COMMENTARY: Improving the experience of birth in poor communities
Pregnancy and childbirth have a profound effect on a woman's life along with that of her spouse and family. Yet often in poor communities the joy which should accompany such a momentous experience is overshadowed by obstetric complications, serious illness, disability and in some cases untimely maternal or perinatal death. For women from poor communities who give birth in ‘Western’ health facilities, these hardships are often compounded by care from health professionals that imposes unnecessary, uncomfortable and humiliating medical procedures, lacks respectful communication and is even on occasions abusive.
Although the cornerstone of international efforts to reduce maternal mortality in poor countries is ‘skilled attendance at birth’, little attention has been paid to the fact that women avoid attending services where they receive disrespectful care. This commentary will outline the issues at stake and propose practical solutions.
Contextual factors within poor communities
Poor communities are characterised by limited access to basic public services such as water, sanitation and electricity.1 Many women live below the poverty line, have minimal schooling, low social status and are burdened with heavy work from an early age—all factors which leave them with little sense of entitlement to health care. In areas of the world where girls are less valued than boys, girls have less access to health care, receive less food and have lower immunisation rates. Poor nutrition and chronic illness increase the risk of death during childbirth.
Many poor communities are located in inaccessible geographic terrain, a factor which makes it difficult for women to reach the health facilities when obstetric emergencies arise. This situation is further aggravated by poor transport. Other factors that contribute to unsafe motherhood include inadequate, inaccessible or unaffordable health care and poor hygiene.
Cultural realities and gender roles have lifelong health consequences for poor women, starting in infancy. In some poor communities, early childbearing, genital mutilation and gender violence, including rape, domestic violence and sexual abuse, increase the women's vulnerability to sexually transmitted diseases and HIV. Women are further constrained by their lack of decision-making power in their families, an aspect that may influence the outcome of labour. The extent to which adverse social circumstances impact on safe childbearing is highlighted by the fact that maternal mortality is the health statistic for which the greatest discrepancy exists between developed and developing countries. It is against this background that we explore the birthing environment in low income communities.
The birthing environment
There is a close correlation between the quality of care provided during childbirth and labour outcome. While the technical clinical care during labour is of fundamental importance, one should not ignore the fact that the birth of a child is an event of great emotional and cultural significance to the family.
Health workers appear to apply, explicitly or implicitly, a hierarchy of priorities whereby limited resources for providing basic care for physical safety are used as a reason not to attend to the emotional needs of women during labour. In this commentary we will discuss how ‘higher order’ needs may be met without compromising basic needs, and indeed the extent to which attention to emotional needs and comfort may improve the physical safety of childbirth.
Over the last half century, the ‘medicalisation’ of labour resulted in the use of procedures that were often uncomfortable or unnecessary, regardless of how they affected women. These included routine enemas, routine pubic shaving, the withholding of food and fluids, the confining of the women to bed, the isolation of women from supportive companions from their community and a preference that women deliver in the supine position. Many of these practices, while based on compelling theoretical rationale, have not been substantiated by empirical research. It is ironic therefore that ineffective and unpleasant medical traditions, which have been abandoned in their countries of origin, continue to be practised in developing countries, while women's traditional practices such as upright birth postures are discouraged.
A large proportion of births in developing countries take place in non-clinical settings, mainly in homes. An objective of international efforts to reduce maternal mortality is for all births to be attended by trained midwives, yet midwifery training programmes often advocate approaches that are impractical in out-of-hospital settings.
Availability, content of care and quality of health services
Respect and recognition of the dignity of each woman should be a central element in rendering care to women during labour. Many of the women who are admitted to a health facility during labour will have encountered experiences that violated their dignity and rights at different stages in their lives and will carry the scars of such experiences to the birthing environment. In the light of these experiences, an attempt should be made to ensure that in addition to having clinically competent health professionals labour is characterised by a respectful climate that contributes to a positive and memorable birthing experience.
Observational studies from low income countries (including one in this issue of BJOG, Weeks et al.2) describe conditions in labour wards which fall far short of this ideal.3–5 Women are often not treated with respect, spending large parts of their labour alone, with minimal comfort, subject to unpleasant practices and sometimes shouted at, struck or slapped by health workers.5
This is of particular concern as poor quality care often leads to poor uptake of services. Studies in Zimbabwe showed that that non-use of services is associated with poor fetal and maternal outcomes6 and that the pattern of utilisation of maternity services by rural women was based on rational decision making, which took into account not only the distance to a service but also whether the care provided was seen to be good.7 South African women describe preferring to stay away from formal care structures for their deliveries.5 This is bad news, given that the greater use of services (‘skilled attendance at birth’) is a key step in reducing the half a million maternal deaths in developing countries each year.
The importance of the empowerment of women is now enshrined in major policy statements. At the International Conference on Population Development (ICPD) in 1994, a new global policy consensus was reached on the relationships between population policy and sexual and reproductive health and rights. This policy places emphasis on women's empowerment and the recognition of choice and opportunity, not coercion and control. The rights-based approach, which was reaffirmed and extended at the Fourth World Conference on Women (FWCW) in Beijing in 1995, and again at the ICPD+5 review in 1999, has an important place in the delivery of safe and client-centred obstetric services.
Interventions aimed at improving childbirth in poor communities
Evidence-based care requires the integration of clinical expertise with the best available evidence from robust research. However, clinicians are often reluctant to change the way they practice, even when rigorous evidence of effectiveness exists.8 Disparities between clinical practice and research evidence are well documented in obstetric care. For example, there is considerable evidence of beneficial effects from the presence of a supportive companion during labour, yet lack of social support and restricting access of family members to labour wards is the norm in developing countries. There is increasing recognition that many factors influence the change process, and that using multiple strategies is more likely to effect change in health professional behaviour and practice.9
The Better Births Initiative
The Better Births Initiative (BBI) developed in response to observational studies of obstetric practice conducted in China,3 South Africa5 and Zimbabwe,7 which indicated that obstetric practice and quality of care could be improved if changes were made to some routine practices. Drawing evidence available in the World Health Organisation Reproductive Health Library (RHL),10 the BBI aims to ensure that clinical practices used in essential obstetric services are grounded in reliable research evidence.
The programme takes the form of structured workshops for labour ward staff and managers with several components. There is a presentation on the principles of an evidence-based approach to care and a video presentation on childbirth companions. Small-group exercises enable participants to discuss their current childbirth practices and write these down in workbooks. They compare these practices with evidence of effectiveness from a reference booklet and decide whether there are practices they think should be changed. If so, they work out a strategy for change with clear commitments as to what each person is responsible for, and are provided with charts on which to monitor their progress towards change.
The principles of the BBI are as follows:
- •Humanity: women treated with respect
- •Benefit: care that is based on the best available evidence
- •Commitment: health professionals committed to improving care
- •Action: effective strategies to change current practices
The materials used for the BBI workshops are available in the WHO Reproductive Health Library (RHL), which is distributed annually free of charge to over 15,000 health professionals in developing countries.10 The RHL is available in English and Spanish, and soon will be available in Chinese.
The BBI programme was evaluated at 10 government maternity units in Gauteng Province, South Africa.11 A single educational workshop was conducted with labour ward staff at each study site. Pre- and post-test observations at approximately six months showed a trend towards an increase in the number of hospitals with good practice at follow up for: not restricting oral fluids, allowing companionship and avoiding routine use of enemas, perineal shaving and episiotomy. Restricting mobility and use of the supine position for birth were not improved.
BBI programmes have been implemented in several provinces in South Africa, as well as in other countries, including Egypt, China,3 Tanzania12 and Thailand. Implementation of the workshop in pilot sites in the Western Cape, South Africa, followed up by two-monthly progress meetings, has resulted in considerable changes to practices and improved motivation of labour ward staff (S Fawcus, personal communication). The programme appears to be most effective when supported by the health services management, and when at least one member of staff at the facility is enthusiastic about bringing about change.
In conclusion, it is clear that many outdated, scientifically unfounded and uncomfortable practices still persist on labour wards throughout the world. This and the disrespectful treatment of women rendered vulnerable by the pain and fear of labour is an indictment on our professions and our society. To address this issue effectively on a large scale will take commitment at many levels. The BBI is one approach to improving care in labour for which materials are available to any health worker who at a local level wishes to bring about change for the better.