What kind of care should women expect from their birth attendants during childbirth? Fatma describes the difference between her first birth in Sweden and her sister’s experience in Turkey. While her sister had a traumatic birth with no pain relief and an unexpected episiotomy, Fatma described how healthcare staff at her delivery made her ‘feel at home’. Fatma reflected on some women’s experience of ‘angry or firm’ birth attendants, demonstrating the impact disrespectful maternity care can have on women, particularly the vulnerable, including immigrants, indigenous or ethnic minorities.
Paper 2 and Paper 4 of the series highlight the growing recognition of mistreatment, abuse, disrespect, and neglect of women giving birth in facilities. Vulnerable populations have an increased risk of adverse outcomes including higher caesarean section and preterm birth rates, as well as less autonomy regarding maternity care. Disrespectful care disproportionately affects immigrant women, ethnic and religious minorities and women living in poverty.
“It was more painful with nobody to support.” Would you feel safe and comfortable giving birth alone? Despite considerable progress increasing skilled birth attendant coverage, many women like Shafaatu still give birth alone, significantly increasing their risk of maternal illness or death. Shafaatu shares her contrasting experiences of giving birth at home alone during her first delivery compared to her second in a facility with midwives, and her views on delivery choices.
What are the main barriers preventing women from accessing quality delivery services? Paper 3 of the series highlights how skilled staff working in an enabling environment are essential to provide high-quality delivery care to every woman and newborn. Women’s access to quality, accessible, affordable, and respectful maternal and newborn care is vital to ensure equity and dignity for all women. No woman should have to deliver her baby alone.
Where do women get information about maternal health and who are they most likely to listen to? Rima shares who she discussed her birth plan with and how it informed her decision-making about how to deliver her baby.
While many caesarean-sections are medically advised, between 3.5 and 5.7 million unnecessary caesarean-sections were carried out in 2010. Paper 2 of the series discusses the overuse of medical interventions – too much, too soon – in maternal health, and its impact on health outcomes.
“It’s more diverse than before.” The shifting burden of maternal health care means there are more immigrant women and refugees seeking maternity care. Malin and Elena, two midwives working in Sweden, discuss the challenges that this diversity presents. For migrant women the language barrier often makes it difficult to communicate with their doctors and midwives, and they may rely on their ‘closest relative’ to translate.
Data in Paper 4 of the Series show that immigrant women in Sweden, who make up 25% of women giving birth, use less antenatal care and less preventative care than non-immigrant women. The reflections of the midwives illustrate the need for maternal health strategies to respond to the ‘rapidly changing population’, as laid out by the action plan in Series Paper 6.
Care in facilities should be humane and dignified, but how do we ensure that all women have access to respectful maternity care? Fatma shares the story of her difficult first birth made easier by quality care and support from her midwives. Fatma was ‘shocked by their kindness’, and this experience led her to give birth to her second child in the same facility under the care of the women she calls ‘sisters’.
It is essential to meet the needs of delivering women to ensure a safe birth. Paper 2 and Paper 4 of the series discuss the need for evidence-based respectful maternity care in order to promote and protect human rights. Paper 3 discusses how access to midwives or skilled birth attendants remains challenging – 90 per cent of maternal deaths happen in countries with only 17 per cent of the world’s doctors and midwives.
What happens when your delivery doesn’t go to plan? Christa planned a facility delivery in Sweden, and when she suspected her waters had broken she went into the hospital. Staff at the hospital sent her home, estimating that she was not close enough to delivery to be admitted. Within an hour of returning home, she began to have contractions. After a rapid labour, she gave birth in her upstairs bathroom without a midwife or a skilled birth attendant. Her newborn son remained attached to her via the umbilical cord for over two and a half hours. Christa was distressed by this traumatic and unplanned delivery.
Paper 4 of the series considers the drivers of maternity care in high-income settings. Maternity care coverage in Sweden is good, and most women have access to antenatal care, delivery care, and a high standard of women-centred care. Less than 1% of births in Sweden are home births. Christa’s experience is rare, but it shows how unpredictable childbirth can be.
“You deliver safe, and go home safe”. Despite feeling there was a lack of privacy and small delivery room, Felicia’s experience giving birth at her local facility was safe and she felt reassured. Her experience of good health outcomes for her and her baby, together with supportive and respectful midwifery meant she was satisfied.
How can we ensure every woman everywhere has access to good quality maternal care? Many pregnant women globally are still not able to access good quality care. They may face not only structural health system constraints, including lack of transport, and facilities with insufficient equipment, supplies and drugs, but also a lack of trained healthcare workers. Wide disparities in quality of health care are also seen in high-income settings, with the burden concentrated among vulnerable women. For example, black women in New York City are more likely to die in childbirth than women in Vietnam, a middle-income country.
Which interventions are considered ‘too much, too soon’? Malin and Elena are experienced midwives in Sweden. They touch on provider autonomy and discuss the over-use of interventions in maternity care, emphasising that it is important not to “do too much when you know it’s not needed”. Over-use of foetal monitoring and excessive post-natal checks may not be of benefit to the mother or her baby. On the other hand, providers value having professional autonomy and decision-making abilities.
Paper 2 of the series looks at the practice of ‘too much, too soon’ in maternal health care, how some interventions are used despite having no evidence of benefit to women or babies – or indeed even having evidence of harm. Other interventions are beneficial in some circumstances but are over-used; these include unnecessary caesarean sections, continuous foetal monitoring and routine episiotomy.