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Skilled professional care: at birth and afterwards
Immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns, as complications are largely unpredictable and may rapidly become life-threatening ( 34 , 35 ). Both maternal and neonatal mortality are lower in countries where mothers giving birth get skilled professional care, with the equipment, drugs and other supplies needed for the effective and timely management of complications ( 10 , 34 ). The history of successes and failures in reducing maternal mortality (including in industrialized countries) shows that this is not a spurious statistical association ( 3 , 36 ). Reversals in maternal and neonatal mortality in countries where health systems have broken down provide further confirmation that care matters.
Successes and reversals: a matter of building health systems
Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth; they further reduced it to current historical lows by improving access to hospitals after the Second World War ( 37 ). Quite a number of developing countries have gone the same way over the last few decades ( 3 ). One of the earliest and best-documented examples is Sri Lanka, where maternal mortality levels, compounded by malaria, had remained well above 1500 per 100 000 births in the first half of the 20th century – despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited. From around 1947 mortality ratios started to drop, closely following improved access and the development of health care facilities in the country ( 38 ). This brought mortality ratios down to between 80 and 100 per 100 000 births by 1975. Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series ( 36 ).
Malaysia also has a long-standing tradition of professional midwifery – since 1923. Maternal mortality was reduced from more than 500 per 100 000 births in the early 1950s to around 250 in 1960. The country then gradually improved survival of mothers and newborns further by introducing a maternal and child health programme. A district health care system was introduced and midwifery care was stepped up through a network of "low-risk delivery centres", backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities. This brought maternal mortality to below 100 per 100 000 by around 1975, and then to below 50 per 100 000 by the 1980s ( 36 , 39 , 40 ).
Until the 1960s Thailand had maternal mortality levels well above 400 per 100 000 births, the equivalent of those in the United Kingdom in 1900 or the USA in 1939. During the 1960s traditional birth attendants were gradually substituted by certified village midwives, 7191 of whom were newly registered within a 10-year period: mortality came down to between 200 and 250 per 100 000 births. During the 1970s the registration of midwives was stepped up with 18 314 new registrations. Midwives became key figures in many villages, proud of their professional and social status. Mortality dropped steadily and caught up with Sri Lanka by 1980. The main effort then went into strengthening and equipping district hospitals. Within 10 years, from 1977 to 1987, the number of beds in small community hospitals quadrupled, from 2540 to 10 800, and the number of doctors in these districts rose from a few hundred to 1339. By 1990 the maternal mortality ratio was below 50 per 100 000 births (see Figure 4.2).
More recently, Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000: major efforts to promote safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care ( 41 ). Honduras brought maternal deaths down from 182 to 108 per 100 000 between 1990 and 1997 by opening and staffing seven referral hospitals and 226 rural health centres and by increasing the number of health personnel and skilled attendants ( 42 ).
These examples illustrate that long-term initiatives and efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well. Breakdowns of access to skilled care may rapidly result in an increase of unfavourable outcomes, as in Malawi or Mongolia (see Chapter 1). In Tajikistan too, economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to a startling erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance ( 43 ). Maternal mortality ratios rose as a result. Similarly, in Iraq, sanctions during the 1990s severely disrupted previously well-functioning health care services, and maternal mortality ratios increased from 50 per 100 000 in 1989 to 117 per 100 000 in 1997, and were as high as 294 per 100 000 in central and southern parts of the country ( 44 ). Iraq also experienced a massive increase in neonatal mortality during this period: from 25 to 59 per 1000 between 1995 and 2000.
The good news is that countries that make a deliberate effort to provide professional childbirth care with midwives and other skilled attendants, backed up by hospitals, can improve maternal survival dramatically. As Figure 4.3 shows, it does take time, and, particularly at high levels, difficulties in measuring the evolution of maternal mortality may make it difficult to sustain the commitment that is needed.
Skilled care: rethinking the division of labour
The countries that have successfully managed to make motherhood safer have three things in common. First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care. Third, they made sure that access to these services – financial and geographical – would be guaranteed for the entire population ( 3 ). Where information is lacking and commitment is hesitant, where strategies other than that of professionalization of delivery care are chosen (see Box 4.4), or where universal access is not achieved, positive results are delayed. This explains why the USA lagged so far behind a number of northern European countries in the 1930s, and why many developing countries today still have appallingly high levels of maternal mortality ( 3 ).
To provide skilled care at and after childbirth and to deal with complications is a matter of common sense – it is also what mothers and their families ask for. Putting it into practice is a challenge that many countries have not yet been able to meet. They have not been helped by the confusing technical terminology used by the international community: BEOC, CEOC, BEmOC, CEmOC, EOC1, etc., to be provided by "skilled attendants" (who may be doctors, nurses or midwives), for whom the division of tasks across these various acronyms is often unclear. Part of the confusion lies in the distinction between "basic" and "comprehensive" care, which was originally conceived as a device to monitor facilities, and not as a description of who can give care to whom in any given situation. The acronyms are even more bewildering because of the difference, still disputed, between "essential" and "emergency" care. It is time to clarify the issues.
Care that is close to women – and safe
All mothers and newborns, not just those considered to be at particular risk of developing complications, need skilled maternal and neonatal care provided by professionals at and after birth. There is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. There is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The defining features of the type of care that is required is that it should be responsive, accessible in all ways, and that a midwife, or a person with equivalent skills, is there to provide it competently to all mothers, with the necessary means and in the right environment. This level of care is appropriately referred to as "first-level" care. Labelling it as "basic", "primary" or "routine" undervalues the complexity and skill-base required to attend to situations that can suddenly and unexpectedly become life-threatening. Table 4.2 summarizes the key features of first-level and back-up maternal and newborn care.
Recommended packages, the result of an international consensus, are extensively described in published guidelines (see Table 4.2). Most interventions, such as surveillance of the progress of labour, psycho-logical support, initiation of breastfeeding and others, have to be implemented for all mothers and newborns in all circumstances. Other elements in the package – such as manual removal of the placenta or resuscitation of the newborn – are only needed when the situation demands it. However, it is crucial that the whole package be available and on offer to all, immediately, at every childbirth.
These interventions can only be provided by professionals with a variety of integrated skills and competences for whom the shortcut label is "skilled attendants". It is vital that a threshold of skills and competences is reached: it is not enough to be partially skilled, for example only able to carry out a so-called normal delivery. "Any fool can catch a baby", as long as nothing goes wrong; as soon as a complication occurs, a situation which is difficult to predict, the level of skills and competence required to recognize the problem and decide on the right action is of a very high order. Choosing the wrong intervention or hesitating for too long to intervene or to refer the woman at the right time and in the right way can have disastrous consequences.
The prototype for a skilled attendant is the licensed midwife. Less cost-effective options include nurse-midwives and doctors, assuming they have been specifically prepared to do this kind of work (most are not – or not sufficiently). Gynaecologists-obstetricians – of whom there is a large deficit in stagnating and reversal countries – are, as a rule, perfectly able to provide first-level care, although they are less cost-effective and more appropriate for back-up referral care. There is no evidence that lower level staff or non-professionals can deal with the complex decision-making required when complications occur at birth (see Box 4.5).
Providing close-to-client first-level maternal and newborn care is not just a matter of "carrying out normal deliveries". Such care has three functions. The first is to make sure that the birth takes place in the best of circumstances, by building a personal relationship between the pregnant woman and the professional. The second function is to resolve complications as they arise, making sure that they do not degenerate into life-threatening emergencies. The third is to respond to life-threatening emergencies when they do occur, either directly or by calling on referral-level care that has to be available as a back-up.
Contrary to what the current emphasis on life-saving emergency hospital care suggests, first-level maternal and newborn care is thus not only uneventful routine care. First-level care does save lives and manage emergencies. It does so by controlling conditions before they become life threatening (by treating anaemia, for example), or by avoiding complications (through active management of the third stage of labour, for example). A midwife or other professional with midwifery skills also actually deals with a range of emergencies on the spot, such as by administering vacuum extraction in case of fetal distress or by arranging emergency referral for caesarean section or other back-up care. What is specific about first-level care is that it takes place in an environment where a woman is comfortable with her surroundings, and where the fear and pain that go with giving birth are managed positively.
Maternal and newborn care at first level thus provides a whole package of care that can go a long way towards improving maternal and newborn outcomes. Experience shows that even in the absence of hospitals, first-level maternal and newborn care can bring maternal mortality below 200 per 100 000 – in optimal circumstances it may actually reduce maternal mortality to levels of 90 per 100 000 ( 37 ). Clearly the contrasting of routine, normal deliveries with life-saving emergency hospital care is not helpful.
First-level maternal and newborn care should preferably be organized in midwife-led birthing centres, combining cultural proximity in a non-medicalized setting, with professional skilled care, the necessary equipment, and the potential for emergency evacuation. Decentralization for easy access obviously has to be balanced by the need to concentrate the staff and equipment necessary to be available 24 hours a day, something more easily done in birthing centres with a team of several skilled attendants than in solo practices. Any hospital with a maternity unit naturally also has to provide such first-level care to all the mothers and babies it admits, alongside the back-up care that is the added value of the hospital. Even within the walls of a hospital, however, first-level care should maintain the demedicalized and close-to-client characteristics of midwifery-led birthing homes.
A back-up in case of complications
In an ideal world, first-level maternal and newborn care would include all the useful interventions, including all the life-saving ones. That is obviously not possible – it would require an operating theatre in each village. That is where the back-up provided by hospitals comes in: to assist the minority of women and newborns who have problems requiring more complex care. Health workers who provide first-level care need back-up when a problem occurs that they are unable to deal with as it goes beyond their competence or beyond the means they have at their disposal. Mothers need the back-up to solve their problem, midwives (or their equivalent) need to be able rely on a back-up for their clients and to maintain credibility. Any pregnant woman has to be sure that if things go wrong, her midwife will either solve the problem or get her to a place where it can be solved.
Back-up maternal and newborn care encompasses emergencies (such as a hysterectomy for a ruptured uterus or treatment of neonatal tetanus or meningitis) as well as non-emergency interventions (such as treatment of congenital syphilis). The criterion to consider an intervention as part of back-up rather than first-level care is not whether the complication is dangerous, life-threatening or an emergency: it is its complexity. If it is technically feasible to carry out an intervention at first level, then it should be part of the first-level maternal and newborn care package.
Back-up is ideally provided in a hospital where doctors – specialists, skilled general practitioners or mid-level technicians with the appropriate skills – can deal with mothers whose problems are too complex for first-level providers. To make the difference between life and death, the required staff and equipment must be available 24 hours a day, and the links between the two levels of care should be strong. To reduce the risks and costs inherent in medical interventions and at the same time provide a responsive, humanized environment for care, overmedicalization, so often seen as part of commercialized care, should be discouraged.
Rolling out services simultaneously
First-level maternal and newborn care and the referral hospital services that should provide back-up have to be rolled out in parallel. In industrialized countries, and also in countries such as Malaysia, Sri Lanka and Thailand, first-level midwifery care has preceded reliance on back-up by hospitals. To replicate this sequence would not be acceptable today, not for authorities, not for the medical establishment, and, most importantly, not for the clients. However, reversing the sequence – that is, developing emergency hospital services only, without a network of first-level care – is not an option either. This happens now in many countries and means that a number of problems and complications are needlessly allowed to degenerate into emergency life-threatening situations.
The challenge of simultaneous roll-out has striking similarities to the one that led the primary health care movement to opt for the health districts, with both health centres and a district hospital, linked by referral mechanisms, and organized to ensure a continuum of care. More than for any other programme, the extension of coverage with maternal and newborn care depends on the development of district health care.
Postpartum care is just as important
While the need for immediate postpartum care is widely acknowledged, later postpartum care is often completely forgotten or neglected. In many low-income countries, even where the proportion of institutional deliveries is already quite high or is increasing, women are often discharged less than 24 hours after a birth ( 34 ), but more than half of maternal deaths occur after this period, as do many of the newborn deaths. Despite the burden of morbidity during this period, uptake of postpartum care in developing countries is usually extremely low, typically less than half the level of uptake for antenatal or delivery care ( 80 ).
Women do not, and probably often cannot, embark on care-seeking paths even when they know that they have a life-threatening condition. For many women, poverty combines with cultural constraints to construct a "social curtain" around them which health services do not penetrate ( 81 ). In places where the majority of births take place at home, postpartum care may be unavailable or women may not know that services exist. Many service providers and families focus on the well-being of the new baby and may not be aware or able to assess the importance of women’s complications such as postpartum bleeding ( 82 ).
Where childbirth is under professional supervision, be it at home or in a health facility, women are usually expected to attend at a health facility for a postpartum check-up six weeks after delivery. This is clearly not sufficient to be effective. Moreover, these check-ups are often provided by different people, in a different location from childbirth services. Women may not attend because they do not know that the service is available to them, they may not perceive any benefit in attending, or the opportunity costs of attending may be too great ( 83 – 85 ). Health staff themselves may not feel empowered or skilled in providing postpartum interventions ( 86 ). Apart from some countries, such as Sri Lanka, rates of postnatal visits among women are low and inequitably spread. The structures that exist are often not fully suited to the needs of poor women who require better first-level care as well as easy-to-reach back-up facilities for complications. In most areas, there are severe shortages of trained health workers with adequate capability to diagnose, refer and treat these problems.
Guidelines for postpartum care exist ( 87 ). They can be implemented by midwives, but also by multipurpose professionals, who may be less scarce. The need now is for a pragmatic approach to implementation in resource-poor settings, and for more attention to be paid to the handover between those who care for the mother and the baby at childbirth and those who ensure continuity afterwards.
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