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Community Welln…Actices Ppt

Community Welln…Actices Ppt



Community Wellness Through Improved Maternity Practices By Drs Jose Gorrin and Ana Parilla. Given at the Puerto Rican Cultural Center in September of 2003

Community Wellness Through Improved Maternity Practices By Drs Jose Gorrin and Ana Parilla. Given at the Puerto Rican Cultural Center in September of 2003



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  • Dios, el mundo concluído, tiróle un beso al azar… el beso cayó en el mar, y es la tierra en que he nacido. God, after He finished Creation, blew a kiss at it… the kiss fell in the ocean, and became the land where I was born. Thank You.

Community Welln…Actices Ppt Community Welln…Actices Ppt Presentation Transcript

  • Community Wellness Through Improved Maternity Practices José J. Gorrín, MD, MPH, FACOG Professor and Director Ana M. Parrilla, MD, MPH, FABM Associate Professor Maternal and Child Health Program Graduate School of Public Health University of Puerto Rico
  • What is a Puerto Rican?
    • One gets to be a Puerto Rican by various means. You are Puerto Rican if you are born in Puerto Rico. You are Puerto Rican if your parents are Puerto Rican, even if you have never visited the island, have never eaten arroz y habichuelas, and have never spoken a word in Spanish. You can be a second or third generation Puerto Rican of mixed marriage, be acculturated to American culture, but when asked, you say proudly, “I am a Puerto Rican.”
    Gontran Lamberty
  • Historical overview
    • The XIX century – agrarian society – birth as a family event – the traditional midwife
    • Early XX century – high rates of fetal and maternal mortality
    • Post WWII – health care reform – the medical model – hospital births, MD as main provider –
    • Change of paradigm
  • Percent of Live Births Attended by CNMs in the USA 1989-2000. Vaginal Total Declercq E. Births Attended by CNMs in the US. Journal of Midwifery & Women’s Health 2003, 48, 83-4.
  • The Present Situation
    • Non-compliance with evidence-based obstetrics
      • Shaving
      • Enema
      • IV fluids
      • Withholding of oral nourishment
      • Artificial rupture of membranes
      • Induction of labor
      • Electronic fetal monitoring (78%)
      • Indiscriminate use of episiotomy (79-88%)
  • Tendency of Episiotomy Use in USA % 2000 National Hospital Discharge survey: Annual Summary with detailed diagnosis and procedure data, Vital Health Statistics 13(153), 2002
  • The Present Situation (cont.)
    • Widespread use of pharmacological methods of pain relief
    • Excessive rates of cesarean section and low VBAC rates
    • Routine separation of mother and her child
    • Inadequate support for breastfeeding
  • Tendencies in Cesarean Section rates in Puerto Rico & USA National Vital Statistics Reports 49(13), 2001 %
  • Tendency of VBAC rates in Puerto Rico and USA National Vital Statistics Reports 49(13), 2001 %
  • Evidence-based Research to Support Ob Practices
    • Supine position – maternal hypotension, placental insufficiency,  pain,  labor, depressed neonates
    • Maternal choices – analgesic effect,  need for drugs, shorter labor, better neonate
    • Shaving and enema – not supported – uncomfortable, humiliating, unnecessary
    • IV fluids – a surgical view - unsupported
  • Evidence-based Research to Support Ob Practices
    • AROM – usually not indicated – IFM not valid excuse – eliminates hydrostatic protection and barrier vs infection
    • Induction – underreported -  risks of hyperbilirubinemia, need for drugs, maternal stress, C/S, iatrogenic prematurity – WHO <10%
  • Evidence-based Research to Support Ob Practices
    • EFM – promises unfulfilled – CP rates unimproved after 30 years – routine use not recommended by AAP/ACOG -  C/S rates, prolongued labor,  maternal mobility,  pain,  exhaustion, negative effect on initiation of breastfeeding
  • Evidence-based Research to Support Ob Practices
    • Pharmacological analgesia – obstetrical and neonatal negative effects known for years -  risks of maternal fever, Apgar scores <7, separation of mother/infant dyad
    • Cesarean section – USA HP 2010 15.5% primary and 37% VBAC -
  • Recommended Public Health Strategies
    • Prenatal empowerment for the pregnant couple
    • Legislation to authorize professional midwives as independent providers
    • DOH regulations for obstetrical practices and services
    • The Mother Friendly Childbirth Initiative
  • Coalition for Improving Maternity Services (CIMS)
  • The CIMS Mission
    • “… promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.”
    • “ This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis and treatment programs.”
  • Whereas:
    • Current maternity and newborn practices that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence.
  • Whereas:
    • Increased dependence on technology has diminished confidence in women’s innate ability to give birth without interventions.
    • The integrity of the mother-child relationship, which begins in pregnancy, is compromised by the obstetrical treatment of mother and baby as if they were separate units with conflicting needs.
  • Whereas:
    • Although breastfeeding has been scientifically shown to provide optimum health, nutritional, and developmental benefits to newborns and their mothers, only a fraction of US (and Puerto Rican) mothers are fully breastfeeding their babies by the age of six weeks.
  • Whereas:
    • The current maternity care system in the USA does not provide equal access to health care resources for women from disadvantaged population groups, women without insurance, and women whose insurance dictates caregivers or place of birth
  • CIMS Principles
  • Normalcy of the birthing process
    • Birth is a normal, natural and healthy process
    • Women and babies have the inherent wisdom necessary for birth
    • Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such
  • Normalcy of the birthing process
    • Breastfeeding provides the optimum nourishment for newborns and infants
    • Birth can take place safely in hospitals, birth centers and homes
    • The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth
  • Empowerment
    • A woman’s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care, and by the environment in which she gives birth
  • Empowerment
    • A mother and baby are distinct yet interdependent during pregnancy, birth and infancy. Their interconnectedness is vital and must be respected.
    • Pregnancy, birth and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.
  • Autonomy Every woman should have the opportunity to:
    • Have a healthy and joyous birth experience for herself and her family, regardless of her age or circumstances
    • Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well-being, privacy, and personal preferences are respected
  • Autonomy Every woman should have the opportunity to:
    • Have access to the full range of options for pregnancy, birth, and nurturing her baby, and to accurate information on all available birthing sites, caregivers, and practices
    • Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests suggested for use during pregnancy, birth, and the postpartum period, with the rights to informed consent and informed refusal
  • Autonomy Every woman should have the opportunity to:
    • Receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs.
  • Do no harm
    • Interventions should not be applied routinely during pregnancy, birth, or the postpartum period. Many tests, procedures, technologies and drugs carry risks to mother and baby, and should be avoided in the absence of specific indications for their use.
    • If complications arise during pregnancy, birth or the postpartum period, medical treatments should be evidence-based
  • Responsibility
    • Maternity care practice should be based not on the needs of the caregiver or provider, but solely on the needs of the mother and child.
    • Each hospital is responsible for the periodic review and evaluation, according to current scientific evidence, of the effectiveness, risks, and rates of use of its medical procedures for mothers and babies.
  • Responsibility
    • Society, through both government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring the quality of these
    • Individuals are ultimately responsible for making informed choices about the health care they and their babies receive.
  • Ten Steps of the Mother-Friendly Childbirth Initiative For Mother-Friendly Hospitals, Birth Centers, and Home Birth Services
  • Step 1
    • Offers all birthing mothers unrestricted access to the birth companions of her choice, including fathers, partners, children, family members and friends
  • Step 1 - continuation
    • Offer all birthing mothers unrestricted access to continuous emotional and physical support from a skilled woman – for example, a doula, or labor-support professional
  • Step 1 - continuation
    • Offers all birthing mothers access to professional midwifery care
  • Step 2
    • Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
  • Step 3
    • Provides culturally competent care – that is, care that is sensitive and responsive to the specific beliefs, values and customs of the mother’s ethnicity and religion
  • Step 4
    • Provides the birthing woman with the freedom to walk, move about and assume the position of her choice during labor and birth (unless restriction is specifically required) and discourages the use of the lithotomy position
  • Step 5
    • Has clearly defined policies and procedures for:
      • Collaborating and consulting with other maternity services
      • Linking the mother and baby to appropriate community resources, including breastfeeding support
  • Step 6
    • Does not routinely employ practices and procedures that are unsupported by scientific evidence, such as:
      • Shaving
      • Enemas
      • IV fluids
      • Withholding nourishment
      • Artificial rupture of membranes
      • Electronic fetal monitoring
  • Step 6 – continuation
    • Other interventions are limited as follows:
      • Induction rate of 10% or less
      • Episiotomy rate of 20% or less, with a goal of 5% or less
      • Total cesarean rate of 10% or less (15% in tertiary care hospitals)
      • VBAC rate of 60% or more with a goal of 75% or more
  • Present situation in several countries
    • Until 1970 – almost universal practice in first births
    • Some countries ca. 2000:
      • Holland 8%
      • France 28.2%
      • Belgium 28.4%
      • USA 32.7%
      • Hungary ca. 100%
      • Puerto Rico 79.3%
  • “ The episiotomy is a ritual of genital mutilation in western obstetrics”
  • Maternal risks of a Cesarean section
    • 5-7 x maternal mortality
    • Complications during and after surgery:
        • Trauma to bladder, uterus and blood vessels 2%
        • Hemorrhage: 1-6% require transfusions
        • Anesthesia accidents
        • Thrombotic phenomena 6-20/1000
        • Pulmonary emboli 1-2/1000
        • Paralytic ileus 10-20/ 100, 1% severe
        • Infection 50% greater rate
  • Maternal risks of a Cesarean section
    • 10% have difficulties performing normal activities 2 months later
    • 25% report pain as their main problem
    • 2x greater risk of hospitalization
    • Negative emotions, low self-esteem, sense of failure, loss of control, post traumatic stress syndrome, fear and anxiety
    • Lower probability of wishing another pregnancy
  • Maternal risks of a Cesarean section
    • Long term risks:
        • Pelvic pain
        • Painful coitus
        • Bowel problems
    • Increased risk of: infertility, miscarriage, placenta previa, abruptio placenta and premature birth
    • Risk of uterine rupture - 1/500 vs 1/1000 in women without uterine scars (including planned repeat CS)
  • Hazards of a C/S to the baby
    • 50% more likely to have low Apgar scores
    • 5x more likely to require respiratory assistance
    • 4x more likely to be admitted to NICU for respiratory problems
    • 1-2% will be cut during the surgery
    • Iatrogenic prematurity
    • 4x more likely to develop persistent pulmonary hypertension, a life-threatening situation
  • Hazards of a C/S to the baby
    • More likely to have difficulty forming an attachment with mother due to the mother’s situation
    • Less likely to be breastfed
  • Hazards of elective repeat C/S
    • 2x greater risk of maternal death
    • Old scar increases the likelihood of surgical injury
    • Greater risk of ectopic pregnancy (leading cause of maternal mortality in 1 st . trimester)
    • Placenta previa:
      • 4x with 1 C/S
      • 7x with 2-3 C/S
      • 45x with 4 or more C/S
  • Hazards of elective repeat C/S
    • Abruptio placenta 4x
    • Placenta accreta
      • 1/1000 with 1 previous C/S
      • 1/100 with more than 1 C/S
    • More hemorrhages, transfusions, blood clots and infection
    • More difficult post partum recovery
  • Step 7
    • Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication
  • Step 8
    • Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions
  • Step 9
    • Discourages non-religious circumcision of the newborn
  • Are there risks with circumcision?
    • Bleeding and hemorrhage
    • Infections
    • Anesthesia complications
    • Surgical failure, including loss of the glans or of the penis
    • Death
  • Many circumcised men suffer from:
    • Extensive scarring
    • Redundant skin tags
    • Bleeding from the scar
    • Penile curvature
    • Painful and tight erections
    • Impotence
    • Sense of personal violation
    • Sense of mutilation
    • Every circumcised male loses some sensitivity in the glans penis
  • “ Routine circumcision is not a medical or social issue. It is a sexual principle and a human rights principle. &quot; Frederick Hodges
  • Male and female circumcision should be aggressively attacked as an act of mutilation and sexual violence against boys and girls.
  • Step 10
    • Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding
  • Ideals vs. Reality in USA & PR Births Programa de Salud de la Madre y el Niño, Escuela Graduada de Salud Pública, Recinto de Ciencias Médicas, Universidad de Puerto Rico 2003. Modified from : Ideals vs. Reality in US Births . BirthNet 2001. Not available 80% Only for complications Not routine Drugs in Labor 78% (in 1997) 84.8% (3.3 million) Not routine Not routine Electronic Fetal Monitoring Hospitals 99.7% Hospitals 99.1% (3.9 million) Where mother prefers Out of Hospital preferred Place of birth Physicians 99.8% Physicians 91.4% (3.6 million) Access to professional midwifery care Midwives for normal pregnancy & birth Birth Attendants PR 2001 (57,000) USA 2001 (4 million) CIMS Suggestions WHO Recommendations
  • Ideals vs. Reality in USA & PR Births continuation Programa de Salud de la Madre y el Niño, Escuela Graduada de Salud Pública, Recinto de Ciencias Médicas, Universidad de Puerto Rico 2003. Modified from : Ideals vs. Reality in US Births . BirthNet 2001. 54.3% During hospital stay not necessarily immediately 68.4% During hospital stay not necessarily immediately Within an hour of birth Immediately Breastfeeding after birth 42% 24.4% (978,000) 10-15% 10-15% Cesarean Rate 79.3% 32.7% (944,000) 20% or less, with a goal of 5% or less Systematic use not justified Episiotomies 16.6% (in 1997) 17.5% (702,000) 10% or less Not mentioned Stimulation of Labor 6.6% (in 1997) 20.5% (819,000) 10% or less 10% or less Induction of Labor PR 2001 (57,000) USA 2001 (4 million) CIMS Suggestions WHO Recommendations
  • It’s time to get some respect for mommy and for me! … HUM!
  • I am not an advocate for frequent changes in laws and constitutions. But laws and institutions must go hand in hand with the progress of the human mind as that becomes more developed, more enlightened, as new discoveries are made, new truths discovered and manners and opinions change. With the change of circumstances, institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which fitted him when a boy as civilized society to remain ever under the regimen of their barbarous ancestors. Thomas Jefferson Author of the Declaration of Independence of the United States of America
  • “ La mujer es la fragua, la unidad de la raza, la unidad de una civilización, la unidad de un pueblo.” Don Pedro Albizu Campos
  • Hanna Ana Sofía Marla Pedro Alberto Cristina
  • Las tetas – Salinas, Puerto Rico