Across the world around 390,000 women give birth each day in culturally, geographically and economically diverse settings. While pregnancy and birth is a journey of hopes, fears, and some uncertainties, the differences in birth outcomes between rich and poor are stark. Each day around 800 women die as a result of pregnancy and birth, 99% of these deaths occur in low-income countries, and the poorest women in every country fare the worst.
One recent large study suggested that in the Netherlands, a developed nation where home births are widespread, hospitals were safer places to give birth for those who are less wealthy.
In almost all societies, then, and throughout history, childbirth has been recognised as a time of increased vulnerability, through which mothers and babies require support.
Even in the most prosperous societies some mothers and babies will die as a result of pregnancy and birth and many more experience health problems which may become long-term. Our ability to predict which women will experience complications is low and the response in many countries has been to aim for 100% hospital births in the belief that a hospital birth will always be a safer birth. This is so in cases where rapid access to emergency obstetric care is required.
But there may be unintended consequences. Citing examples from middle-income countries where two-thirds of women now give birth by caesarean section, The Lancet midwifery series suggests that a focus on hospital birth and emergency care without the balancing effect of skilled midwifery can result in the rapid increase in unnecessary, expensive and potentially damaging interventions.
In some low-income countries, as I found while working with midwives in Malawi, policies to increase rates of hospital births may result in women giving birth in overcrowded and under-resourced facilities with increased risk of sepsis and sub-standard care. Even in higher-income countries, where hospital birth is the accepted norm, giving birth in an environment where risk and complications are anticipated and where medical intervention is routine may predispose women to experience complications.
The Birthplace study in England found that women deemed high-risk who gave birth in non-obstetric unit settings had less interventions and better outcomes than those who gave birth in obstetric units. Conversely, low-risk women giving birth in obstetric units were more likely to have major interventions and less normal births. It is not clear why this is the case.
Studies from other contexts have indicated that negative beliefs about the likely future experience of healthcare or treatment may have a significant negative impact on health outcomes through the Nocebo effect, where something that should be inert has harmful effects.
Women also ask – does emphasis on risks and dangers create a negative feedback cycle? Hospital birth is associated with routine use of procedures that may mitigate against normal birth such as continuous electronic foetal monitoring which has been associated with a significant increase in caesarean and forceps births, possibly because routine electronic monitoring leads to more tests and concerns about foetal well-being, commonly known as the “cascade of intervention”. Women are also often required to give birth lying flat with legs in stirrups, which reduces the capacity of the pelvis and makes birth more difficult.
Call the midwife
The term “midwife” means with-woman, but midwifery care is not just about “being there”. Examples of effective midwifery care includes providing the continuity of a carer, encouraging mothers to remain upright for labour and birth and providing massage for labour pain management. A key element is the provision of continuous support through labour and birth – and there is good evidence that women are more likely to experience shorter labours and normal birth if this is the case.
Increasing safety does not require increasing technology. The Lancet series indicated that the most effective way of improving health outcomes regardless of birth setting was improving access to skilled midwifery care, which has the potential to reduce maternal deaths globally by 30%. Using rigorous evidence from Cochrane Reviews, the authors of one of The Lancet papers found that 72 out of 122 identified effective practices fell within the skills and care provided by midwifery care (though not specifically to the profession of midwifery).
What is it about support that adds such benefit for mothers and babies – and why is the care provided by skilled midwives so crucial? A study undertaken in Scotland opened the black box of midwifery support in labour. The study, which involved observation of more than 100 hours of labour including 50 mothers and midwives, found that midwives gave almost continuous emotional support (being attentive, encouraging, coaching, comforting) with increasing intensity as labour progressed towards birth, while simultaneously giving physical support – massage, helping the woman move into comfortable positions, washing, providing fluids and nutrition, advising, informing and listening, leaving women alone for only short periods of time.
This intense, continuous, active support promotes the normal release of oxytocin (also known as the feelgood hormone) necessary for uterine contractions (which may be disrupted by medical interventions, such as administration of synthetic oxytocin to induce or augment labour) and enables mothers to draw on their own strengths to cope with the rigorous work of labour and birth and to bond with their newborn baby.
Childbirth is the most fundamental human condition that both defines and defies our diversity. Despite the evident contribution of medicine and the lure of new technologies, the evidence shows that human support is still crucial for women giving birth in every part of the world.