Prevalence of childbirth practices in various hospitals of Delhi

Context: Childbirth practices. Aims: To evaluate the prevalence of various birth practices amongst obstetricians of Delhi. Materials and Methods: Obstetricians from various hospitals of Delhi were questioned about various birth practices that they followed and the results were analyzed. Results: There was infrequent use of beneficial practices that should be encouraged and an unexpectedly high level of harmful practices that should be eliminated. Some beneficial practices were applied inappropriately, and practices of unproved benefit were also documented, some of which are of potential harm to the mother and baby. Conclusion: Birth practices were not in accordance with the WHO guidelines. This points toward a lack of awareness of evidence-based medicine.

Keywords: Obstetricians, birth practices

Childbirth is a very significant event in the life of a woman with important physical, physiological, and psychological implications. Although there has been significant improvement in the maternal and perinatal outcome in last century, the mortality and morbidity still remain exceptionally high in the developing world.

Improving maternal health is one of the millennium development needs. Availability of skilled attendants at delivery is an important factor in decreasing maternal mortality. ^[1] Inspite of the promotion of evidence-based medicine, there is still large difference in the actual birth practices and scientific evidence both in developed and developing countries, but the gap is larger in developing countries due to ignorance and illiteracy. We conducted a questionnaire-based survey on various birth practices (both useful and harmful) in various hospitals of Delhi in which we asked obstetricians about the various rituals (both harmful and useful) they practice during labor to find out the actual prevalence of various procedures in clinical practice.

An open-ended questionnaire was designed incorporating details of the obstetricians regarding their qualification, institute, post, and practices they commonly followed during labor (Annexure I). Obstetricians from various hospitals of Delhi, India, were requested to fill the predesigned questionnaire. The questionnaire included practices in all stages of labor and the post-partum period including advice given at discharge. Beneficial practices, clearly harmful or ineffective practices, practices for which insufficient evidence exists and practices which are frequently used inappropriately were all enquired into.

The data were compiled and results were calculated about the prevalence of various birth practices in the various hospitals of Delhi, India, using SPSS 10.0. Results

A total of 203 obstetricians from various hospitals of Delhi, India, filled the predesigned questionnaire regarding the prevalence of various birth practices during labor practiced in their hospitals. The age group of the obstetricians varied from 24 to 55 years. More than 80% obstetricians were females. One hundred and fifty-four obstetricians interviewed worked in a government set-up, while the remaining were in private. Of those in government set-up, 35 worked in non-teaching hospitals, while others worked in a teaching hospital. Half of the obstetricians of the study population in private set-up had their own nursing homes/clinics, while the other half worked in private hospitals. Of the total number of people who filled the questionnaire, 67.4% (137) were residents, the remaining were consultants.

The incidences of various birth practices that are routinely followed during the first stage of labor are given [Table 1]. [Table 2] gives the incidence of various harmful, useless and beneficial practices that were followed during the second and third stages of labor. Most prevalent practices in the postpartum period have been tabulated in [Table 3].

Practicing evidence-based medicine is the scientific practice in modern era. Application of this approach to obstetrics has encouraged adoption of practices of proven benefit and discontinuance of harmful or unnecessary practices during childbirth. It is encouraging to note that certain unnecessary or harmful practices have significantly reduced in prevalence. Thus, routine use of castor oil was not practiced by any obstetrician, but still 90.15% obstetricians still used enema in laboring women, which is an ineffective or harmful practice. Similarly, use of public hair shaving was still practiced by 74.39% of obstetricians. Other harmful or ineffective procedures like routine infusion of intravenous fluids in labor and strict supine position was still followed by 93.6% and 73.4% obstetricians respectively inspite of evidence to the contrary which is a very high prevalence.

Various demonstrably useful procedures are still not universally practiced. Single use of disposable material was practiced by 96.50% of people and sterile gloves for primary examination by 89.16% obstetricians. Only 84.2% obstetricians allowed their patients oral fluids during labor. Although recommended, routine use of partogram, additional pain relief, epidural on demand, and right to privacy of a patient were practiced not by all obstetricians.

In second and third stages, certain harmful or ineffective practices were still rampant with lithotomy position during labor being practiced by 91.62% of obstetricians interviewed. Some doctors still routinely administer intravenous ergometrine in the third stage, and/or perform uterine lavage/exploration after delivery, routine episiotomy to all patients inspite of evidence to the contrary. The prevalence of demonstrably useful practices (100%) included sterile cutting of cord and routinely calling pediatrician for all deliveries. Active management of the third stage and examination of placenta after delivery was done by almost three-fourth of the obstetricians.

All the obstetricians interviewed monitored the vitals of the parturient in the postpartum period. Prevention of hypothermia in the baby was also ensured by all those interviewed. Contraceptive advice was given by more than half of the obstetricians, but only few of them gave the women dietary advice on discharge. About half the obstetricians routinely called their patients for follow-up.

In a hospital practice versus evidence-based practice in an Egyptian teaching hospital, Khalil et al. ^[1] also reported infrequent use of beneficial practices and an unexpectedly high level of harmful practices that should be eliminated. Our observations are similar to that of Khalil et al. ^[1] from Egypt, another developing country.

Various studies from Zambia, ^[2] Niger ^[3] Israel, ^[4] and Mexico ^[5] also show high prevalence of harmful or useless practices due to cultural beliefs. In developing counties, there has been more emphasis on maximizing access to safe delivery and improving quality of emergency obstetric care to reduce maternal mortality, which is still unexceptionally high. There is less stress on eradication of useless or harmful practices than universalization of demonstrably useful practices probably due to the fact that many obstetricians still practice from their and their seniors experience without consulting Cochrane data base or evidence-based medicine.

WHO’s technical working group ^[6],[7] has recorded clearly harmful or ineffective practices in labor the prevalence of which should be zero. These practices include use of castor oil, enema, shaving of pubic hair, routine rectal examinations, use of unsterile instruments and gloves, uncontrolled use of oxytocin, routine administration of ergometrine in the third stage, and routine digital exploration of uterus after delivery among others. Some of these practices like digital exploration of uterus can cause severe complications like infection and even shock. The routine use of ergometrine can not only cause nausea, vomiting, and headache but also rise in blood pressure and gangrene of extremities in rare cases. The frequent use of ineffective or harmful practices or low frequency of use beneficial practices may have adverse impact on the maternal and perinatal outcome.

Various studies ^[8],[9],[10] have also found similar results. Hence, all obstetricians should attend CME’s on evidence-based medicine to update their knowledge of various birth practices.

Source of Support: None, Conflict of Interest: None

[Table 1], [Table 2], [Table 3]