. Rigid adherence to a stipulated duration of the second stage of labour, such as 1 hour, if maternal and fetal conditions are good and if there is progress of labour (4.5).

12. Operative delivery (4.5).

13. Liberal or routine use of episiotomy (4.7).

14. Manual exploration of the uterus after delivery (5.7).



Categories: gender & feminism, health, medicine

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5 replies

  1. I laboured at home for as long as possible and then in a bath at the birth centre, with dim lighting and my partner, and with the midwife popping in periodically to check on me. I didn’t have any vaginal examinations. I was in the birth centre for about three hours before my son arrived. The only thing that doesn’t conform to the code is that I was moved from the bathroom to my own room for the delivery because women at my hospital aren’t ‘allowed’ to give birth in the bath. Although of course sometimes they do, because babies don’t come conveniently to schedule, and some women are more obstinant about staying put. I had planned on refusing to move, but when the time came, I didn’t actually want to be in the bath anymore, and there was no room next to it. So across the hall I went. I did get to deliver in my own room, and then stay there over night. I could have stayed longer, but no one looked at me funny for wanting to go home after one night. It was Christmas Day, and as nice as the birth centre was, I just wanted to be in our own house with our own bed.
    I had follow up midwifery care at home, which was ok, but I think the breastfeeding support could have been better. There was no gap between discharge from the hospital and my first visit to maternal and child health (which included a lactation consultant).
    It really annoys me that I couldn’t get this level of care at just any maternity hospital, but had to shop around. It really annoys me that I had to prep my partner in the final stages of pregnancy so that he could act as my advocate if health workers started talking about what I would “have” to do, or what I was “allowed” to do. I’m inclined to think a doula/trusted older sister/mother type person is a good person to take for support/advocacy. Especially if you’ve been labelled “high risk”.
    As an aside: my son was born in the caul, and the midwife suggested my partner take a photo between contractions, which he declined because I’d told him “No naked birth photos”. I was too exhausted to speak, so I couldn’t interject, but I would have quite liked a photo. I couldn’t see from my position (birth stool, with arms and head on the side of the bed, midwife behind me) so I still have no idea what he looked like immediately after he was born. When the sac was broken he needed suction, which was explained to me, and quick, but I couldn’t see that either, and my body was too jelly-like to move.

  2. These ones disturbed me,
    CATEGORY C: Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue
    1. Non-pharmacological methods of pain relief during labour, such as herbs, immersion in water and nerve stimulation (2.6).
    8. Nipple stimulation to increase uterine contractions during the third stage of labour (5.6).

    (well maybe not the nerve stimulation one)
    Only because, when you look at them, we KNOW that they work, we may not know HOW we know, but we KNOW… tis the intuitive level that is so constantly negated that undoes us, imho. Really midwives have been using herbs for hundreds of years, granted we do need to know which ones, and we’re a long way away from those simple days when a midwife would walk down the road to check on us, picking her herbs has she walked out her cottage.
    I LOVE this bit though:
    * Obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centers and to influence obstetrical views nationwide.
    I’d love great big posters of it up on the walls of each hospital in this country!
    Thanks for posting these, I knew they were out there, but hadn’t found them.
    Love to read the review, in fact see the film, of the Business of being born! looks awesome!
    Katherine Cunningham’s last blog post..A Question of Potential

  3. Only because, when you look at them, we KNOW that they work, we may not know HOW we know, but we KNOW… tis the intuitive level that is so constantly negated that undoes us, imho.

    Yes – the strength and the weakness of this particular report lies in that it is evidence-based in the strict, standard, positivist, current-scientific-method EBM way. This means that it doesn’t take into account intuitive and experience-based knowledge as “evidence based medicine” (but, notably, it doesn’t dismiss these either).
    On the other hand, it can be used to argue with EBM-worshippers on their own terms, giving them no opportunity to dismiss it as irrelevant or unscientific.
    There may be more recent data showing immersion to be useful for analgesia – just as there is more recent data in support of “delayed” cord clamping, no AROM, and a very, very low episiotomy rate.
    It is notable that recent developments in obstetric and midwifery research support lower levels of intervention, not higher; yet actual practice is heading in the other direction.

  4. Perhaps that would be the gap between the theory and the practice, probably measurable in years, and something that they have measured. Hopefully it’s not too long!
    All I know, is that floating in the water while birthing made me feel so VERY held, safe and the warmth took an edge of the intensity that I felt when I left the water. Perhaps not for everyone, but I always felt so at home in water.
    Katherine Cunningham’s last blog post..Sexual stimulus

  5. This is very helpful for me, especially as I am getting used to the fact that children will be coming sooner than I previously thought for us. Thank you for posting — it gives me a bit of a springboard in beginning to research all of this for myself.
    amanda w’s last blog post..Boot straps

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