A study by Montoya et. al. (2020) reports on the lack of evidence-based birth care in Mexico, as well as the occurrence of disrespect and abuse towards women during their labor and delivery.
In their introduction, they outlined both evidence-based practice by the WHO and non-evidence-based practices that they were observing for in the study.
The WHO established three easy to implement practices to improve outcomes and prevent significant childbirth complications:
- Active Management of the Third Stage of Labor (AMTSL), shown to prevent obstetric hemorrhage,
- Delayed Umbilical Cord Clamping (DCC), which prevents neonatal anemia for at least their first 6 months
- Immediate Maternal-Newborn Skin-to-Skin Contact (SSC), which is linked to immediate breastfeeding, long-term benefits for mother and baby, and lowered risk of postpartum hemorrhage.
However, routine implementation of these are rare in Mexico, and the pervasive practices in their healthcare setting are potentially or outright harmful practices, such as the following:
- Routine episiotomy
- It is only recommended for specific complications such as fetal distress, shoulder dystocia or breech presentation.
- No evidence that it decreases perineal damage, future vaginal prolapse or urinary incontinence
- Associated with an increase in third and fourth degree tears and subsequent anal sphincter muscle dysfunction, hematomas, infections, and pain.
- Performed in 38%-66% of all vaginal births in Mexico
- Fundal pressure (Kristeller maneuver)
- Involves the application of manual pressure on the fundus of the uterus to expedite a vaginal birth.
- Increases the risk of uterine rupture, levator ani muscle injury, rib fractures and other maternal morbidity.
- Used routinely in 17%-40% of all vaginal births in Mexico
- Manual uterine exploration and sponge curettage
- Involves the insertion of a gloved hand wrapped in gauze into the uterus to remove remaining placental parts
- Associated with severe pain, infection and uterine rupture
- At least three studies in several Mexican states found that more than 80% of the women who received birth care have undergone this practice.
These results of their observational study are frankly, alarming. Aside from the aforementioned information, it was also found that of the 401 births across 15 Mexican public hospitals, only ONE birth was recorded with complete avoidance of all non-evidence-based practices. The five evidence-based beneficial practices for the mother (i.e., FHR monitored at least 15 minutes prior, Administration of a uterotonic soon after birth, Delivery of the placenta by controlled cord traction, Uterine massage, and Placenta examination after birth) were completed only in four (0.32%) births.
Aside from these, abuse and disrespect are still pervasive in the setting despite the existence of Mexican laws that penalize obstetric violence. Of the few filed complaints reported, none were ever resolved, and these complaints were only lodged in extreme cases that resulted in death of the mother and/or newborn, which suggests that obstetric violence continues to be “underreported, invisible, and neglected”.
Majority of the women were also not allowed companions, lacked privacy, were not allowed to consume oral fluids, not given the opportunity to choose birth position, did not experience positive communication from their provider, and were uninformed about the medications and procedures received or the needed routine postpartum and newborn care. Women who have had multiple previous pregnancies were also not given uterotonics as they are perceived to be “low-risk” (which is false).
It horrifies me to imagine what these mothers had to go through in the hands of healthcare workers who are supposed to help ease them through the pains of labor. Instead of receiving safe, correct, and efficient care, most had to suffer through blatant disrespect of their autonomy as a person, and had underwent unnecessary interventions that furthered the risk of complications, and had even likely increased their pain and suffering.
With this, I can see how maternal health is a reflection of the deeper dynamics of power and inequity that shapes the ground of the societies in which they are embedded. It is also an indicator of the development and inequality levels of a nation, as it is a reflection of poverty and social exclusion. The normalization of these disrespectful and harmful practices towards women is difficult to combat, even if there is an implementation of systemic-wide change. It is not enough to increase awareness of this disrespect, abuse, and use of non-evidence-based interventions; there must also be a shift in how societies value mothers’—and women’s—health, in general, so that true equity is achieved for everyone.
Montoya, A., Fritz, J., Labora, A., Rodriguez, M., Walker, D., Treviño-Siller, S., ... & Lamadrid-Figueroa, H. (2020). Respectful and evidence-based birth care in Mexico (or lack thereof): an observational study. Women and Birth, 33(6), 574-582. https://doi.org/10.1016/j.wombi.2020.02.011