Safe and efficient maternity services for resourced and under-resourced countries


The article highlights two important aspects in relation to maternity care in the UK, but probably also in relation to low-income countries.

With current funding, most obstetric units are unable, and will probably not ever be able, to provide one-to-one care for all labouring women and have a consultant in the birth suite at all times.

Is it then time to reconsider other methods of providing maternity care? Nearly 87% of women gave birth in hospital in 2012. With an ageing midwifery workforce and less experienced midwifery graduates, is it not time to take the bull by the horns and allocate financial resources to set up midwifery-run obstetric units adjacent to or within a short distance of every hospital for women who have had a previous vaginal birth and who do not currently demonstrate any risk factor? The experience in Southern Africa with well-defined and agreed protocols for care and intrapartum transfer has been shown to be safe and efficient (Delivering Health, Saving Lives. UN Population Fund, World Health Organization, International Confederation of Midwives, 2011). Such units can be made more family friendly and use less costly staff, such as maternity health workers or ‘doulas’. Visits by hospital-based midwifery and medical staff would ensure adherence to guidelines and provide moral support. Maternity care can then be culturally appropriate and woman centred, evidence based, and easily accessible at the local level.

There has been an increase in intervention rates, particularly in caesarean section and induction of labour, with similar trends reported in Australia and other countries (Improving Maternity Services in Australia: A Discussion Paper from the Australian Government, Department of Health and Aging, 2009), and more so in private compared with public hospitals. The report fails to discuss contributions from complex cases that may result in higher rates of obstetric intervention, such as multiple pregnancies, older women, obesity, and concurrent medical illness. There has been an increase in such women over the last 10 years. These women are at increased risk of hypertension, gestational diabetes, fetal growth restriction, and preterm birth, to name a few. Care in hospitals must continue to be multidisciplinary for such women who are prone to both anticipated and unanticipated obstetric emergencies. Good research is therefore urgently needed to critically address the reasons for obstetric interventions. It is imperative to ensure adequate funding to enable more consultant cover in the birth suite, however, as this is likely to not only reduce unnecessary intervention but also result in better outcomes, and thus reduce clinical negligence claims in the long term. Around £480 million is spent annually to settle cases of litigation, mostly around management in labour and caesarean section.

The report has focused on maternity services in the UK, but is relevant to low-income countries where funding for health care in many countries is <5% of gross domestic product (GDP). Brain drain from such countries has also had a high impact on the wellbeing of pregnant women in sub-Saharan Africa.

Disclosure of interests

The author has no conflict of interest to declare.