Rađanje u Iranu
Nakon rađanja u Japanu, evo malo o rađanju u Iranu, s linkova http://birthinternational.com.au/dia...es/000606.html i http://birthinternational.com.au/dia...es/000607.html.
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.More on birth in Iran
Its hard to know where reform of the maternity services In Iran might begin. On the second day of the workshop, the group spent some time thinking about how women could be made more comfortable and less fearful when labouring in the hospital. There is little that can be done about the physical facilities as the pictures below reveal.
Women arriving in labour are first taken into a small assessment room, where the baby’s heart will be monitored and basic checks undertaken. If there is any irregularity detected at this point, the women will go straight to theatre, otherwise she will then be moved into the main labour ward.
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This is the first stage area where women labour in this hospital (which is typical of most in Iran). Moveable screens were added recently and I was told that curtains have been ordered for around each bed. There were two women in labour in this six bed room when I visited – both were alone, lying on the bed and had drips in place.
slika
There was a group of medical students in attendance, shown here consulting together around the bed of one woman. All the births are managed by the doctors (or students) and the midwives are there to carry out their instructions.
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One full dilatation is achieved, the woman is then moved into this delivery room. Three beds here, with no privacy whatsoever. I was told it is unusual for three women to be giving birth at the same time, but two was not uncommon. The green plastic sheet is covered with a sterile sheet before the woman is lifted onto the bed and into the stirrups. The women will have sterile leggings applied she will be draped with sterile sheets for receiving the baby.
slika
Once born, the baby’s the cord will be immediately clamped, the baby shown briefly to the mother, then taken to the resuscitaire for checking before going immediately to the nursery, where it will stay for at least 2 hours. The woman will be stitched after the mandatory episiotomy then moved again, to a recovery room where she will wait until the two hours are up and she can be moved to the ward and reunited with her baby.
If any problem is detected during labour, the solution will be an immediate caesarean, under general anaesthetic – the theatre is next door to the first stage area. In this hospital, 50% of births are by caesarean.
Where can change begin in such a system? The doctors are all powerful, completely dictating the management of every birth and seemingly oblivious of evidence based care, midwifery skills, mother’s wishes or anything else that might impact on their practise. They have the “once a caesarean always a caesarean” rule firmly in place, so it is no wonder that surgical birth rates are rocketing.
Midwives have little voice, power or status within the system. They learn about normal physiology but it is an academic knowledge as they have little chance of seeing it in action and gaining confidence through practise is virtually impossible.
Some of the questions I was asked indicated that the information they were giving students was from obstetric texts – it seems that Williams Obstetrics is the main reference manual. One belief they voiced was that precipitate labours have a very high risk of post partum haemorrhage – where do they get such ideas? They also have very definite views that many kinds of perineums just won’t stretch and that is why routine episiotomy is performed.
Although we talked about all kinds of things, such reducing V.E’s, giving women drinks in labour rather than routine IV hydration, not shaving the perineum, abandoning enemas and not separating mothers from their newborns, I am not at all confidence that they believed me when I stated many of their routine procedures were outdated and even dangerous. These midwives, mostly from academic institutions were aware of The Cochrane Library and other good sources of research, but seemed unable to translate the theory into any kind of practical application. It is sad that most have never seen a normal birth (by my definition – not just a vaginal birth, which is what they normal). A pilot Birth Centre is on the drawing boards at the Ministry of Health, but how this could function without skilled midwives is a mystery to me.
I will be making some suggestions in my post visit report on how midwifery might be strengthened. It will be interesting to see how they tackle the problem….. Meanwhile, they were a terrific bunch of women, keen, warm and very hospitable. I have had an eye-opening time, and I think they did as well!
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