DOI: 10.1111/1471-0528.
15284
www.bjog.org
WHO recommendations, dollars and sense
JN Robinson
Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA, USA
Linked article: This is a mini commentary on OT Oladapo et al., which appeared in the July issue (BJOG 2018;125:
918–22). To view this article visit https://doi.org/10.1111/1471-0528.15237
Published Online 15 June 2018.
In 2016, the World Health organiza-
tion (WHO) outlined its vision for
high-quality care for all pregnant
women and their newborns (WHO
recommendations on antenatal care for
a positive pregnancy experience. Gen-
eva, Switzerland: World Health Organi-
zation; 2016 (http://www.who.int/repro
ductivehealth/publications/maternal_peri
natal_health/anc-positive189pregnancy-
experience/en/). In this edition of BJOG,
it has now updated these recommenda-
tions emphasizing the importance of a
positive experience during childbirth.
Respectful Maternity Care (RMC) is
central to this revision. There is very
likely to be broad consensus, and strong
support, for eleven of the twelve key ele-
ments of RMC among all well-inten-
tioned accoucheurs worldwide: safety,
privacy, dignity, education, support,
quality, equality, communication, choice,
and competence and continuity in care.
However, there may be debate about
what constitutes provision of the twelfth
domain: efficient and effective care. Effi-
ciency raises the spectres of cost and
resources, which in turn tends to bal-
ance the priority of the needs of the
individual with the good of the commu-
nity. A conundrum of intrapartum
management is that labour is not a
1068
Mini commentary
pathological process, and just as this can
justify a management style of a nonin-
terventionist nature, it can also rational-
ize management practices based on a
foundation of efficiency. It is interesting
that practices or interventions that were
instituted for improvement in obstetric
outcome, once of disproven efficacy,
now find a raison d’^etre in the name of
productivity. Intermittent auscultation
is labour intensive, a foetal heart moni-
tor is not paid by the hour, and several
monitors can be managed by a single
provider. Delaying augmentation until 5
cms of cervical dilatation and carrying
out 4 hourly cervical examinations may
be very comfortable practices in a 23
bed Delivery Suite doing 6500 deliveries
a year in Boston, maybe less so in a
smaller unit doing many more deliveries
in another part of the world. Honour-
able aspirations often must bend to
practicality, even in units with the most
luxurious budgets. It may be in the
harsh reality of the contemporary world
that there is no such thing as a lavish
budget, and in fact, efficiency is queen.
If this is the case, it may impede univer-
sal adoption of some of these recom-
mendations.
Other than cost and efficiency,
potential adversaries of some of the
ª 2018 Royal College of Obstetricians and Gynaecologists
recommendations may be liability and
choice. In a country with a plethora of
plaintiff lawyers, abandoning the
admission cardiotocogram may pro-
voke some discomfort. Some mothers,
like some providers, see a shorter
labour as a desirable goal. I suspect
listing the active management of
labour as a ‘hindrance’ may be unpop-
ular with many.
The principles behind the recommen-
dations in this WHO update of intra-
partum care can be lauded, and the
recommendations themselves are based
on solid science and are a step in the
right direction. While the great majority
of them can be embraced, we should be
careful not to let them become the fod-
der of an overzealous following. Some
might say that a healthy mother and
baby in themselves frequently enough
lead to satisfaction with childbirth,
while the details of the journey are often
quickly forgotten.
The practice of modern obstetrics is a
feat of balance and finesse, not just based
on science and good intentions.
Disclosure of interests
None declared. The completed disclo-
sure of interest form is available to view
online as supporting information. &