Birth in Iran
I have returned from Iran and can now post several articles and some photos about my experiences in Iran. This is the first report.
Today was the first day of the workshop I am facilitating in Iran. They (the Ministry of Health, the UN Population Fund and the Hospital that is hosting the event have gone to endless trouble to make everything as comfortable as possible and they are being wonderful hosts – I am embarrassed by all the attention I am receiving.
The group is made up of some policy makers from the Department of Health (who are midwives and doctors), Midwifery educators from a number of Universities (many of whom are also practising midwives), some Obstetricians (who only stayed for a few hours), some students and other key midwives. They have been forthcoming and interested, asking many questions!
After the formal opening speeches, we got down to work. First I asked the group to tell me about birth in Iran. After some consultation with colleagues in small groups, they described the typical care pattern for pregnant women, noting that there are variations between city and rural areas. It seems that pregnant women have the following routine:
- - Pregnancy care in a public hospital clinic or with a private obstetrician or midwife, with about 15% of births in the private system.
- She will receive the usual pattern of visits – monthly until 28 weeks, then fortnightly until 36 weeks, then weekly until 39 weeks then twice weekly until the birth.
- Routine blood tests are done. Ultrasounds are common, with one offered at almost every visit in the private system.
- If a woman has not given birth by 40 weeks she is routinely induced at that time. Prostaglandens gel is not used – the only method for induction is an ARM and Syntocinon.
- She will labour in a shared room with several other women in first stage. She may have a companion, usually her mother or sister – men are not part of the birth scene in this Muslim country.
- She will labour on a bed, with no screening around her, in the first stage area.
- She will have a mini shave and enema on admission and a CTG trace in some hospitals.
- Vaginal examinations are performed at least every hour and sometimes more often, especially when there are students around. These VEs will usually be done by a different person each time.
- No food or drink is allowed in labour, and she will have an IV drip instead.
- Pethidine and nitrous oxide are frequently used for pain relief, and epidurals are available in some places (teaching hospitals).
- Once first stage is completed, the woman is moved to the delivery room, where she will be put into stirrups in lithotomy position, given an episiotomy (mandatory for all first births) and fundal pressure will be applied to ease the baby out.
- The baby will be suctioned, the cord cut, and then shown to the mother for a minute before being whisked to the resuscitation trolley. The placenta will be removed with controlled cord traction before an oxytocic drug is given to manage bleeding (this is the American way of managing third stage).
- Breastfeeding is offered when the woman is in the recovery area. Breastfeeding rates are high with aobut 95% initiating breastfeeding and 45% still breastfeeding at 6 months.
- She will stay for one day in hospital after a normal birth and three days after a caesarean. There is not follow up after discharge – the family care for her.
- If a caesarean birth is indicated (and this happens up to 75% of the time in some hospitals) it will be done under general anaesthetic – epidurals are not routinely offered for surgical births. Few forceps or vacuums are offered, and caesarean is the preferred method used whenever there is a problem in labour.
Doctors perform almost all of the births in both the public and private system, with the midwives acting as assistants. Midwives usually care for 5 woman at a time during labour.
There is no organised system for prenatal education for women at all – whatever they learn will be picked up during the 5 minute midwifery consultations during pregnancy.
This is a brief outline of what I learned today. It is not a pretty picture but is typical of birth in developing countries. It seems they have learned their birth management techniques from the Americans 40 years ago and haven’t shifted since – there is a long way to go.
We touched on evidence based care, informed consent, defensive practice and litigation today and will explore these in depth later on. I spent most of my day fielding basic questions that reflected almost total disbelief that birth could happen in any other way. Certainly some in the group have experience of physiological births, some because they were practising many years ago, before birth had become so centralised in large hospitals. The midwifery educators have knowledge of the evidence but are struggling to convey it to their students who are unlikely to see any of it in practise. I was told at one point that much midwifery education is based on medical texts not midwifery tests, with Williams Obstetrics being the basic text for both midwives and doctors.
It is hard to know where to start with all this. We’ve done the pelvis exercise an explored how they can use the pelvis to resolve difficulties during birth. There is a perception that I am going to teach them “the method” for training women and this is going to be hard to debunk, given that they are used to telling women what to do and expecting them to conform. All I can do is show them another way and leave them with evidence and ideas. Perhaps on the next visit (yes, they are already talking about that!) we can go further, but my first task will be to try and shift some attitudes towards birth and get them thinking.
