Maternal Health, Birth Models, & Midwifery: A Proposed Solution

Mary Kern
College of Nursing 2015

Context
What exactly is the plight facing mothers in the developing world? According to the World Health Organization’s fact sheet on maternal health (2010), approximately 800 women die each day from preventable causes related to pregnancy and childbirth. Additionally, maternal mortality is highly associated with living in rural areas and underserved communities, a reflection of lack of access to healthcare. An example of lack of access is demonstrated well in a Partners in Health publication. PIH (2012) created an infographic comparing the birth experience for American women versus women in rural Lesotho. For the women in Lesotho, they, walk an average of up to five hours to a healthcare facility. This is in comparison to the twenty minute car ride the average woman takes in the US to a healthcare facility. This type of access is all too common in the developing world, which explains why 99% of all maternal deaths occur in the developing world, with one half of them in subSaharan Africa and another one third in South Asia.

But what exactly are these causes? Why does a skilled birth attendant, midwife, or physician’s presence matter so much? Eighty percent of maternal deaths are attributed to the following four causes, according to WHO (2010): hemorrhage after childbirth, infections after childbirth, high blood pressure during pregnancy (preeclampsia and eclampsia), and unsafe abortion. Thus, the need for these trained professionals is dire. For hemorrhaging    after    childbirth,    the administration of oxytocin can make all the difference as it helps the cervix to contract and control the bleeding. Infections can be
prevented by having a trained professional properly sanitize their hands while assisting with birth along with having the appropriate supplies for a sterile environment. These professionals can also identify what an infection looks like more easily. For the matters of preeclampsia and eclampsia, these high blood pressure issues can be detected in advance with proper prenatal checkups so that measures to ensure safety of both mother and child, such as administration of magnesium sulfate or induced labor, can be taken more swiftly. Unsafe abortions can be remedied by providing facilities for safe abortions, along with family planning supplies and education for the general public.

The good news is that a lot of these interventions are working. From 1990 to 2010, maternal mortality dropped almost 50% and in these improvements, there are opportunities for women to empower themselves. This provides an entirely sustainable solution. Women are becoming the OB/GYNs, midwives, and birth attendants themselves in these developing nations, and this provides them with an occupation and role within their societies. They become an asset and gain respect for the service to the community by spreading information on what is important for prenatal nutrition, along with what’s normal with antenatal care. Not to mention, these improvements in women’s living condition also provides a higher standard of health for the infant and the rest of the family’s well being.

Along the lines of family planning, knowledge can be passed from woman to woman about options available to make their own decisions; the woman’s body becomes her own, no longer an object the society makes it to be. This establishment of ownership and control over oneself is one of the greatest forms of empowerment.

Beginnings of Birth Models
As far as successful birth models go, Sweden is one to take note of and its integral usage of the midwife. The role of the community midwife was very much solidified in Sweden during in 19th century, according to Dr. Ulf Högberg’s article for the American Journal of Public Health entitled, “The Decline    of Maternal Mortality in Sweden: The Role of Community Midwives.” Specifically, in 1819, a national midwife training program was established for all of the parishes within Sweden, requiring at least one midwife per parish. The program paid for all of the students’ expenses, and the state defined the required curriculum and training. This professionalization of the midwife in Sweden was critical, as the requirement of their role elevated their status to be complementary to physicians, rather than the typical asymmetry of power that is often felt between the two positions. Because of Sweden’s prioritization of maternal and infant care during this time period, by 1894, 94% of the country’s births were attended and the maternal mortality rate had dropped from 490 deaths per 100,000 births to 100 deaths per 100,000 births in a period of 33 years. Then, medical advances picked up in the early 20th century, improving the rates of maternal mortality in all Western nations, but Sweden’s rate was still one third of the United States’ rate. Presently, Sweden is one of the safest countries to give birth in, with a maternal mortality rate of 5 per 100,000 live births. The midwifery framework of this country’s birthing model is what makes it so efficient and good for mothers and babies— similar to the frameworks of Norway, Iceland, and The Netherlands, which are all considered some of the best countries to deliver a baby in.
It is impossible to deny the importance of the midwives’ role in achieving healthier birth outcomes.

A Present Day Application & Program Idea in Ghana
Every week in Ghana, 50 women die during pregnancy and childbirth. More than 400 babies also die weekly. The Ghanaian government has made strides to improve this issue by passing legislation in 2008 for free healthcare for women who are pregnant, new mothers and babies—but this measure isn’t enough. There is a huge disparity in the rural and urban populations in their access to health personnel. In the urban population, 80% of births are attended by a health professional. In the rural population, however, only 40% of births are attended by a health professional. Take Mary Issaka for example; she is one of few midwives who serves in the rural regions of Ghana. Recipient of the ‘International Midwife Champion’ prize, she is a provider for the Bolgatara, which is a northmost region of Ghana. Since 2003, she has delivered 2,240 babies and made major strides in her community. When she first arrived to Zorkor Health center, maternal deaths were very common. Many of the women in the community preferred to give birth at home, but Mary was able to create a welcoming labor ward with traditional hot bath techniques for delivery and by preparing traditional millet flour beverages for women after giving birth, amongst other things. Thus, the women in the community sought out the health center, increasing birth attendance in the region six fold.

We need more Mary Issakas in rural Ghana today. The unfortunate part is that she, like 85% of current Ghanaian midwives, is over the age of 50. What is the cause of this unsettling statistic? The “brain drain,” or the emigration of highly trained/intelligent people to other countries, is what is hurting the future of Ghanaian midwifery, along with other fields. There is no incentive for a woman to stay in Ghana and practice as a midwife because the pay is substandard, the position comes with little respect, and the training is expensive. A birth model restructuring would set out to alleviate all of these issues and benefit mothers, babies, and young women entering the field of midwifery; a brighter, healthier future allaround. Following suit of nations with exceptionally low maternal mortality and infant mortality rates (such as the Nordic countries), the project sets to establish a community midwife birth model in order to best serve all populations of Ghana. By doing so, women all across the country will have access to appropriate prenatal and postnatal care, labor assistance, and referral ability to a major facility if there is a need for extra medical attention (i.e., a Caesarean section).

The critical piece for this project is the recruitment and training of high school graduates, such as students supported by the Campaign for Female Education (Camfed). By identifying a high achieving group of girls with leadership skills, they are the ideal candidates for going on to midwifery. Based on test scores, a nomination by Camfed, and an essay expressing interest in midwifery, a committee comprising of representatives from an activist organization, like the White Ribbon Alliance in Ghana, and the Ghana Health Service will determine who will qualify to attend one of sixteen midwifery schools in Ghana with all expenses paid. A key component of the training will be curriculum designated by the White Ribbon Alliance as methods and techniques for respectful maternity care, something that is lacking in many health systems today, and advocacy training for maternal health rights. After the three years, the new midwives are required to serve an assigned region under the discretion of the Ghana Health Service for three years.

With a handsome starting salary, a 5% per year increase after the three required years (similar to the pay increase by year with school teachers), and full government benefits, the program will work to keep these well- trained, strong leaders in the rural areas where their expertise is needed most.

Maternal health is of the utmost importance, and this project idea is one of the most sustainable ways to ensure that progress is being made. In order to have healthy, well raised children, the mother must be alive and well to do so. Additionally, all of the rights and freedoms that are being fought for in the interest of women are for nothing if the women themselves are dying needlessly. By having healthy pregnancies and deliveries, along with general women’s health, women will be able to exercise rights to land ownership or ability to take out a microfinance loan. Women will be able to help raise nurtured children who can succeed in school if they themselves are healthy. In Ghana in particular, women do most of the farming and household work, so families are losing a huge contributing member in the family if women are ill.

Right now, $15 billion in productivity is lost every year due to the deaths of mothers in developing countries, according to the United Nations Population Fund (UNFPA). The other piece of this is that the young women who are becoming midwives themselves will be empowering women in Ghana, showing the necessity and prestige that should go along with a critical role in society. These young women will be well-educated, which means later marriage and less unplanned pregnancies as they will have more knowledge about the authority they possess over their own bodies. A restructuring of the birthing model would benefit Ghana as a whole and would serve as a model for countries who wish to restructure their present birth model situation.

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