Supporting midwifery is the answer to the wicked problems in maternity care
Journal – the lancet global health
Article type – Opinion
Publication date – Jun – 2022
Authors – Hannah G Dahlen, Daniela Drandic, Neel Shah, Franka Cadee, Address Malata
Keywords – Health ServiceTrust, health-care provider, low-income and middle-income countries (LMICs), midwives
Open access – Yes
Speciality – Obstetrics and Gynaecology
World region Global
Language – English
Submitted to the One Surgery Index on July 1, 2022 at 9:48 pm
The film Don’t Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care.
Although life-saving when indicated, medical interventions in childbirth can be harmful when overused.1 A challenge in striking the right balance is that the bar for benefit when it comes to birth outcomes has been set at immediate survival. This approach overlooks clinical complications, such as placenta praevia or accreta associated with caesarean, and fails to value the personal autonomy of women and communities. In global settings, caesarean section rates, which are often used as a proxy to understand the safety of a maternity system, have recently come under scrutiny. Inquiries into adverse outcomes in the Shrewsbury and Telford Hospital National Health Service Trust in the UK has led to sensational media reporting and concerns about the dangers of setting caesarean section targets. This reporting has led to a focus on individual decision makers rather than faulty systems. We know a bad system will beat the best health-care provider every time
The centrality of midwives in supporting the physiological process of giving birth is at the core of this debate. Midwives have been singled out for blame when it comes to poor outcomes, with little consideration given to the fragmented models of care they work in, where they do not always have professional autonomy and respectful collaboration. This attitude creates an environment of professional and philosophical conflict that does not put women’s optimal care and needs at the centre. Relational models of care such as continuity of midwifery care, which are supported by high-level evidence as being cost effective and leading to optimal outcomes,3 are ignored. Such models have the potential to save 4·3 million lives per year, but realising this opportunity requires a deeper understanding of why they are not reaching scale.
The way we treat women during pregnancy, childbirth, and postpartum, and the institutional options of care we provide them within health systems, directly reflect the way we value women in our societies. In too many settings we are ignoring the benefits of midwifery models of care, degrading the status of midwives, and removing financing from midwifery services and education, under the guise of safety that ignores physiology and women’s chances for optimal mental and physical health.
There is a shortage of approximately a third of the midwives we need globally, which is crucial considering that midwives who are educated and regulated to international standards of care can provide 87% of essential maternity care needs and would prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths.4 Midwifery provides a 16 times return on investment.3, 5 Evidence is mounting on how midwives improve maternity care globally; yet, midwives are leaving the profession—burned out, disillusioned, and under valued.6 The latest sensationalised media reporting in the UK has demoralised midwives even more, with global impacts. As a predominantly female profession, midwives continue to be marginalised, overworked, poorly paid, and do not have decision making authority in many countries.
The aim of intervening in the physiological processes of pregnancy and birth is to improve outcomes and safety for women and babies. Commonly used birth interventions such as caesarean sections and induction, which were previously used to treat obvious complications, are used more commonly for women that are unlikely to benefit from them, and can even cause harm to healthy women. These harms contribute to gender, racial, and geographical inequities, and there is growing concern regarding generational inequities. Less concern is afforded to women suffering from birth trauma, which is higher following intervention in birth, especially when women feel poorly informed and coerced into this.10
Although high-income countries (HICs) often drive the dominant discourse when it comes to maternity care, in some low-income and middle-income countries (LMICs) women cannot access a safe caesarean section even when it is needed, demonstrating significant inequalities in maternal care. Caesarean section rates have escalated in LMICs without adequate training or access to additional skills such as anaesthetics, leading to deadly outcomes; and maternal mortality rates are up to 100 times higher in LMICs than HICs. There is increased economic hardship for communities and stretched health systems, and distrust of hospital care and health-care providers.8 Women who become pregnant after caesarean section are at a higher risk of subsequent surgery, with inadequate attention given to additive morbidity over their reproductive life course.
The use of technology and interventions in childbirth scale up quickly and are difficult to de-implement, even when there is evidence of harm. Fiscal accountability and resource-intense care that contributes to the health-care carbon footprint (10% of the US total) should be key considerations.
To meet the 2030 Sustainable Development Goals and prevent an unfolding disaster, we call for urgent action and a united voice on the four main groups of action in the Midwifery 2030 Pathway (panel).
OSI Number – 21637