More Rhogam Info

REMEMBER this is a blood product.......pooled blood..........

Many issues here
1.  A blood product
2.  Necessary during pregnancy - Europe only gives after delivery; UK & US
now give dose during pregnancy and after birth (money???)
3.  Mercury in many Rhogams - if given during pregnancy problem for fetus
4.  If baby Rh neg and Mom Rh neg - no problem for future births
5.  If dad Rh neg and Mom Rh neg - more than likely baby Rh neg -
6  And there are women who have changed their RH status

You have to research MUCH on your own and come to your own decision

Do google search with

anti-d: exploring
midwifery knowledge

sara wickham

A version of this article was also published in
MIDIRS Midwifery Digest
December 2000, Vol 9, No 4, pp 450-455.
Reprinted with permission.


This article presents the results of a qualitative study which explored the
knowledge and beliefs held by midwives regarding the necessity for
postnatal anti-D administration to all rhesus negative woman who have given
birth to rhesus positive babies. Data were collected using interviews,
electronic mail dialogue and written notes from 17 midwives in 8 countries
who considered themselves practitioners within the 'midwifery model'*. The
data were analysed using grounded theory. The results showed that the
midwives do not believe that anti-D is necessary for all woman, and that a
number of factors may mitigate a woman's need for this product. It was
suggested that the need for anti-D may, in part, be iatrogenic.


For a number of years, midwives have been embracing a philosophy of
evidence-informed practice. One of the effects of this movement has been
that, when held up to close scrutiny, most of the interventions introduced
into physiological birth have been discovered to be futile, and sometimes
harmful, when used on a routine basis.

The routine postnatal administration of anti-D to rhesus negative woman who
have given birth to a rhesus positive baby is one of the very few
interventions which has not, to date, been challenged by midwife
researchers. Anti-D is generally regarded as one of the medical world's
'success stories'; a product which has saved the lives of potentially
thousands of babies. Yet more and more woman are questioning their need for
this product, in the light of concerns about blood-borne pathogens and the
risks to their immune system.


In 1963, it was suggested that the administration of intramuscular anti-D
immunoglobulin cleared fetal red cells from the maternal circulation and
prevented rhesus isoimmunisation (1). Following this proposition, 9
clinical trials (2-10) were set up between 1968 and 1971 in Western Europe,
Canada and the US in order to test this theory. The results of these
clinical trials, which were considered to have proved this theory, led to
the decision to administer this product on a routine basis. This policy has
remained largely unchanged to the present day, with more recent research
focusing on the specific dose required and the issue of antenatal

Literature Review

A systematic review of the literature was undertaken at the onset of this
project and a research protocol was developed as a tool for evaluation of
original research papers. Application of this protocol to the 9 clinical
trials showed that only two of these had utilised effective randomisation
and the double-blind inquiry method, which suggests that the results may be
subject to bias. One of these (8) was set up in response to what the
authors felt were the methodological shortcomings of initial work in this
area, but this was stopped after only 54 women were entered because anti-D
was offered to all women on the basis of previous research.

The results of the trials showed that, on a population basis, anti-D was
effective in preventing rhesus isoimmunisation. However, a closer look at
the data shows that anti-D may not be necessary for all women: between
1.96% (3/153) and 13.39% (15/112) of women in the control groups were
isoimmunised at 6 months postpartum. Overall, the average rate of
isoimmunisation of women in the control groups was 7.5%, which implies that
around 90% of woman may not need anti-D.

No research has yet considered why some women need anti-D while others
remain unaffected. It is impossible to predict from the clinical trials
whether this is a detectable difference, whether protection is likely to be
conferred by some pre-existing condition or could be due to differences in
transplacental haemorrhage or antibody production following exposure to the
rhesus antigen.

It seems unlikely from the research evidence that transplacental
haemorrhage is inevitable at any stage of pregnancy or birth. This is seen
in around 15% of cases where a rhesus negative woman gives birth to a
rhesus positive baby (11-13). We do not know whether transplacental
haemorrhage is related to maternal or birth-related factors, although a
study of the incidence of this during curettage following abortion found
that trauma to the uterus increased its likelihood (14).

No research has been carried out into the long term implications or
potential risks of routine postnatal anti-D administration either for women
or subsequent babies, although there has been controversy about this in
some areas (15). There is evidence of the transmission of the HIV (16) and
Hepatitis C (17) viruses in anti-D, although the absolute risk of
transmission of viral or other infectious material in blood is
unquantifiable, because of the possibility of as yet undiscovered pathogens

Anecdotally, a number of woman report short-term but unpleasant rashes,
flu-like symptoms and compromise to their immune systems for up to two
years following anti-D administration. Some midwives are also questioning
whether anti-D may have negative effects on the reproductive health of
subsequent babies, particularly girls, whose blood composition may be
affected by the effects of the product on their mother's immune system or
blood composition or their own DNA. There is general agreement that further
work needs to be undertaken into the risks and adverse effects of postnatal
anti-D in women and subsequent babies (18,19).

The historical context of this research is an important consideration. The
decision to routinely administer anti-D was made on the strength of the
evidence from the clinical trials. At the time, the focus was on preventing
rhesus disease in babies, and this was achieved. However, the results of
the reseach show that not all women need anti-D, although no attempts were
made to determine whether this was predictable.

The environment of maternity care has undergone myriad changes since this
decision was made. There is a need to provide information for individual
women, while enabling these women to make informed choices about their
care. Midwives are in a difficult position with regard to informing women
about anti-D, and a number of women are currently questioning the need for
this intervention. The fact that none of this research included midwives,
or was undertaken within a midwifery model was one of the main issues which
led to this study.

Aims of the Study

The aims of this study were twofold:

1. To explore the nature of the beliefs, knowledge, views and ideas in
relation to the area of postnatal anti-D administration of midwives who
practise within the midwifery model and believe strongly in the normality
of the birth process. It was felt that this may serve to expand the
evidence in this area, acknowledging that evidence may come from sources
other than quantitative research.

2. To determine whether analysis of this knowledge adds to the debate and /
or supports the development of an alternative paradigm from that which
currently exists in relation to postnatal anti-D administration.


Quantitative research evidence is not the only form of knowledge acceptable
to and useful in midwifery practice. Midwives may use tacit knowledge or
intuitive judgement, they develop knowledge through their own experience
and that of the women they serve, and they acquire knowledge through their
senses (20). Because the medical model traditionally uses a positivist,
quantitative approach, and this study aimed to explore other types of
evidence, qualitative methods were considered the most appropriate.
Grounded theory was chosen as the specific research method as it allows for
on-going development of theory which is 'grounded' in actual research
information (21).

A combination of purposive and convenience sampling was employed in this
study and participants were targeted in a number of ways. Colleagues who
had previously expressed an interest in the area and midwives on Internet
discussion lists were invited to participate. A short article outlining the
study topic and inviting responses was also published in an international
midwifery journal (22). These methods also led to a degree of snowballing,
where participants told other midwives about the research; this led to
further responses.

Altogether, 17 midwives from eight countries participated in this study.
All of the midwives considered themselves as practising within the
'midwifery model' and may be accurately termed 'holistic' in their approach
to midwifery. Each provided a detailed initial written response to a
'trigger' set of study questions which detailed their thoughts, feelings,
beliefs and knowledge in this area. The second stage of data collection
involved semi-structured interviews with five of the participants, and
electronic mail dialogue with another seven, in order to clarify responses
and seek further information in relevant areas. While it is recognised that
using e-mail to collect data is a new area, and not without problems, this
was the only way in which dialogue with midwives from countries as far
apart as Japan, Australia and Mexico was able to take place.

The data was analysed on an on-going basis. Responses were studied and
broken down into initial categories which emerged through the data. These
categories were refined and linked according to later data. Efforts were
made to ensure that responses were used accurately and in context, and a
hermaneutic approach was used once the results had been collated to 'check
back' with five of the participants, who all agreed that the findings of
the study accurately represented their original meaning.


Aspects of three of the main categories derived from this study are
described below, together with direct quotes from the participating
midwives to illustrate their meanings and knowledge in the area.

1. Anti-D as a routine intervention: midwifery philosophy

"No intervention is necessary on a routine basis"

In terms of their philosophy, most of the midwives who participated felt
that there was no such thing as an intervention which was justifiable on a
routine basis. This was hardly surprising, considering that the research
targeted midwives who considered themselves practitioners within the
midwifery model. The overwhelming feeling which came through the data was
that midwives felt there had to be some sort of 'explanation' for the need
for anti-D, and that this information was vital to women.

Almost all of the participants directly stated that they felt anti-D was
probably not necessary on a routine basis, and a number of reasons were
given for this:

"I do not think anti-D is necessary on a
routine basis because of the associated
expense / maternal risk factors.
I only arrange for the administration of anti-D
to my clients if there is a clinical indicator
for its use during pregnancy or after birth."

"I KNOW [participant's emphasis] in my heart
that anti-D is not necessary for all of these women.
All of my experience as a midwife confirms to me
that birth works. I just wish I knew why . [and]
exactly what affects this."

"I just find it incredibly hard to accept
that there is such a huge loophole in such a
sophisticated system."

This 'midwifery model' perspective - that anti-D is not necessary on a
routine basis, and that there is likely to be an explanation for individual
variations in relation to this issue - contrasts vividly with the stance of
the medical model, where rhesus isoimmunisation is seen to be akin to a
potential disease requiring treatment.

2. The need for anti-D: historical factors

"If anti-D is necessary for some women, there must be a reason why."

One of the themes which emerged was the question of whether some women's
need for anti-D had been cause by another factor. Again, this perspective
contrasts with the medical view that the need for anti-D is inherent and
the result of an immunological 'malfunction' in all women's bodies.
Although speculation in this area took a number of different directions,
the main focus was on problems caused by the medicalisation of birth:

"[At the time of the clinical trials] we were
doing managed third stage . and all women got
an epis[iotomy]. Well, I wonder how many of those
women would have been sensitised if we had done
more physiological third stages; whether this
was causing higher rates of sensitisation than
might happen in a normal population of women
who had natural birth."

Following discussion of iatrogenesis came the suggestion that the rate of
isoimmunisation in physiological birth may be so low that giving anti-D to
all women would no longer be justified by a risk-benefit analysis:

"And if we knew what the real rate
[of isoimmunisation in physiological birth]
was, well maybe the risks of anti-D would be
a more relevant factor. We should be looking
at the data for real woman - individually and
now - not the population that had their birth
messed with in 1969!"

The point was made that rhesus disease may, if left alone, have been a
self-limiting condition. One midwife summarised this by saying:

"Ironically, it may be because we have
placed such a high value on the individual
human life that, on a population level, we are
going to suffer the consequences. I say
ironically because doctors tend to ignore the
individual in favour of the population in their
research; it's a bit of a paradox
when you think about it."

3. The need for anti-D: factors limiting sensitisation

"Birth works, if you trust it, understand it, and respect it."

Midwives cited a number of factors which they felt were involved in
isoimmunisation. It was felt that isoimmunisation was not a normal feature
of physiological birth and, in particular, that intervention in the third
stage was a primary cause of isoimmunisation:

"Isoimmunisation doesn't worry me all that much.
I know of several older women with negative blood
types who had thirteen children and never had anti-D.
I tend to trust that nature knows what it does."

"Why is there a chorion and an amnion?
We need to ask - why does the chorionic plate
exist at all? Unless maternal and fetal
circulations were not meant to mix."

Other responses in this category have been summarised in Tables 1 and 2.
Table 1 lists the factors which are thought to influence the likelihood of
isoimmunisation, while table 2 lists the factors which midwives felt might
give protection against isoimmunisation.

Table 1: Factors thought by participants to influence the likelihood of


ABO incompatibility may confer a degree of protection against
isoimmunisation - antigens to A and B cells destroy fetal blood before
production of anti-D occurs.
It was suggested that if a very small amount of fetal blood enters the
maternal circulation, there may be a natural mechanism for detecting and
destroying these cells without producing anti-D. 
A 'natural immune defect' is thought to occur in some women which prevents
isoimmunisation even if fetomaternal haemorrhage (FMH) occurs.
While the 'received view' in the area is that women are naturally
immuno-suppressed during pregnancy, which leaves them open to
isoimmunisation, it was suggested that one of 'nature's reasons' for
immunosuppression was to ensure that women did not produce antibodies to
fetal blood. 


The third stage of labour needs to occur physiologically without any
attempt at 'management'. Oxytocic drugs and any cord traction may interfere
with separation and cause transplacental haemorrhage. 
Other interventions in pregnancy and labour are also thought to increase
the possibility of FMH. As well as those which are already known (eg
amniocentesis), midwives also cited ultrasound scanning, exogenous
oxytocin, intrauterine catheters, episiotomy (which decreases the level of
circulating endogenous oxytocin), fundal pressure, directed pushing and the
use of local and epidural anaesthesia (which contain vasodilating drugs). 
The matthews-duncan method of placental separation may indicate FMH. 
An 'extremely large' placental site was thought to increase the likelihood
of FMH.


It was also suggested that the question of why some women become sensitised
is linked to environmental factors; eg xenoestrogens and other pollutants
which may interfere with normal physiology and / or compromise immune status.

Table 2: Factors identified by participants which may
give protection against isoimmunisation.

Optimal nutrition during pregnancy was cited as being of benefit in
strengthening the placental bed and reducing the chance of FMH. Midwives
felt women should concentrate on eating whole foods, fresh, raw vegetables,
pulses and seafood. 
Midwives also suggested that women should avoid substances such as food
additives, caffeine and alcohol which may deplete essential minerals. 
A number of natural substances are thought to strengthen the placenta and
confer immune system protection; these include magnesium, iodine, vitamin
C, bioflavinoids, red raspberry leaf, elderflower, echinacea, garlic and
It was suggested that fluoride interferes with the formation of collagen in
the placental wall, and that women should avoid fluoridated water and
toothpaste before and during pregnancy.
Following on from the idea that immunosuppression was an important feature
in preventing isoimmunisation was the suggestion that the hormones released
while breastfeeding in the early days may also be a protective mechanism
against antibody production.
Several midwives stressed the importance of emotional and spiritual aspects
of birth and the women's psyche. Although no prescriptive preventative or
supportive treatment was offered, it was suggested that midwives should
explore this area with women before and possibly during birth in order to
'clear' any issues which may arise that inhibit normal physiology.


The participating midwives offered a vast range of both general and
specific knowledge and ideas within the midwifery model; only a small
portion of which can be included here due to limitations of space. They
demonstrate a move away from the 'received view' in the area, offering a
range of ideas to explain the issues concerned and with a very definite
focus on the practicalities of midwifery practice. Interestingly, the data
collected is not really at variance with the scientific research concerning
anti-D; the difference between data collected in this study and current
medical views is more one of philosophy.

It could be argued that it is only within the medical paradigm that anti-D
is seen as being necessary as a preventative measure for all rhesus
negative woman who have given birth to a rhesus positive baby; the midwives
in this study viewed this as an intervention which might be offered to
appropriate women, but added that these woman should realise that they had
a range of choices in this area.

Where midwives view the process of birth as a natural event which has a
social and spiritual meaning, issues surrounding isoimmunisation are viewed
in a different light. Medicalisation has caused the issue of rhesus
negativity to become labelled with a notion of pathology, while these
midwives see the issue as based in physiology. This is in keeping with the
well-documented effects of Cartesian dualism on the medical model of birth
(23). As it is now understood that this dualist model and a total focus on
the physical bear little relation to the dynamic and holistic nature of
birth, the evidence gained from this study suggests that the medical
research on which policies concerning anti-D are based offer only a small
part of the evidence in this area. The implication of this is that we are
simply not able to offer women enough information upon which they can base
an informed choice.

The study also highlights the issue of unbiased information- giving to
women; whatever the views or philosophy of the individual midwife, women
need to have accurate and up-to-date information upon which they can base
their choices. Perhaps midwives offering women information also need to be
honest about their personal philosophical standpoint, in order that women
can put the information they receive into this context.


This study by no means provides all of the answers; in many ways, it simply
raises more questions. Several areas with potential for further research
have been highlighted by the results, and the study has generated a great
deal of 'new' information for consideration and reflection by midwives. At
the onset of this study, I wondered if anti-D was the exception to the
general rule that no intervention was necessary on a routine basis in
birth. These midwives have helped to demonstrate that this may not be the
case. Yet there remains a great deal of work to be done, in order to
clarify the decision and the issues, both for midwives and women.

* It should be noted that the term 'midwifery model' is used here in a very
specific sense, which may necessitate clarification. The 'midwifery model'
describes a philosophical and practical approach to birth and midwifery
which focuses strongly on the concepts of physiology, normality and holism.
Proponents of this attitude are focused on the needs of the woman and trust
in women's bodies, birth and nature. It is an integrating approach which
has been further explored by Davis-Floyd (24), who contrasts the midwifery
(or wholistic) model with the technocratic approach to birth, and by the
Midwives Alliance of North America (25) who define the model further in
their Statement of Values and Ethics. Participants in this study were aware
of this conceptualisation of this model and deemed themselves practitioners
within this philosophy.


1 Clarke CA, Donahoe WTA, McConnell RB (1963)
Further experimental studies on the prevention of Rh haemolytic disease
British Medical Journal, 1963, No 1, pp 979-984.

2 Ascari WQ, Allen AE, Baker WJ, Pollack W (1968)
Rho(D) immune globulin (human) evaluation in women at risk of Rh immunization.
Journal of the American Medical Association,
Vol. 205, No. 1, pp 1-4.

3 Bishop GJ, Krieger VI (1969)
One millilitre injections of Rho(D) immune globulin in prevention of Rh
immunization. A further report on the clinical trial.
Medical Journal of Australia, No. 2, pp 171-174.

4 Clarke CA, Donohoe WTA, Finn R, Lehane D, McConnell RB, Sheppard PM,
Towers SH, Woodrow JC, Bowley CC, Tovey LAD, Bias WM, Krevans JR (Medical
Research Council Working Party) (1971)
Prevention of Rh haemolytic disease: final results of the 'high risk'
clinical trial.
British Medical Journal, Vol. 217, No. 2,
12 June 1971, pp 607-609.

5 Chown B, Duff A, James J, Nation E, Ellement M, Buchanan D, Beck P,
Martin J, Godel J, McHugh M, Jarosch J, DeVeber I, Holland C, Cunningham T,
McLachlan T, Blum E, Bryans F, Stout T, Decker J, Bowman J, Lewis M, Peddie
L, Kaita H, Anderson C, VanDyk C. (1969)
Prevention of Primary Rh Immunization: First report of the Western Canadian
Canadian Medical Association Journal, No. 100, pp 1021-1024.

6 Dudok de Wit C, Borst-Eilers E, Weerdt CHM, Kloosterman GJ (1968)
Prevention of Rh immunization. A controlled trial with a comparatively low
dose of anti-D immunoglobulin.
British Medical Journal, Vol. 211, No. 4,
23 November 1968, pp 477-479.

7 Robertson JG and Holmes CM (1969)
A clinical trial of anti-Rho(D) immunoglobulin in the prevention of Rho(D)
Journal of Obstetrics and Gynaecology of the
British Commonwealth, Vol. 76, pp 252-259

8 Stenchever MA, Davies IJ Weisman R, Gross S (1970)
Rho(D) immunoglobulin: A double blind clinical trial
American Journal of Obstetrics and Gynecology,
Vol. 106, No. 2, pp 316-317.

9 White CA, Visscher RD, Visscher HC, Wade MD (1970)
Rho(D) immune prophylaxis: a double blind co-operative study
Obstetrics and Gynaecology, Vol. 36, No. 3, pp 341-346.

10 Woodrow JC, Clarke CA, McConnell RB, Towers SH, Donahoe WTA (1971)
Prevention of Rh-haemolytical disease: results of the Liverpool 'low-risk'
clinical trial.
British Medical Journal, 12 June 1971, No. 2, pp 610-612.

11 Stenchever MA, Davies IJ, Weisman R, Gross S (1970)
Op Cit.

12 Zipursky A, Israels LG (1967)
The pathogenesis and prevention of Rh immunization
Canadian Medical Association Journal,
Vol. 97, No. 21, 18 November 1967, pp 1245-1257.

13 Woodrow JC and Donahoe WTA (1968)
Rh-immunization by pregnancy; results of a survey and their relevance to
prophylactic therapy
British Medical Journal, 1968, No 4,, pp 139-144.

14 Lachman E, Hingley S, Bates G, Ward AM, Stewart CR, Duncan LB (1977)
Detection and measurement of fetomaternal haemorrhage; serum alpha-protein
and kleihauer technique.
British Medical Journal, Vol. 240, No. 1,
28 May 1977, pp 1377-1379.

15 Katz J (1969)
Transplacental passage of fetal red cells in abortion; increased incidence
after curettage and effect of oxytocic drugs.
British Medical Journal, Vol 214, No 4,
11 October 1969, pp 84-86.

16 Harmon P (1987)
Rhogam at 28 weeks
Midwifery Today, No 4, Winter 1987, pp 24-25.

17 Dumasia A, Kulkarni S, Joshi SH (1989)
Women receiving anti-Rho(D) immunoglobulin containing HIV antibodies
Lancet, Vol II, No. 8660, 19 August 1989, p 459.

18 Meisel H, Reip A, Faltus B (1995)
Transmission of Hepatitis C virus to children and husbands by women
infected with contaminated anti-D immunoglobulin.
Lancet, Vol. 345, No. 8959, 13 May 1995, pp 1209-1211.

19 Crowther C and Middleton P (1997)
Anti-Rh-D Prophylaxis Postpartum
In: Neilson JP, Crowther CA, Hodnett ED and Hofmeyr GJ (Eds) (1997)
Pregnancy and Childbirth Module of the Cochrane Database of Systematic
Reviews. (Updated September 1, 1997). Available in The Cochrane Library on
disk and CD-ROM). The Cochrane Collection; Issue 4, Oxford, Update Software

20 Siddiqui J (1994)
A philosophical exploration of midwifery knowledge
British Journal of Midwifery, September 1994, Vol 2,
No 9, pp 419-422.

21 Hill Bailey P (1997)
Finding your way around qualitative methods in nursing research
Journal of Advanced Nursing, Vol 25, pp 18-22.

22 Wickham S (1998)
Rhogam: do midwives hold the evidence?
Midwifery Today, Summer 1998, No 46, pp 34-35.

23 Ginesi L (1998)
Maybe Descartes got it wrong
Midwifery Today, Autumn 1998, No 47, pp26-29, 71.

24 Davis-Floyd R (1992)
Birth as an American Rite of Passage
University of California Press, Berkeley.

25 Midwives' Alliance of North America (MANA) (1998)
Statement of Values and Ethics
MANA, Newton, KS.

Further information about anti-D, related research and the study discussed
in this article can be found in "Anti-D in Midwifery: Panacea or Paradox".

For more information about this book, or to order a copy,
click here.

given after birth
Section I. B. 2
given after birth