Midwives, not medicine, rule pregnancy in Sweden, with enduring success

AFP RELAX NEWS Monday, October 7, 2013, 11:14 AM


Only one ultrasound in nine months and no need to see the doctor or obstetrician: at first glance, Sweden's pregnancy care appears rather simplistic.


But while it may be far from the medical approach to pregnancy seen in most Western countries, where mothers-to-be have loads of doctor's appointments and tests, the Swedish system, where midwives reign supreme, has proven its merits.


According to the organization Save the Children, Sweden is the second-best country in the world to become a mother, behind Finland.


Neonatal mortality is low, at 1.5 deaths per 1,000 — the second lowest in Europe behind Iceland — as is maternal death in childbirth, at 3.1 per 100,000 births, according to the European Perinatal Health Report from 2010.


In Sweden, midwives are entrusted with caring for the health of the expectant mother and the foetus. It is the only pregnancy care available to women, and is free for the patient, falling under state health care benefits.


"A doctor can be called in at the midwife's initiative as soon as she notices that something is not right," says Sofie Laaftman, a midwife in central Stockholm.


For those accustomed to intensive medical care during pregnancy, the Swedish way may seem rudimentary: a few blood and urine tests are done to detect vitamin deficiencies or anomalies, the mother's blood pressure and the heartbeat of the foetus are checked, and a little nutritional advice is doled out.


During a normal pregnancy without complications, just one ultrasound will be done over the whole nine months — and not a single gynaecological exam.


Meanwhile, in France for example, a 2011 report from the health ministry showed 20 percent of expectant mothers had more than six ultrasounds and four percent had more than 10 — without any obvious benefit.


"Pregnancy is a normal condition" and not an illness, says Marie Berg, professor in health and care sciences at Sahlgrenska Academy at Sweden's University of Gothenburg.


Laaftman echoed that notion, saying most women under 40 did not need more medicalised care since their bodies were healthy and capable of giving birth, which is after all a natural process.


A scientific study published in August by the Cochrane Collaboration, an organisation of health practitioners, concluded that "most women" — those who have no complications in pregnancy — would benefit from seeing a midwife during pregnancy rather than a doctor.


Care by a midwife can actually reduce the number of premature births, the study's authors say. In Sweden, only five percent of babies are born prematurely.


But the lack of contact during pregnancy can be tough for some expectant mothers.


Christina Singelman, a 31-year-old expecting her second child, recalls the sense of loneliness she felt during her first pregnancy: from the time she registered at the clinic until her first ultrasound, some 10 weeks went by without a single appointment.


But if the woman is under the age of 40, has no prior medical conditions and has fallen pregnant by natural methods, "there's no reason to have more frequent checks in the beginning," insists Laaftman, the Stockholm midwife, who cares for about 100 pregnant women at a time.


Adina Trunk, 33, saw two different midwives for her two pregnancies.


"They were both very competent but the system puts them in a very passive position. It's always up to the expectant mother to take the initiative, to ask questions and possibly ask to see a specialist," she says.


"And since this is a culture where people don't like to make a fuss, it keeps costs down," she adds.


Midwives also take care of the delivery, although that is with an entirely different team than the one that has followed the mother throughout her pregnancy.


A doctor will only intervene if there are complications during the delivery, or if the woman in labour asks for an epidural, which is the case in about half of all deliveries.


Entrusting pregnancy and delivery care to midwives to such an extent is unique in the world.


Midwives in Sweden have been in charge of pregnancy care since the 18th century.


While the rise of the modern medical profession meant midwives in much of Europe were forced to yield at least part of their responsibilities to doctors, Sweden's midwives held onto their traditional role thanks to doctors' consent and, in recent times, a strong union.


The system has never been called into question, owing primarily to its strong track record.


The number of Caesarian sections is relatively low in Sweden, at around 17 percent of births in 2011, and only 10 percent of women undergo episiotomy, an incision to widen the opening for delivery.


"It's an efficient system in terms of cost management," says University of Gothenburg professor Berg.


In countries where doctors care for pregnant women, she says, the number of "tests and ultrasounds often multiply, which opens the way to easy money."

Meet Tamara Villavicencio

Consuelo York

Aimee Krol has completed her Doula Certification!

Introducing our recently certified doula:

"Great Concern" over U.S. deaths in Pregnancy, Childbirth from CBS News

CBS News
Tavis Ukena

The number of U.S. women who die during or soon after pregnancy may be higher than previously thought -- and it's on the rise, according to a new study.

Between 2000 and 2014, the nation's maternal death rate rose by almost 27 percent, researchers found. However, over that time, reporting methods changed, the study authors noted.

For every 100,000 live births, nearly 24 women died during, or within 42 days after pregnancy in 2014. That was up from nearly 19 per 100,000 in 2000.

The numbers, published online Aug. 8 in Obstetrics & Gynecology, are worse than previous estimates. Federal health officials have already reported a spike in the nation's maternal mortality figures, but they estimated a rate of 16 per 100,000 as recently as 2010.

The new findings give a clearer picture of where the United States really stands, according to lead researcher Marian MacDorman, of the University of Maryland.

And it's not a good place, her team said: With the 2014 numbers, the United States would rank 30th on a list of 31 countries reporting data to the Organization for Economic Cooperation and Development -- beating out only Mexico.

A large share of the national increase does have to do with better reporting, MacDorman said. Since 2003, U.S. states have been slowly adopting a revised standard death certificate that includes several pregnancy "check boxes."

But, she said, about 20 percent of the increase reflected a "real" rise in women's deaths.

"Certainly, maternal death is still a rare event," MacDorman stressed. "But it's of great concern that the rate is not improving -- it's increasing."

The big question is, why?

"Our study couldn't get into the causes of death," MacDorman said. "We were just trying to get at the numbers."

But Dr. Nancy Chescheir, editor-in-chief of Obstetrics & Gynecology, speculated on some factors that could be driving the increase.

For one, she said, women in the United States are having babies at older ages, and they are also increasingly likely to be obese and have medical conditions such as diabetes and high blood pressure. So women are now going into pregnancy at greater risk of complications compared to years past.

There was a bright spot in the study findings, however: In contrast to other states, California showed a decrease in maternal deaths, reaching an estimated 15 per 100,000 in 2014.

That, according to Chescheir, may stem from a "massive public health effort" known as the California Maternal Quality Care Collaborative. State agencies, hospitals, health plans and other groups worked to identify two leading causes of maternal deaths in the state -- preeclampsia and hemorrhage during childbirth -- and took steps to address them.

Among other things, the group created online "toolkits" to help hospitals better manage preeclampsia and hemorrhaging, Chescheir said.

"They've done a fantastic job of rolling these resources out," she said.

MacDorman agreed, and said other states may be able to learn from California's experience.

But when U.S. women die during or soon after pregnancy, it often has nothing to do with obstetric complications, Chescheir pointed out. Violence and drug abuse are major causes.

A second study in the same issue of the journal looked at maternal deaths in Illinois between 2002 and 2011. More than one-third were the result of car accidents, homicide, substance abuse and suicide; 13 percent, in fact, were homicides.

Chescheir said doctors have a role to play in preventing those deaths, too -- by screening pregnant women for drug usle, domestic abuse and depression, then referring them for help.

Doctors should also talk to women about how to use seatbelts during pregnancy, Chescheir said. Some women, she noted, stop using seatbelts because they think they're unsafe during pregnancy.

The point is not to alarm women, both Chescheir and MacDorman stressed.

"For the vast majority of women, pregnancy goes well," Chescheir said.

But, she added, "it's important to remember that pregnancy is a time of some risk."

Ideally, Chescheir said, couples should plan ahead for pregnancy -- in part so the woman can get any health conditions under control, and lose weight if needed.

"Go into pregnancy in the best health possible," she advised. "That's the first step."

International MotherBaby Initiative posted this Webinar by Vicki Penwell, Mercy in Action. She teaches on how they were able to implement the 10 steps in a disaster relief setting.:
https://www.youtube.com/watch?v=7tFkCPAAMG8

An update about Save the Mothers Org in Uganda:

Mother Baby Friendly Hospital Initiative

Say the word “hospital” and most North Americans imagine busy, bustling places that are antiseptic clean, fully staffed, and equipped with the latest life-saving technologies.

Unfortunately, that’s far from the reality at hospitals in Uganda, where 97 percent of health facilities do not offer needed emergency obstetric care services. In Uganda, close to three quarters of all maternal deaths occur in large regional and national referral hospitals, (to which women have been referred from lower health units).

There are three major delays that lead to mothers dying from pregnancy complications. The first is the delay in seeking care. The second delay is in transport to the facility, which can be hours or even days away from a laboring woman’s home. Finally, once at the health facility, medical treatment may be unavailable or unaffordable.

Now, Save the Mothers is working with Ugandan hospitals to help them become better equipped to provide the care mothers need.

Through our “Mother Baby Friendly Hospital Initiative” (developed with input from Uganda’s Ministry of Health and the World Health Organization), STM graduates are working with hospital administrators and staff in assessing, recommending and implementing changes, then monitoring the outcomes and progress in improving maternal and newborn services. From simple changes—such as adding curtains in the delivery room—to replacing 40-year-old operating room beds, the Mother Baby Friendly Hospital Initiative is also delivering change by bringing about social transformation in hospitals so that mothers are treated with respect and dignity.

Mother Baby Friendly Hospital teams also engage related community-based organizations and personnel (including traditional birth attendants) to coordinate efforts toward reducing obstacles and barriers to safe motherhood, specifically addressing the delays laboring women face in getting to hospitals.