By Marcella Distrutti.
Evidence shows that institutional delivery is positively associated with reductions in maternal mortality rates, still considered a multi-factorial health challenge in Latin America and the Caribbean. Nevertheless, having all births attended by professionals in hospitals does not guarantee a high quality of care and, as a consequence, low figures of maternal deaths. This situation happens in countries across the region, including Brazil, where maternal mortality remains high despite institutional delivery at 98%.
In Brazil, studies suggest that unnecessary procedures and those caused by medical treatment (iatrogenic procedures) during childbirth still occur in hospitals, both in the public and private sectors. Over-medicalization has also soared, as demonstrated by the high rate of C-sections (56% of all live births in 2012, both in the public and private sectors).
According to the literature, low maternal mortality rates can be attained with diverse cadres of health care providers, including professional midwives (with a university education) – a model that has been implemented successfully in countries like Sweden and the United Kingdom. Could this be one of the answers to some of the problems currently faced by the Brazilian model?
Professional midwifery is a four-year degree in Brazil – or a four-year nursing degree followed by a specialization. According to Brazilian law, professional midwives can attend low-risk births. In practice, however, very few midwives are involved in delivery care, due to the traditional way in which hospitals organize health care.
What could the potential benefits of changing this practice be?
- Professional midwives could improve access. Difficulties related to the regulation of specialized care in many states of Brazil culminates with women, often, not knowing in which hospital they will deliver and having to find a vacancy during labor. Vis-à-vis the lack of health personnel in facilities located in small municipalities, women seek care in large public hospitals located in urban centers, which are often overcrowded. Professional midwives could deliver uncomplicated childbirths in small cities, provided that referral and transport are guaranteed in emergencies, as well as in large hospitals, where midwives working in teams are likely to attend more childbirths than obstetricians alone.
- Professional midwives could help revert the trend towards medicalization – not only regarding the rising rates of C-sections but also concerning other iatrogenic procedures, such as the elective induction of labor and episiotomy. Unfortunately, as it happens in many countries, providers’ payment methods, amongst other factors, generate perverse incentives for productivity to be increased, which in turn contributes with the performance of unnecessary interventions to accelerate delivery. The discretional use of such procedures, without medical justification, suggests poor quality of care and it can lead to complications that might affect maternal and neonatal outcomes.
- Professional midwives’ training focuses on the autonomy of women, possibly improving the birthing experience. There are many recounts in the literature of women who were not involved in decisions regarding their childbirth, whose needs and preferences were not taken into consideration, and who felt vulnerable and insecure during labor. Midwives empower women and give them control over the birthing process, diminishing the number of invasive procedures and enabling a natural experience, including freedom of movement and positions during labor. Women also feel that the care that midwives provide is more personal, enhancing feelings of trust and safety. The quality of the training midwives receive, however, matter, and it’s important that their education continue to focus on what can be called a more humanistic
For all these reasons, it is important that Brazil, as well as other countries in the region with a similar context (the rising rate of C-sections, for instance, is happening in many places), consider policies to promote childbirth by professional midwives in health services, where obstetricians are available in case they are needed. This debate has been occurring in Brazil for a couple of years, led by committed people in government, representatives of health workers, and the civil society, as well as the women themselves.
The Rede Cegonha program launched in 2011, for example, represented a great push, with resources to build natural birth centers nearby hospitals where women could be attended by professional midwives. But progress has been slow and unless investments in infrastructure are combined with broader strategies to grow awareness around the issue, broaden health professionals’ and students’ perspectives (and train them on more patient-centered care), value midwives, lessen fragmentation and inspire teamwork, and, most importantly, inform women, results might fall short of expectation.
Promoting a new model of childbirth, more based on the use of professional midwives, could help improve access to care in a timely manner, reverse the trend towards medicalization and low quality of care, and enhance the birthing experience to women, all with a potential positive impacts on maternal morbidity and mortality in the region. Also, as renowned obstetrician Michel Odent once said, “to change the world, we must first change the way in which babies are born.”
What is the maternal mortality rate in your country? Do you think that, as in Brazil, it could be reduced by institutionalizing the participation of professional midwives? Tell us what you think in the comments section below or mentioning @BIDgente in Twitter.
Marcella Distrutti es Especialista en salud en la División de Protección Social y Salud del Banco Interamericano de Desarrollo. Su trabajo se centra en el fortalecimiento de los sistemas de salud y en el financiamiento de los mismos.