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Who delivers and where?

Video describing where women deliver and the complications that can arise if they don't have access to health facilities or skilled birth attendants.
OONA CAMPBELL: So in this step we’ll be talking about who delivers women and where are they delivered. Knowing where women deliver and who attends them helps us to understand the health system context but also likely challenges and future options for delivery care. Where might birth take place? Well, birth can take place at home or in a relative’s home or someone else’s home. And birth can take place in transit.
Other births take place in facilities. Some of these cannot provide routine care or basic emergency care. Some can provide routine care and basic emergency care. While others can provide both routine and comprehensive emergency care. Who might attend a birth? Well, in some cases, no one. In some cultures it’s valued for women to deliver by themselves. Relatives are a common group that do deliveries. And in some cases, for example, it might be an older aunt who would deliver members of the extended family. In some countries, there are traditional birth attendants.
And these are women who are not trained within the health system but who will deliver women in villages, for example, but will deliver quite a few women, not just their extended family. In other contexts, we have midwives or auxiliary midwives who deliver women or doctors and obstetricians. And these two last groups are called Skilled Birth Attendants, or SBAs. Now we’d like you to undertake a mini thought experiment. I’d like to introduce you to two women. This is Joanna who’s 34. She lives in the UK. She’s on her second pregnancy and has had eight antenatal visits with a midwife and one visit with a doctor.
Joanna delivers with the midwife in the maternity ward of a hospital that’s capable of providing caesarean section and blood transfusion. She will have postnatal visits from the midwife at home when she’s discharged from the hospital.
This is Sarah who’s 25 and lives in Ethiopia. She has three children. And for this pregnancy, she has had two antenatal visits, which involved a one-hour walk to a health centre. Sarah delivers at home with the help of an older aunt.
The first question for you is, what is the most likely outcome for Joanna and her baby and for Sarah and her baby? What do you think would happen to Joanna if she had a complication during delivery? What about Sarah? The strategy for reducing maternal mortality needs to focus on monitoring women and their babies during labour and for 24 hours postpartum. It also needs to focus on safety and primary prevention and early detection and basic management of problems. Treatment, if it can be provided, should also take place if needed or referral somewhere else for emergency care. Our best bets for maternal survival include having skilled birth attendants for all women. Most births with skilled attendants are in facilities.
But one important question is, what level of facility is best? Here we have some examples of where women deliver and who delivers them across a number of countries. We start with Ethiopia. This is Sarah. And here we can see that the vast majority of births take place at home, mostly with unskilled attendants. But some take place at home alone.
In the next example, Malawi, we can see that the proportion of births taking place at home, in blue, is much smaller. And the vast majority of births take place in health facilities, mostly at lower-level facilities and mostly with midwives. But we can also see, in orange, that some births in facilities take place at home. Here women have taken the trouble to arrive at a facility. But there’s no one there to actually look after them. And this is evidence of poor-quality care. The next example is Jordan. And here we can see that the births, in blue, are almost invisible. And nearly all births take place in health facilities. Most of them take place in higher-level facilities, in hospitals.
And most are undertaken by doctors rather than midwives. Sometimes with this type of care women are prone to get too much intervention, particularly if this happens in the private sector where interventions are incentivised. The next example is in the UK. And here, again, we can see that the proportion of home births is very small and that most births take place in facilities with midwives. Although substantial numbers of women are also delivered by doctors. The last example, the Netherlands, is an example of a high-income country with the highest proportion of home births. But even here we can see it’s only 16%.
The vast majority of births in the Netherlands take place in facilities. Although some take place in maternity units, which are lower-level facilities.
In conclusion, understanding at a population level where women deliver and who delivers them helps us to identify the main elements needed to ensure that women and newborns with complications get care. But they also highlight the key issues likely to arise and indicate the scope for future changes in both the cadre, that is to say the professional doctor or midwife doing care, and also the location of delivery. Thank you.

the main things needed to ensure that women and newborns with complications receive care, the key issues likely to arise, and necessary improvements to healthcare services.

As you watch the video, pay close attention to the thought experiment proposed by Oona and consider the potential experiences of the two women, Joanna and Sarah. We highlight some of the key information about each woman and her situation below, so try to focus on possible outcomes resulting from their respective situations.

A thought experiment

Joanna is 34 and lives in the UK. She is expecting her second baby, has had 8 antenatal visits and 1 visit with a doctor. She delivers with a midwife at a hospital maternity ward capable of providing caesarean sections and blood transfusions. She will receive postnatal visits from a midwife at home.

Sarah is 25 and lives in Ethiopia. She is expecting her fourth baby and has 2 antenatal appointments which involve a 1 hour walk to a health centre. She delivers at home with the help of an older aunt.

  • What is the most likely outcome for Joanna and her baby and for Sarah and her baby?

  • What do you think would happen to Joanna if she had a complication during delivery? What about Sarah?

You may wish to consider who would recognise the complication. Are they trained or untrained? Who would organise transport and other provisions? If it was needed, who would provide emergency care or treat a complication?

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