Learning from historical decline: Sweden and Sri Lanka

SPEAKER: What can we learn from the success story, employing midwives to reduce maternal mortality. This Gapminder graph shows maternal mortality ratios over time from three countries, Sweden, the United Kingdom, and the United States. You see on the vertical axis the maternal mortality ratio, the risk of a woman to die when pregnant. And on the horizontal, time, starting at 1800. The graph shows how the maternal mortality declined throughout the 19th and 20th century. Sweden started to document births and deaths in 1748. The parish priest had to document births and deaths and migration and to send this data regularly to the statistical bureau, the Tabellverket.

At the statistical bureau, data was summarised year by year and compiled in large statistical books, as you see on this photo. The priest knew about all births and deaths in the parishes, as he had to baptise the babies, even newborns who died immediately after birth. He would be called then for an emergency baptism. The priest was also there to bury dead bodies. As a result the Swedish data are considered fairly complete. This was possible because Sweden had more or less one religion and one church all over the country. Now, coming back to the Swedish midwives. The Swedish– the first Swedish midwifery school opened in 708.

The high maternal mortality ratio was considered as unacceptable, and the decision to increase the number of midwives was taken 1751, shortly after the first national data became available. In 1829, midwives were licenced to use the forceps, an instrument which could be used to pull the head of the baby out if it was stuck in the birth channel. Obstructed labour was a frequent cause of maternal deaths at that time. In the 1880s, antisepsis technique emerged as hand-washing was introduced. This was one of the main reasons why maternal mortality declined rapidly in the years thereafter. The Swedish midwives were well-educated. They were also well-equipped with instruments, as you see on this slide.

They were able to follow normal births and give psychological support, mostly at home, as Sweden had a very rural and dispersed population that time. Additionally, midwives were able to manage some complications, such as obstructed labour and postpartum haemorrhage, today the most frequent cause of death. It is important to realise that the midwifery approach was well-supported nationally. The availability of data to follow progress annually was considered a key factor. Moreover, the midwives had to report every birth they attended to the national health authorities. So a strong accountability system was established from the very start. There was political pressure to reduce maternal mortality and a strong investment in midwifery regulation.

All these factors together, with the professionalisation and the selection of key interventions, such as aseptic practises, are considered the key drivers of the decline. A health historian, Irvine Loudon, summarised– comparing the decline in maternal mortality in the United States, the UK, and Sweden– it was not so much the place of delivery as the type of birth attendant which was crucial. Now I come back to the first slide, but I have added another country. The blue bubbles represent the maternal mortality ratio from Sri Lanka over time. We see an even faster decline in maternal mortality in Sri Lanka than we did see in Sweden in the early years.

I zoom in and show the decline in Sri Lanka in more detail. Malaria control and the introduction of modern medicine was considered important for the reduction of maternal mortality, together with a rapid scale-up of midwifery services to rural areas. The transition from less than 10% of deliveries attended by a midwife to over 70% took place in only 30 years. Similar to what is discussed as important factors in Sweden for the decline, I’ll discuss political [? will ?] the counting of maternal deaths by government authorities, and the increasing professionalisation. Starting around 1940, a very rapid decline in mortality ratios were seen in almost all high-income countries.

The background is the increasing availability of modern medicine, such as antibiotics, oxytocin, safer blood transfusion, and safer operations. But also, improved living conditions and improved access to treatment and transportation contributed. As better birthing services became available in hospitals, the advantage of midwifery care in terms of mortality became smaller. Still, countries like the United States where doctors provide much of the maternity care have higher rates, while the lowest maternal mortality ratios in the world are seen in countries with strong midwifery systems like in Sweden. And midwives might be the key factors for providing women-centered care and prevent unnecessary interventions like Caesarean sections.

So midwives have been important in the past for maternal care, and they will continue to be important in the future. I worked with Hans Rosling at Gapminder. And this lecture is a memory of Hans Rosling, who died on the 7th February, 2017.