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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.

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.

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.

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.

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!

The group at work

Having lunch together

All in together

Posted by andrea at April 17, 2006 06:46 PM