British Journal of Obstetrics and Gynaecology, September 1992, Vol. 99,
pp. 709 - 710
WHO appropriate technology for birth revisited
In August 1985 The Lancet published the WHO recommendations for birth
in an article entitled 'Appropriate technology for birth'. This publication
followed the appearance, in the same year, of the WHO book, Having a baby
in Europe, which described the current status of childbirth care in
Europe. both these publications resulted in controversy as to their validity.
In many, if not most, parts of Europe as well as in other regions this
controvery continues.
Questions such as: How were the publications arrived at? How representative are
their contents? Are these biased, 'liberal' views? And, most importantsly, how
well do these recommendatoins match up to research findings?
Development of the WHO recommendations for birth
The United Nations declared 1979 as the International Year of the Child. At
the Regional Committe for Europe in that year, concern was expressed over a
number of issues including: the rapidly expanding technology being applied to
birth with its associated rising costs; the doubling or even tripling of the
caesarean section rate which took place in the 1970s, the question of whether
this was associated with the increasing use of electronic fetal heart rate
monitoring; the increasing demands from women's groups to resume control over
their birth experiences and the poorly understood inequities relating to
perinatal mortality (Wagner, 1991).
The outcome of this debate was a decision by the WHO to undertake research into
perinatal services and to develop recommendations for appropriate technology
for birth.
A series of events followed. The first was the establishment of a
multidisciplinary, 15-member, perinatal study group. This consisted of
representatives from obstetrics, paediatrics, nursing, midwifery, epidemiology
and statistics, health administration, sociology, psychology, anthropology,
economics and consumer groups. Meeting at least once a year as a full group,
and more frequently in subgroups, the team investigated the available
literature, the perinatal services in 23 of the then 32 WHO-Europe member
states, mother-infant contact practices in a detailed study of ten
representative member states and alternate (meaning outside of the formal
health care system) perinatal services in Europe, as well as in the USA and
Canada (Wagner, 1991).
Debate and eventual consensus between the members of the team resulted in
Having a baby in Europe (WHO, 1985). This was directed towards
lay readers; Perinatal Health Services in Europe: Searching for Better
Childbirth (WHO, 1985) was aimed at the academic reader.
The second major step in the process followed: the organisation of Birth
Conferences. These were national conferences designed to debate the
applicability of the recommendations of the WHO books to a country. These
conferences have almost always involved professionals and consumer groups as
well as non-governmental organizations and the media. To date 43 conferences
have been held in 23 European member states, as well as in the USA, Canada,
Australia and China (Wagner, 1991).
The birth conference movement led to three major interregional meetings. These,
combining in particular the WHO areas of Europe and America, covered appropriate
technology for pregnancy, for birth and for after the birth. These conferences
always involved multidisciplinary representation and required participants to
submit their papers well in advance to enable translation and circulation
before the meeting. At the conference issues were debated until consensus was
reached. The outcome of these deliberations was published in the
Lancet (WHO, 1985).
How valid are these recommendations?
There is no doubt that much deliberation, research and discussion went into the
development of the WHO redommendations for appropriate technology at birth.
Nevertheless, some questions persist. How valid are these recommendations? How
representative were the participants in the various conferences and research
teams? Is it not possible, if not probable, that individuals willing to
participate in such meetings and activities would have an interest in 'changing
the system' and would be biased? Most important, how well do the recommendations
match up to research findings?
The recent publication by Chalmers, et. al. (1989) encompassing a
careful scrutiny of randomized control trials of perinatal technology allows
these questions to be answered. This two volume tome contains many reviews of
great value but of particular relevance here are four appendices. These list
the forms of perinatal technology that
- reduce the negative outcomes of pregnancy and childbirth;
- are promising but require further evaluation;
- have unknown effects and require further evaluation; and
- should be abandoned in the light of the available evidence.
The WHO recommendations for appropriate technology for birth are examined
in Table 1 in terms of their classification by Chalmers et. al. (1989).
This appendix deals only with the specific birth technology recommendations
and does not assess the general recommendations regarding perinatal health
care policy and the setting of policy.
The recommendations of the WHO for appropriate technology at birth, developed
through survey research, discussion and debate, are strongly endorsed by the
findings of carefully controlled and critically evaluated randomized control
trials. The recommendations provide sound guidance for those
providing perinatal care.
Table 1. WHO recommendations for birth classified according Chalmers
et. al. (1989)
- The well-being of the new mother must be ensured through free access of
a chosen member of her family during birth and throughout the postnatal
period. In addition, the health team must provide emotional support.
- Women must participate in decisions about their birth experiences.
- The healthy newborn must remain with the mother whenever possible.
- Immediate breast feeding should be encouraged even before the mother
leaves the delivery room.
- There is no justification to have a caesarean section rate of higher than
10 - 15 %. Vaginal deliveries after a caesarean section should
be encouraged.
- Electronic fetal monitoring should not be routine.
- There is no indication for shaving pubic hair before delivery.
- There is no indication for routine enemas before delivery.
- The dorsal lithotomy position during labour and delivery is not recommended.
Women must decide which position to adopt for delivery.
- Systematic use of episiotomy is not justified.
- Induction of labour should be reserved for specific medical indications.
- The routine administration of analgesic or anaesthetic drugs should be
avoided.
- Artificial early rupture of membranes, as a routine process, is not
justifiable.
- Enhanced social and psychological support from care givers reduces negative
outcomes. Leaving women unattended during labour should be abandoned.
- Failing to involve women in decisions about their care should be abandoned.
- Separating healthy mothers and babies routinely should be abandoned.
- Unrestricted mother-infant contact after delivery and unrestricted
breast feeding reduce breast feeding failure.
- Repeating caesarean section routinely after previous caesarean section
should be abandoned. (There is litte improvement in outcome with rates above
7 %.)
- Routine continuous monitoring of fetal heart rate without fetal scalp
blood sampling should be abandoned.
- Shaving the perineum routinely should be abandoned.
- Administering enemas or suppositories routinely should be abandoned.
- Restricted maternal position during labour and delivery should be
abandoned. Upright versus recumbent position during first and second stage
reduces negative outcome.
- Performing episiotomy routinely should be abandoned.
- Inducing labour routinely at less than 42 weeks gestation should be
abandoned.
- Prescribing sedatives or tranquilizers routinely should be abandoned.
- Amniotomy to augment spontaneous labour appears promising but requires
further evaluation.
Beverley Chalmers
Consultant
World Health Organization
Regional Office for Europe
Maternal and Child Health
8 Scherfigsvej
DK-1200 Copenhagen
Denmark
References
Chalmers I., Enkin M. & Kierse M.J.N.L. (eds) (1989) Effective Care
during Pregnancy and Birth, Vol I & II, Oxford University Press, Oxford.
Wagner M. (1991) Appropriate perinatal technology of having a baby in Europe.
In: From Research to Decision Making, WHO, Geneva, 1991.
WHO (1985) Appropriate technology for birth. Lancet ii, August 24,
436 - 437.
The World Health Organization
WHO Regional Office for Europe (EURO)
Centre of Information on Public Health in the European Region
(CIPHER)
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