Is vacuum extraction still known, taught and practiced? A worldwide KAP survey
Abstract
Objective: Is vacuum extraction–the method of first choice for assisting vaginal delivery in case of prolonged labor–losing ground in the developing world? And if it is, why? The paper tries to answer these disturbing questions, and examine their consequences.
Methods: A rapid Knowledge–Attitude–Practice (KAP) survey was conducted during 2003–2004 on the question of assisted vaginal delivery (AVD) by the use of the vacuum extractor. Public health specialists and obstetricians from 121 developing countries were consulted about their knowledge of the method in their country, its reputation (i.e. their attitude) and its use (practice).
Results: Overall 48% of the respondent countries have confirmed knowledge, positive attitude, teaching and countrywide use of the method, while 37% said the method is known and used by only a limited number of specialists who do not teach it, and 15% admitted no knowledge and therefore no use.
Conclusion: Given the evidence-based international recognition of the benefits of vacuum extraction (if practiced correctly and for appropriate indications), it is unjust to deprive women with prolonged labor (and their fetuses) of a simple intervention that can contribute to reducing life threatening complications. This unsophisticated worldwide survey, while not providing in-depth explanations, calls for rehabilitation of vacuum extraction in countries where it is disappearing and surgical extraction is not yet readily accessible to all women with prolonged labor.
1 Introduction
Vacuum extraction is the method for achieving vaginal delivery when labor is prolonged. Yet it is losing ground in many developing countries? Why? To answer this question, a rapid Knowledge–Attitude–Practice (KAP) survey was conducted during 2003–2004 on the question of assisted vaginal delivery (AVD) by vacuum extraction.
When there is a prolonged or difficult labor, there are 3 instrumental techniques for easing the way of the live fetus out of the uterus through the vaginal outlet: forceps, vacuum extraction, or symphysiotomy [1], [2]. Deliveries by forceps and vacuum extraction are usually understood to be “assisted, or instrumental, vaginal delivery”[3]. Forceps is more difficult to use correctly and should be left to highly qualified professionals [4]. Symphysiotomy is less promoted nowadays because, like cesarean section, it requires surgery and it cannot compete with cesarean section when surgery is possible. Vacuum extraction (“ventouse”) is not universally known and used, despite the fact that it is simple and safe to use, provided the user follows basic rules. Indeed, in case of an obstructed labor, the most effective and well known technique for extracting the baby is by cesarean section, but it is a surgical intervention with its own costs and its own risks, requiring an operation theater, anesthesia, sterilization, instruments and scrubbing. While not addressed in the present paper, the use of a vacuum extractor is also often recommended to ease the fetus out during cesarean section.
For historical reasons, vacuum extraction (VE) is not taught in all schools of obstetrics, and therefore remains unknown, and/or unused, in several countries. In some countries VE was formerly taught but is now known and used only by a few specialists in large referral or teaching hospitals, and is no longer available or encouraged in peripheral hospitals. One reason given by obstetricians is that delivery by vacuum extraction should be used only where cesarean section is not immediately available. In fact, in Latin America, cesarean section has become the only recourse in case of prolonged labor, and almost none of the countries in that region train their medical staff in instrumental vaginal delivery [5]-[7]. Another reason for not using vacuum extraction, this one given by pediatricians, is the fear of side effects or complications for the newborn [8]. Pediatricians, however, generally tolerate the use of the forceps, perhaps because they perceive it is less likely to hurt the baby than VE. Furthermore, some clinicians express concern that there could be an increase in the risk of mother-to-child transmission of HIV through the use of the vacuum extractor [9].
Why then is VE still widely used in some countries, by both doctors and midwives, as a procedure to facilitate the expulsion of the fetus and reduce the risks of fetal distress?
The message in United Nations-promoted guidelines [10], professional textbooks [11] and other manuals [12]-[14] is clear: assisted vaginal delivery by vacuum extraction must be part of the basic life-saving obstetric interventions in non-surgical facilities everywhere. VE is listed as one of the six signal functions in basic emergency obstetric care (EmOC). Along with the use of the partograph to monitor cervical dilation and fetal descent, vacuum extraction can help manage a prolonged labor, shorten the second stage, facilitate flexion and orientation of the cephalic pole, avoid referral, and preserve the future (if not save the life) of the newborn and sometimes the mother. An important feature of this technique is that it can be practiced by qualified midwives or nurse-midwives, and by non-specialist doctors, provided they are well trained, legally allowed (licensed) by their ministry of health, and protected by their professional associations.
Recently, an Australian team, in association with a US-based manufacturer of innovative technologies, developed simple and cheap versions of the ventouse, that are either disposable or re-usable [15], [16]. This is an indication of renewed interest on the part of professionals and the public health community. Their simplicity and robustness makes these new versions usable anywhere, but especially in emergency situations and in remote places.
2 Methods
We used a very simplified version of the KAP (Knowledge, Attitude, Practice) methodology introduced by social scientists. The KAP survey was conducted on the occasion of country visits or during regional workshops by direct interviews with obstetricians, midwives, or public health experts specializing in maternal health. We used a convenience sample that was neither random nor scientific. Whenever needed, to confirm a statement or to obtain more information, additional questions were asked by mail to national program managers, obstetricians in the public sector, or university professors. No European countries were included in the survey.
Three sets of questions were asked:
-
Knowledge: is VE known, and taught, in your country? If so, by whom?
-
Attitude: how is VE perceived? For what reasons is VE either recommended or ignored?
-
Practice: is VE practiced? In what situations? By whom? Can midwives use it?
Responses were classified into 3 broad categories:
- 1.
VE is not known, not taught, and not used,
- 2.
VE is known and used but only by selected professionals in selected places, not taught in all medical/midwifery schools, vacuum extractors are found only in large hospitals,
- 3.
VE is well known, taught, and widely used by all professionals in all facilities, although the equipment is less available than should be.
3 Results
Table 1 shows the number of countries for which we obtained information, organized in five geographic regions. In all, 121 countries were approached, and 111 (92%) provided valid responses.
Region | Countries investigated | Responded | % Response |
---|---|---|---|
Sub-Saharan Africa | 42 | 41 | 98 |
Latin America and Caribbean | 25 | 23 | 92 |
Asia and the Pacific | 25 | 23 | 92 |
Arab States and Middle East | 18 | 13 | 72 |
Central Asia | 11 | 11 | 100 |
Total | 121 | 111 | 92 |
Findings are presented by region in Table 2, with numbers and percentages of the number of responding countries. It appears that 74% of the countries in Latin America and the Caribbean (with a few exceptions for historical reasons) ignore use of the vacuum extractor, and therefore do not promote its use. None of the countries in the other 4 regions ignore VE.
Region | Not known, not taught, not used | Known, but used only by specialists in selected settings | Known, used, and taught in obstetric schools | Remarks: VE used by either midwives or doctors |
---|---|---|---|---|
Sub-Saharan Africa | 0 (0%) | 15 (37%) | 26 (63%) | 9 |
Latin America and Caribbean | 17 (74%) | 3 (13%) | 3 (13%) | 2 |
Asia and the Pacific | 0 (0%) | 7 (30%) | 16 (70%) | 10 |
Arab States and Middle East | 0 (0%) | 7 (54%) | 6 (46%) | 0 |
Central Asia | 0 (0%) | 9 (82%) | 2 (12%) | 0 |
Total, out of 111 countries | 17 (15%) | 41 (37%) | 53 (48%) |
More than a third of all countries responded that they, teach and use the technique. In some countries in this category, particularly in sub-Saharan Africa, the technique is known and ready to be taught in schools, but awaits only an official green light from the legal authorities of the ministry of health to regulate its use. In other countries in this category, it can be practiced only by qualified doctors and not by midwives.
Finally almost half of the respondent countries fell in the 3rd category, where not only all specialists but a great proportion of midwives and general practitioners are trained and encouraged to use VE. This is particularly true in sub-Saharan Africa and in Asia and the Pacific, where more than two-thirds of the countries promote universal use of the technique by mid-level providers (when the equipment is available and functioning).
4 Discussion
Although this unscientific survey did not cover all developing countries, the findings present a reasonably accurate picture of the current situation in the five regions: the technique of VE is still well known, particularly in the most populated countries. The survey did not provide a historical trend, but from the interviews, it appears that VE is losing ground in face of the growing use of the cesarean section (which, with very few exceptions, is in the hands of obstetricians only). This is not good news for many reasons. First, cesarean section is far from being available everywhere. Second, the quality of the training and supervision of mid-level providers is deteriorating. Third, midwives have too commonly not been delegated the authority to perform this life-saving procedure.
All this goes against the current global strategy of promoting skilled attendance at all births, along with encouraging the posting of professional service providers in remote maternities, and delegating authority to them for performing basic EmOC procedures [17], [18].
On the other hand, there are also risks to be considered, primarily associated with inappropriate indication or poor performance. The risks are minimized by proper training, adherence to proper indications and protocols, and good supervision.
5 Conclusion and recommendations
Vacuum extraction is a basic EmOC function that can be performed in non-surgical facilities, at low cost, with much less risk than that of letting a prolonged labor go unassisted. Thus, there are two recommendations:
-
First: a worldwide campaign should be launched to rehabilitate this simple intervention, promote its use by all professionals involved in delivering babies (skilled birth attendants), and encourage governments, legislators, and professional associations to protect the providers. The role of WHO (Headquarters as well as Regional Offices), and international professional associations such as FIGO and ICM is crucial in bringing this issue to the attention of all countries, in issuing guidelines, and in convincing national professional associations. The role of pediatricians is equally important, and they must weigh the risks and the benefits to newborns. It appears that the risks of letting a difficult labor go unassisted, and the risks associated with negotiating and organizing a referral outweigh the risks associated with the technique itself. At the same time, the campaign should promote the integration of hands-on training in VE into professional curricula and in-service training programs, and the procurement of equipment at reasonable cost for distribution to all basic EmOC facilities. Two issues will require attention: first, maintenance of the equipment remains a challenge; too many vacuum extractors are left in corners of delivery rooms or shelved for lack of rubber seals or spare cups. Second, supportive supervision should be provided, offering constructive comments and reviewing cases using an audit approach.
-
Second: the impact that can be expected from an increased use of VE should be investigated further. More work should be done to estimate quantitatively the benefits as well as the risks for the mother and the newborn. The benefits are of two types: maternal and neonatal.
-
Maternal: along with the partograph, and backed up by a rapid and effective referral system, vacuum extraction can contribute in a limited number of cases to averting maternal death and severe disability. By shortening the period of compression of the fetal head on the vesico-vaginal or vesico-rectal walls, which can cause necrosis, it can also prevent obstetric fistula. More often it limits maternal morbidity, increases comfort and saves on costs of referral. It also reduces the recourse to unjustified referral and cesarean section.
-
Neonatal: this is the area where vacuum extraction can contribute the most in terms of mortality and morbidity reduction by shortening and easing the expulsion, preventing birth trauma, asphyxia and brain damage, and minimizing the need for resuscitation.
-
Acknowledgements
Many thanks to the respondents and informants who provided information on their country situations, as well as to colleagues who provided comments and suggestions about the manuscript. In particular Patricia Bailey, Luc de Bernis, Matthews Mathai, Margareta Larsson, Isabelle Moreira, Saramma Mathai, Javier Dominguez, Feruza Fazilova, Wame Baravilala.