The overuse of interventions, in particular interventions that are used electively and without medical reason, have the potential to harm both mothers and babies. I would like to go through a brief snapshot of birth-related interventions globally, in particular, looking at what has been referred to as the global epidemic of cesarean section. We will also review recommendations from the World Health Organization and FIGO aimed at reducing caesarean section, and the contribution of midwifery care in limiting intervention. It's been estimated that the optimal caesarean section rate, when responding to medical need would be somewhere between 10 and 15, perhaps as high as 19%. Here we can see that all countries with red trending colors are above that optimal rate. And on the other hand, we can see the other end of the spectrum. The two darkest shades of blue here, are countries that fall below the 10% rate that is thought to be necessary to protect mothers and babies from life threatening pregnancy complications. Thus, as you can see, there are a few countries that remain where the C-section rate is optimal. Here's a list of countries either above or approaching a cesarean section rate of one in every two babies. Do we know what this means on the individual level and the population level? Do we know what this level of unnecessary intervention means in terms of strain and financial burden to health care systems? Increasingly, the evidence suggests that we have veered drastically in the wrong direction, a direction that is away from protecting the health of mothers and babies, and away from high quality, safe, affordable Care. Well, it's important not to overlook. That caesarean section can absolutely offer a lifesaving intervention when indicated, no question. And some benefits may also accrue, such as lower incidence of urinary incontinence, and urogenital prolapse. However, caesarean section is associated with a higher risk of maternal morbidity and mortality as compared to spontaneous vaginal delivery. This risk increases in a dose response fashion such that repeated caesarean section is associated with higher risk of complications. Infants delivered by cesarean section have different hormonal, physical, bacterial, and medical exposures and outcomes. Emerging Science in this area, has associated these exposures with altered immune and metabolic functioning later in life. Other birth related interventions, beyond caesarean section are also high in many environments. The 2013, Listening to Mothers III survey conducted among mothers in the United States paints a picture of this frequent pattern of intervention during birth. Nearly 90% of women responding to this survey experienced electronic fetal monitoring. Two thirds of these were monitored continuously, which is not necessarily evidence-based care. Around two and three received intravenous fluids. Almost 80% were not allowed to eat, and 60% could not freely drink while in labor. Two thirds of those with vaginal births had an epidural in labor, and one third were given pitocin to speed their labors. One in five had their membranes artificially ruptured. 17% of women had an episiotomy. And nearly a third had a caesarean section. The high use of these interventions reflects a system-wide maternity care philosophy that does not approach birth as a normal physiologic process. Rather, it's a philosophy that views childbearing as a series of potential complications waiting to happen. And as with cesarean section, the use of these interventions is also associated with a higher cost of care. Addressing this problem of over-medicalization, the World Health Organization has developed a series of recommendations for non-clinical interventions that are aimed to reduce caesarean section rates. This provides a road map of highly implementable strategies. Many of these are low-cost and easily built into existing services. Recommendations that target childbearing individuals directly include, childbirth training workshops, with sessions about fear, about pain relief options, about cesarean section risk and benefit. Nurse-led applied relaxation training programs for discussion of anxiety, and stress, and deep breathing techniques. Psychosocial prevention programs that develop skills like emotional self-management, conflict resolution, problem solving, mutual support and parenting strategies. And psychoeducation directed toward individuals with overwhelming fear of childbirth that normalizes these reactions. Another set of recommendations that target healthcare providers include, implementing evidence-based clinical practice guidelines with a mandatory second opinion before a caesarean section is performed. While this may not be an option in all settings, where it is, the evidence shows this strategy is in fact effective in reducing the caesarean section rate. Also, implementing cesarean section audits and timely feedback to healthcare professionals. Finally, World Health Organization recommendations of interventions targeting systems an institutions include, collaborative midwifery obstetrician models of care. In particular, a staffing in which midwives provide most of the care, and work with 24 hour backup from an obstetrician who's available to provide in-house coverage without other competing clinical duties. And finally, implementing financial strategies that do not incentivize operative delivery. These recommendations are reinforced by FIGO, the International Federation of Gynecology and Obstetrics. The following list of guidelines to stop this epidemic of cesarean section, as they call it, was published in The Lancet in 2018 and as a few other action items. It includes providing the same delivery fees for physicians for caesarean section and for vaginal delivery in both public and private settings. It includes obligatory reporting of hospitals annual caesarean section rates in a risk adjusted manner. And subsequent financing that's based on that rate, again, using another form of economic pressure to bring practice into line. Standardize use of the Robson World Health Organization classification system for cesarean sections. You can link out to that here. Informing women of the benefits and risks of a cesarean section. And using money that saved from a lower C-section rate to improve resources. For example, provide better preparation for labor and delivery. Improve care and provide skills training for doctors and midwives, including training in instrumental deliveries. For example, the use of forceps. We turn now to some perspectives from emerging areas of science, in particular epigenetic and microbiome research that describe the risks of stress and intervention at birth on the health and well being of babies. We will hear again from doctor Holly Powell Kennedy, who will report on epigenetics. The benefits of physiologic birth and the theoretical risk of over-medicalization during childbirth.
