No Pain Labor & Delivery – Global Health Initiative

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NPLD-GHI Logo

No Pain Labor & Delivery – Global Health Initiative (NPLD-GHI, 无痛分娩中国行) is a non-for-profit organization. Founded in 2006, the program focuses on correcting the unnecessarily high caesarean delivery rate and the poor utilization of neuraxial labor analgesia in China.

History[edit]

The nongovernmental No Pain Labor & Delivery - Global Health Initiative (NPLD-GHI), established and designed to educate Chinese women and their health care providers about the safe and effective use of labor analgesia, was developed at the Northwestern University Feinberg School of Medicine in 2006. After its first trip in 2008, >500 volunteers participated in NPLD-GHI from the United States, Belgium, Canada, Germany, Israel, and China by 2016. These individuals include physician anesthesiologists, obstetricians (including maternal-fetal medicine specialists), neonatologists, midwives, labor and delivery nurses, senior anesthesiology residents/fellows, interpreters, and other volunteers. More than 200 lectures have been given as part of NPLD-GHI's educational program. Participants of NPLD-GHI co-hosted weekend conferences have increased from <100 in 2008 to just under 3000 in 2016 (6 conference sites). In recent years, NPLD-GHI members have participated in up to 15 obstetric and obstetric anesthesia conferences annually. Approximately 300 attendees participate each month in each Modern L&D Virtual Lecture Hall.The 55 participating hospitals cover care for a parturient population of approximately 500,000 annually. The Obstetric Anesthesia Infrastructure Development (OAID) project was initiated at 31 hospitals in 25 cities from 2008 to 2016. The annual number of hospital sites visited increased from 1 in 2008 to 6 in 2016. Since 2014, 6 additional hospitals each year have participated in the Obstetric Anesthesia Support (OAS) project to meet the local increased demands. Furthermore, its Private Hospital (PH) Project has been initiated since Sept. 2015.

Background[edit]

Neuraxial labor analgesia is commonly available in high-income countries. These techniques have been shown to be safe and effective for alleviating labor pain.[1] Neuraxial analgesia is associated with improved maternal and neonatal outcomes[2] and has been recommended by American College of Obstetricians and Gynecologists (ACOG), American Society of Anesthesiologists (ASA) and The Society for Obstetric Anesthesia and Perinatology (SOAP) as a proactive approach for high-risk parturient safety during labor.,[3][4] In contrast, a 2007 study reported that neuraxial labor analgesia was used by <1% of parturients in China.[5]

Initiation[edit]

NPLD-GHI was established and designed to educate Chinese women and their health care providers about the safe and effective use of labor analgesia, was developed at the Northwestern University Feinberg School of Medicine. Launched in 2008, NPLD-GHI's goals were to improve maternal and neonatal clinical outcomes by increasing the rate of labor epidural analgesia by 10% and to promote sustained change in obstetric anesthesia care, with measurable improvements in outcome.[6]

Collaborations and Members[edit]

Project Structure[edit]

The first 3 are basic obstetric projects: the Obstetric Anesthesia Infrastructure Development (OAID) Project, the Obstetric Anesthesia Support (OAS) Project, and the Private Hospital (PH) Project.The fourth is the Advanced Obstetric Anesthesia 1 + 2 + 3 Project (AOA123), designed not only to advance engaged hospitals from providing a safe and effective neuraxial labor analgesia services to reaching a full range of state-of-the-art obstetric and anesthetic services, but also to have self sustainable improvements.[6]

Basic Obstetric Anesthesia projects[edit]

The Obstetric Anesthesia Infrastructure Development (OAID) Project was launched in 2008 at the Women's Hospital of Zhejiang University School of Medicine. It has since been implemented at 24 additional hospitals. The OAID project involves a week-long, hands-on session offered by an interdisciplinary team from the United States, Canada, and Europe. The program is offered at 1 to 6 sites per year, depending on the number of volunteers and available resources. OAID is offered only to sites that meet specific screening requirements

NPLD-GHI OAID Site Screening Assessment:

  • Adequate anesthesia manpower for 24/7 obstetric anesthesia coverage.
  • Multidisciplinary incentives for labor analgesia.
  • Financial and administrative support from hospital administration.

After the assessment, a team of 11 - 12 volunteers including obstetric anesthesiology attending physicians, anesthesiology residents, obstetricians, labor and delivery nurses, neonatologist or neonatal intensive care nurse, and interpreters travel to one of the screened hospitals. The team leader is typically a Chinese-born obstetric anesthesiologist practicing in the United States. The team leader is thus fluent in both Mandarin and English and familiar with Western standards of obstetric care. A typical week schedule consists daily themes: 1. Orientation day, 2. Mother safety day, 3. Baby safety day, 4. No pain day, 5. Patient satisfaction day, 6. Crash day, 7. Conference day.[6]

The Obstetric Anesthesia Support (OAS) Project was established in 2014 as an alternative to OAID for hospitals that only partially met the screening metrics for OAID. Typically, this is intended for hospitals that lacked the necessary administration support. Rather than a 1-week visit by a NPLD-GHI team, the labor ward professionals from these hospitals are invited to OAID sites during the NPLD-GHI training week to observe educational activities. The goal of OAS is to maximize the NPLD-GHI's impact in hospitals with limited resources, especially personnel, and for the visiting Chinese professionals to take the knowledge acquired during the NPLD-GHI training sessions back to their own hospitals and implement it locally.[6]

In order to meet the demands from Chinese private hospitals due to recently China's healthcare system reform,[7] NPLD-GHI has started its Private Hospital (PH) Project, another alternative to OAID for mainly private hospitals since Sept. 2015.[8] A total of 12 hospitals have participated in the PH project by Oct. 2016.

Advanced Obstetric Anesthesia[edit]

Advanced Obstetric Anesthesia 1 + 2 + 3 Project (AOA123) was established as a follow-up program for hospitals that participated in the OAID project. The goal of the AOA123 project is to further promote labor analgesia and vaginal delivery in high-risk patients and to provide additional training in the management of obstetric emergencies.[6]

NPLD-GHI AOA123 Site Screening Assessment:

  • Existing 24/7 obstetric anesthesia coverage.
  • Neuraxial labor analgesia rate over 50%
  • Weekly multidisciplinary debriefing meetings with hospital administration present

To participate in the AOA123 program, hospitals first undergo a follow-up assessment to monitor the sustained effects of the OAID week. The assessment occurs at least 1 year after the primary visit. The follow-up measures, initiated after 2012, were introduced after observing that some hospitals failed to sustain the agreed upon improved anesthesia protocols. The assessment includes appropriate allocation of both time and resources, and the documentation of the site's commitment to the success of the project.[6]

1. One High Risk Obstetric Anesthesia Clinic/Consultation

2. Two Emergency Systems

3. Decrease in Cesarean Delivery Rates in Three High Risk Parturient Population

Achievements[edit]

NPLD Sites

Visited Sites[edit]

Notes: Click the image to interact with the map

The engaged Chinese hospitals on interactive Google Map

1) Drop pins indicate Obstetric Anesthesia Infrastructure Development Project (OAID)

2) Round dots indicate Obstetric Anesthesia Support Project (OAS)

3) Diamonds indicate Private Hospital Project (PH)

4) Stars: Advanced Obstetric Anesthesia 123 Project.

Impact Studies[edit]

Preliminary data demonstrate that we have been successful in increasing the utilization of neuraxial labor analgesia. We have also seen a decrease in the rates of caesarean deliveries, episiotomies, and postpartum blood transfusion. Below is a summary of outcomes data from our two sites in China. A more comprehensive version of the text is available by clicking on the link, and the details of them are available at the ASA web site and others.

2012 Global Health & Innovation Conference in Yale University

No Pain Labor & Delivery has Impacted Chinese Parturient’s Pain Relief and Maternal/Infant Safety in a Positive Way

Eposter at 2012 ASA meeting in Washington

An Impact Study of Availability of Epidural Labor Analgesia on the Rate of Cesarean Delivery − A Report from the Chinese No Pain Labor & Delivery Experience

Presentations in the Annual SOAP Meeting

Impact of Neuraxial Labor Analgesia on Oxytocin Augmentation and Postpartum Hemorrhage-A Report from No Pain Labor & Delivery in China

An Impact Study of No Pain Labor & Delivery on Labor Analgesia Rate and Obstetric Outcomes in a Chinese Academic Hospital

Impact of Neuraxial Labor Analgesia on Newborn Safety Markers: A Report from No Pain Labor & Delivery in China

Presentation in 2014 Annual Maternal-Fetal Medicine Conference

No Pain Labor & Delivery: a collaborative educational-global health initiative to transform current knowledge and skills into better maternal and neonatal outcomes

International Journal of Gynecology and Obstetrics 2015

Impact of the introduction of neuraxial labor analgesia on mode of delivery at an urban maternity hospital in China

American Society of Anesthesiologists Monitors 2015

Obstetric Anesthesia Education Gives Birth to Improved Outcomes in China

Anesthesia & Analgesia 2016

No Pain Labor & Delivery: A Global Health Initiative’s Impact on Clinical Outcomes in China.[6]

National Practice Changes[edit]

This multidisciplinary, education-oriented organization focuses on improving obstetric anesthesia practice, obstetric practice, and neonatal care in China (a country that makes up 20% of the world's population). Our participants come from major medical institutions across the US, including Northwestern, Harvard, Johns Hopkins, and Stanford. We use data from several large impact studies, including a total of 55,000 deliveries to demonstrate an improvement in maternal and fetal outcomes, including a reduction in the cesarean delivery rate. With the implementation of our ideas and practices, roughly 15,000 unnecessary caesarean deliveries can be prevented and episiotomies. We are also making some progress in reducing the number of unnecessary episiotomies. Anecdotal reports suggest that we have even saved the lives of at least ten women and their babies through the dissemination of our crash cesarean delivery protocol. We are bringing a positive change to Chinese culture where laboring mothers can fully appreciate the miracle of childbirth without experiencing the unnecessary pain that comes with it.

2008: Establishing Obstetric Anesthesia Guideline

2011: National mandate for a DECREASE in cesarean delivery rate

2012: Creation of a NATIONAL BILLING CODE for neuraxial labor analgesia

2012:Updating Obstetric Anesthesia Guideline

2013: Updating obstetric guidelines for arrest of labor in the 2nd stage

2014: Updating obstetric guidelines for arrest of labor in the 2nd stage again

2014: China Labor and Delivery Study Lead by Jun Zhang, MD, PhD

References[edit]

  1. ^ Hawkins, Joy L. (2010). "Epidural analgesia for labor and delivery" (PDF). N Engl J Med. 362: 1503–10. doi:10.1056/nejmct0909254. 
  2. ^ Leighton, B (2002). "The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review". Am J Obstet Gynecol. 186: S69–77. doi:10.1067/mob.2002.121813. [1]
  3. ^ Goetzl, LM (2002). "ACOG Committee on Practice Bulletins -Obstetrics. ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists". Obstet Gynecol. 100: 177–91. PMID 12100826. 
  4. ^ "Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology". The Journal of the American Society of Anesthesiologists. 2016; 124:00–00. [2]
  5. ^ Tian Fan, Zi; Lian Gao, Xue; Xia Yang, Hui (2007). "Popularizing labor analgesia in China". Int J Gynaecol Obstet. 98: 205–7. doi:10.1016/j.ijgo.2007.03.007. [3]
  6. ^ a b c d e f g Hu, Ling-Qun; Flood, Pamela; Li, Yunping; Tao, Weike; Zhao, Peishan; Xia, Yun; Pian-Smith, May C.; Stellaccio, Francis S.; Jean-Pierre, P. Ouanes; Hu, Fengling; Wong, Cynthia A. (2016). "No Pain Labor & Delivery: A Global Health Initiative's Impact on Clinical Outcomes in China". Anesth Analg. 122: 1931–8. doi:10.1213/ane.0000000000001328. 
  7. ^ "China's Healthcare Reform". chinabusinessreview.com/. [4]. 
  8. ^ "Implementation of obstetric anesthesia service in Chinese private hospitals: A new approach by No Pain Labor & Delivery – Global Health Initiative". Translational Perioperative and Pain Medicine. 1: 14–19. 2016. [5]

External links[edit]