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Lamaze International’s Recommendations for Preventing Maternal Deaths

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The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movementoffer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

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  1. January 27th, 2010 at 16:16 | #1

    “One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again.”

    But in a large study of maternal deaths, Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery (American Journal of Obstetrics and Gynecology – Volume 199, Issue 1 (July 2008), among 95 maternal deaths in 1.5 million deliveries, there was only one case of fatal obstetric hemorrhage due to placenta accreta, and we have no information as to whether this was associated with a previous C-section.

    Indeed, the authors state:

    “Despite expressed concern for a rising rate of placenta accreta associated with the increasing cesarean delivery rate, we saw only 1 death from placenta accreta in almost 1.5 million deliveries, even with a cesarean rate in our facilities at or above the national average during this period of time.[4] Thus, the feared increase in maternal deaths because of placenta accreta does not appear to have materialized.”

    You write: “Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices.”

    And there is precisely ZERO evidence that they will prevent even one maternal death. So why, exactly, are you recommending them to treat a problem when they have never been shown to be effective in treating that problem?

  2. avatar
    Patsy
    January 28th, 2010 at 00:40 | #2

    In the hospital where I used to work, if women came in in early labor, they were monitored for 20 minutes, and then sent walking the halls. (Not tethered to anything.) They were rechecked two hours later, and if there was no cervical change, they were encouraged to go home. Guess what? They didn’t want to go home. So they walked two more hours. No change. They still didn’t want to go home. What are you supposed to do? They were offered two options: go home or be induced. I guess most of them didn’t read the Lamaze six healthy birth practises. I think women’s autonomy also allows them to be induced. But that is besides the point. How do you get from admission in early labor to maternal death? Give me a break.

  3. January 28th, 2010 at 10:10 | #3

    “And there is precisely ZERO evidence that they will prevent even one maternal death. So why, exactly, are you recommending them to treat a problem when they have never been shown to be effective in treating that problem?”

    The 6 healthy birth practices are intended to prevent the problem, not treat it.

  4. January 28th, 2010 at 11:39 | #4

    “The 6 healthy birth practices are intended to prevent the problem, not treat it.”

    Right, and there’s no evidence that they do so.

  5. January 28th, 2010 at 15:45 | #5

    I don’t think it’s a bad thing to try and see if using these practice will #1 prevent c-sections, #2 also keep baby healthy. I would love to see more research around these areas. Some of them have some already supporting them:

    let labor start on it’s own: we have seen research and more is coming out that inducing with pitocin can increase the risk of c-section(this is usually for nullips, or those with very unripe cervixes).

    encourage freedom of movement: This is one that I would love to see more research on. Even if it doesn’t prevent c-sections, most women find it more comfortable and satisfying to do so. If it isn’t harming baby, why not let a mom do this. But, I really would like to see any research that may offer insight into whether or not this prevent c-sections.

    offer labor support rather than labor management: Labor support has also shown to reduce the c-section rate(though, I would word this different and say offer labor support and use labor management when needed)

    avoid all routine interventions not supported by evidence: I think this should be more specific. Which interventions would cause c-sections? (I mentioned pitocin which has been studied extensively, but I would think there would need to be more studies done with other interventions.) Of course, if an intervention is not needed, there is no risk to baby or mom, and the mom would rather not have it, then why do it? EFM with normal pregnancies comes to mind.

    avoid interfering with a woman’s freedom to push in an upright position or any position of her choice: Again, I don’t see this as having a correlation to c-sections, but it does have a correlation to infant apgar scores and hypoxia at birth, and use of forceps or vacuums. Again, if a there is no danger to infant or mother, and mother would prefer a certain position, why not.

    We are trying to solve a problem, we should be looking at options that might help and study them. If we view an increase in c-section rates as a problem, then maybe we should go back and look at how we help women in birth. Just because something isn’t tested doesn’t mean it won’t work. What it means is that we should look at it, use it(if there aren’t any risks), and do research on it.

  6. January 28th, 2010 at 15:51 | #6

    @Patsy
    Hospitals started recommending not admitting women in early labor because it was causing more interventions and thus leading to more problems with both mom and baby. I know where I work, if we were to induce a women in the same situation as what you described, we’d be in hot water. We just simply cannot induce a women unless they are 39 weeks or there is an indication for it. Plus they have to have a ripe cervix, and in one hospital nullips cannot be electively induced period. They do this because they have noticed a trend towards more c-sections in these situations…thus that would increase the mortality rate for mothers.

  7. January 28th, 2010 at 15:53 | #7

    “Despite expressed concern for a rising rate of placenta accreta associated with the increasing cesarean delivery rate, we saw only 1 death from placenta accreta in almost 1.5 million deliveries”

    But this is one death that might have been preventable…

  8. January 28th, 2010 at 17:15 | #8

    “But this is one death that might have been preventable…”

    We don’t know if it was even associated with previous C-section.

    Maternal mortality is a serious problem and it deserves a serious response. Using maternal mortality to promote Lamaze principles without scientific evidence that they have any impact on maternal mortality is cynical in the extreme.

  9. avatar
    Sally Byrnes
    January 29th, 2010 at 21:42 | #9

    I am shaking my head here. Amy, perhaps we need to define intervention. Induction, ‘sterile’ pelvic exam with ruptured membranes,constant fetal monitoring, internal fetal heart rate monitoring, bed rest, all these are interventions. When I was delivering women in a tertiary care centre, I allowed none of these ‘routine’ interventions. Over ten years, I had very few complications. Allowing a woman to move as she wishes, eat or drink as she is moved to, these are not interventions, they are natural events. Just how do you explain the extremely high C-section rate, with accompanying high fetal poor outcomes in the US?

  10. avatar
    Sally Byrnes
    January 29th, 2010 at 21:43 | #10

    I also never did a routine episiotomy.

  11. January 30th, 2010 at 10:29 | #11

    ” how do you explain the extremely high C-section rate, with accompanying high fetal poor outcomes in the US?”

    How do explain not knowing that the US has one of the lowest perinatal mortality rates in the world? According to the WHO the US rate is lower than Denmark, the UK and the Netherlands.

  12. February 2nd, 2010 at 16:59 | #12

    “however, infant mortality rates for infants born at 37 weeks of gestation or more are higher in the United States than in most European countries.”
    -November 09 NCHS Data Brief available here: http://www.cdc.gov/nchs/data/databriefs/db23.htm

  13. February 2nd, 2010 at 22:49 | #13

    “infant mortality rates for infants born at 37 weeks of gestation or more are higher in the United States than in most European countries”

    But infant mortality is the wrong statistic for evaluating obstetrics. The correct statistic is perinatal mortality.

  14. avatar
    Augusta
    February 4th, 2010 at 07:16 | #14

    @Amy Tuteur, MD

    I understand what you’re saying Amy (Tuteur), about the importance of using the “correct” measure for obstetrics. But I think it is very short-sighted to say that just because a neonate survives the first 28 days of life it means that obstetric care was as good as it can be. To me, it seems that our infant mortality rates (which you have never disputed are much higher than many developed nations) should remain equally low. What happens around the time of birth can certainly set children up for lifelong problems. If those problems cause them to die within the first year, then it seems that should still be a measure of the effects of the obstetric care they received.

  15. February 4th, 2010 at 12:52 | #15

    “But I think it is very short-sighted to say that just because a neonate survives the first 28 days of life it means that obstetric care was as good as it can be.”

    What is the best measure for international comparisons of obstetric care? According to the WHO, the best measure if perinatal care. Infant mortality is a measure of pediatric care. Therefore, if you want to use infant mortality to go after the pediatricians in the US, you’d have some basis for doing so. To use it to proclaim that US obstetric care doesn’t meet the standards of other countries is disingenuous at best, and an attempt to deliberately mislead people at worst.

  1. January 31st, 2010 at 13:36 | #1