We previously compared the United States and rural Ethiopia. Originally I was going to post this as a “Birth in Two Nations” blog but I found that Ila’s story was related to more than one country and circumstance. I was reminded of the story of Monique’s friend in Monique and the Mango Rains while reading the first block quote from Ila. Firstly, she worked all the way up until her pregnancy. This was just like the case in Mali, however, Ila found rest for a month after giving birth whereas the women in Mali were not so lucky. Though it was urged that they take a break, the duties of life usually did not allow for this. At first I chucked this up to the fact that in South Calcutta Ila had her in-laws to help but in Mali the woman may live with her in-laws but she was expected to serve them as well as opposed to being served by them.

Secondly, I drew a parallel to American births when Ila made mention of a nurse doing all the check ups but a doctor delivering the baby. We discussed this in class while talking about the pros and cons of hospital birth. Though her birth took place in a nursing home (which I took to be similar to a birthing center) it still seemed to have the level of intimacy of a hospital which is low. More autonomy is removed in not being told the sex of the child before birth even if you would like to know (though this is probably in the best interest of the child as girls may have been aborted).

Lastly, I drew a relation to Adaora’s presentation. Indian has several religions and Ila’s wasn’t stated but I wonder what role religion had in her birth process. As Adaora stated for the Hausa of Northern Nigeria, the Muslim religion had an effect on what medical care a woman in labor could receive. For Ila it did not seem to matter the gender of the health professionals but the husband nor his parents were allowed to be present. However, her male relative was the one who brought her to the nursing home (which would have also been the case for the Hausa). I found it quite interesting how this story seemed to have bits and pieces of the different cultures we had discussed, a perfect example of the crossroads developing India finds itself, between a grasping onto of the traditional and a deserve for new Western ways of doing things.

The reading about pregnancy and birth in Rajasthan from “Reproductive Agency, Medicine and the State” gave a new perspective about pregnancy and the relationship a baby has with its family, in particular the mother. While many of our readings have spoken to how in many societies males are central to the decision making, I found it very interesting how in this culture they not only decided when and what medical attention was sought out, but the relationship between the mother and the baby. Interestingly though babies here are not considered a real person until they are born; in contrast to Western societies where fetuses are often times considered part of the family before the 2nd trimester. However, it is noted that this is because of the high rates of miscarriage and infant mortality in Rajasthan. Here, women are considered to be the “vessels”  for the baby and the men are the “creators” putting more importance on them, furthering the nurturing roles of women in the society. As we have heavily discussed how the head male’s dominance has greatly influenced seeking medical attention in birth there has been little on how a mother see’s the pregnancy and the relationship of seeking medical attention. I have found this perspective of a baby being a “non-person” to be a new insight to this relationship. Mother’s were less inclined to seek medical and prenatal care until they felt the pregnancy would come to term. I feel it is very important to considered cultural aspects like this even though it is still linked to the issue of male dominated society. Education is still the root to improving pregnancy and infant mortality rates. This reading really shows that it is not only important to educate midwives and skilled attendents but educate the mothers. The more they know the more inclined they may be to help/make better decisions about the pregnancy.

        Reading in “Maternal & Child Health” regarding the balance of tradition and midwifery in Guatemala opened my eyes to the reality of giving birth in other nations outside of the United States. While most Americans seek modern technology before, during and after pregnancy and childbirth, this is not the case in many less developed and economically struggling nations. Notably, I was surprised to find that although approximately 71% of births in Guatemala are attended by midwives, a high percentage of these personnel do not meet WHO or UNICEF criteria for skilled birth attendants. When reading the statistic about having midwifes attend the majority of births, I was under the influence that because of this the nation’s infant and maternal mortality rates must be lower than in other nations without the help of birth attendants. However, as the chapter points out Guatemala is among the highest in maternal and infant mortality rates in the Western Hemisphere.  The initiatives taken in the nation helped to train midwives in proper techniques, acknowledging signs of obstructed labor, and help to reduce these rates. One concept I found interesting was the need for support given to midwives, in return for the support they give to pregnant women and their families. For this reason the program Midwives for Midwives was developed, giving them an area for open and honest communication for the work they do and how it affects them. Looking more into this program, I found that between 2007 and 2010 a total of 450 midwives were trained in Guatemala. I find this statistic very hopeful for the future, and the possibility of sustaining the work and dedication numerous health officials have shown the region.

Source: http://www.midwivesformidwives.org/about-us

It was really disheartening to hear about all the issues that rural women and birth attendants in Guatemala face. After reading the second chapter of MCH, I realize that I still have much to learn with how birth looks in different parts of the world. I am aware that not everywhere is going to have hospitals, birthing centers, or even skilled attendants handling the births.  That written, I did not think about a place where so little is known about birth, even those who are seen as the authorities on birth. Most of the examples of birth that take more of a cultural approach that we have seen knew for the most part the basics of pregnancy. For instance, the movie we watched with the black midwives, although the material used might not have been as advanced as a hospital they were extremely skilled and knowledgeable about how pregnancies should go and how to handle emergencies. Same thing goes for Monique in the book we read, even though the setting was rural and she lacked a lot of tools and medication she was skilled in what she was doing when it came to delivering a child. So, with reading this chapter it makes me wonder how the black midwives and Monique got to be so skilled. I am aware the aforementioned characters most likely went through extensive training and assisted on births before becoming so adept- but who taught their teachers? What I am asking is, how does that cycle start? How can you begin a tradition of being aware of things like a fetal heart rate, or what to do during hemorrhage and pass it down? Assuming there are no interventions such as MFM or the like. While pondering this, I came across the idea of an established tradition of birth is what the previous examples had and what the women in Guatemala lacked. I am sure no one came in and had a program of how to teach Monique’s predecessors, as that is not the norm in many parts of the world. In Guatemala, from what I have read, it appears there is really no tradition of birth, like in New Zealand where the community aspect of birth was extremely heightened. I did not get the same sense of the birth of a child being a community experience or really any experience. It seemed that there are traditional midwives who tend to those who are far removed from hospitals but nothing much past that. There are many factors that contribute to this such as illiteracy, no formal training, and the extremely low regard women are held in. I think having such a pronounced low place in society contributes heavily to poor maternal and fetal outcomes. So more community and better appreciation of women could be a solution outside of intervening and just bringing in technology and education.

There are  advantages and disadvantages of giving birth at home, in a birth center, and in a hospital. It can be argued that a hospital provides a safe environment because expert medical help is available should unexpected interventions be needed during the birth process and there are a variety of pain relief options (Nice, 2007). However, women who give birth in a hospital are also more likely to receive some form of medical intervention and many may not be able to relax as well or have as much autonomy because they are in an unfamiliar environment (Wickham, 1999).

Contrasting hospital birth is the idea of giving birth at home. A home birth can be empowering because it allows a woman to labor in the comfort of her own, familiar environment. This may allow a woman to be more relaxed, mobile, and comfortable to do as she pleases throughout labor (Wickham, 1999).  Women are also less likely to have unnecessary interventions if giving birth at home (Oleson, Clausen, 2013). However, there is also the concern that if an emergency arises that there will be a delay in care because the woman must transfer to a hospital.

Lastly, birth centers seem to provide a middle ground between the two extremes of giving birth in a hospital or at home. Birth centers can provide a safe and home-like place for women to give birth and received prenatal and postnatal care, but usually have more resources and may provide quicker transfer to a hospital should an emergency arise (White, 2014).

In the summary of the Chapter 11 case study, “Providing a Safe Space for Birth in Warkworth, New Zealand” the author writes, “…there is no one thing that promotes a positive birth experience for women and their families, but rather an interconnected weaving of many things. Commitment is the common ingredient” (White, 2014).  I believe this is an incredibly profound statement that ultimately sums up what our class agreed upon after our discussion on birth location. All of the previously mentioned advantages and disadvantages of different birth locations only skim the surface of the issues revolving around birth and birth location; as birth is such a unique experience for every woman. This is why I believe that our goal should not be to decide which birth location is best, as this will clearly vary, but to commit to perfecting each of these options so that they are safe and accessible to all women.

Sources:

Nice. 2007. Intrapartum Care – care of healthy women and their babies during childbirth. National Institute of Health and Clinical Excellence. Clinical Guideline 55. London: NICE. www.nice.org.uk

Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD000352. DOI: 10.1002/14651858.CD000352.pub2.

Symthe, L., Payne, D., Wilson, S., Wynyard S. (2014). Providing a safe space for birth in Warkworth, New Zealand. In White R. (Ed.), Global Case Studies in Maternal and Child Health (pp. 187-208). Seattle: Ascend Learning Company.

WIckham, S. (1999). Homebirth: What are the issues? Retrieved 2014, from Midwifery Today: www.midwiferytoday.com/articles/homebirthissues.asp

I really enjoyed our debate on the very controversial issue of where women should give birth.  I feel that the birthing center has the strongest argument as the ‘best of both worlds’ as far as having aspects of both hospital and home birth, in both developed and undeveloped countries. In birthing centers, there are certified midwifes who not only can manage many complications, but can also provide the support and confidence that women need – thus providing holistic care.  A birthing center can have a ‘home-y’ feel where women can experience childbirth as an emotionally and culturally meaningful life experience like they would at home, rather than in a place associated with sickness.  In addition, giving birth in the hospital costs a lot of money, introduces infants to many pathogens, and results in far more interventions than are needed, which has negative effects on both the mother and infant.  The birthing center can eliminate all of these negatives, while also having a referral plan to transfer women to a hospital if a rare but serious complication should occur. New Zealand has a beautiful model of culturally-appropriate midwifery care in birthing centers that is extremely effective (Smythe, 2014), and I think it would behoove the rest of the world to follow their example. In undeveloped countries—where choice may be an ‘illusion’ as hospitals are far away, understaffed, or lacking equipment—it is all the more essential that more birthing centers are constructed.  In the US, as more birthing centers are being established, the public also needs to be more educated in an unbiased manner on all the different options out there for birth.

Symthe, L., Payne, D., Wilson, S., Wynyard S. (2014). Providing a safe space for birth in
Warkworth, New Zealand. In White R. (Ed.), Global Case Studies in Maternal and Child Health (pp. 187-208). Seattle: Ascend Learning Company.

While I was reading the maternal and child health chapter about Haiti about healthcare services and costs. The chapter pointed out that women in Haiti felt healthcare services (including those pertaining to birth) should be free of charge. Conversely, the healthcare workers had the notion that payment is important because the services would be rendered worthless (179). This was a really striking statement and I personally do not really understand it. If you provide a service for free, especially one as beneficial as healthcare or maternal care I do not see that as detracting from its value. If one thinks about the terrible rates of mortality Haiti has for health issues brought on by poverty its interesting that free services making things worth less is the mindset of health workers. These health care workers are in direct contact  with poverty and see the effects of it as well as insufficient maternal care everyday. This also speaks to a bigger issue, which relates to infrastructure. This ideal must be something that is being taught among healthcare professionals  or a conclusions drawn sparked by misconception and a break in communication between workers and mothers. Whatever it is something that needs further consideration outside of this project. I say this because this project sponsor made sure to have pre-natal services and the like provided for free, which is nice for those in Torbeck Plain but what about those living in other areas with the same fee for value system? Finding some common ground on maternal care costs and needs are essential. The progress of women being able to properly take their children to term, survive the birth, and raise the child into adulthood are dependent on things like healthcare workers and fees in rural areas.

Deciding where to give birth is very personal decision, but it is dictated by societal influences, such as socioeconomic status, availability to different types of care, and geographic location. Oftentimes, women don’t have the freedom to choose where to give birth. For example, women in rural or low-income areas may not have access to hospital birth. On the other hand, many women in places where birth is largely medicalized- such as the United States- do not know that they have options outside of hospital births or do not have access to alternative birth locations. Women should be provided with multiple options during their pregnancy, so they can decide what may be best for them. There are advantages and disadvantages for each birth setting, and because each woman and experience is different, we should not generalize and state that one birth setting is best for all women.

Home birth

Advantages: comfort in one’s own home, ability to eat, drink, and move freely, ability to choose in what room and position to give birth, often more affordable than hospital birth, fewer interventions (http://www.cdc.gov/nchs/data/databriefs/db84.htm)

Disadvantages: possible delay of emergency medical care, limited access to pain-relieving drugs, may not be covered by insurance, not available to women deemed “at risk”

Hospital birth

Advantages: close access to medical care, full staff available to attend the birth, open to patients of all medical backgrounds

Disadvantages: no drinking or eating, movements limited, labor is often rushed, likeliness of intervention increases, standard birth position on back, lack of informed consent, requires travel, expensive

Birth center birth

Advantages: freedom to eat, drink, and move, rooms designed for specific types of birth (water birth, etc.), multiple trained staff available, ability to choose position, fewer interventions, more drugs and technologies on hand than home birth

Disadvantages: requires travel, possibly delay of emergency medical care

Note that many of these disadvantages and advantages depend on the individual birth setting and caregivers and that this is a general composition.

There should not be laws that dictate where women give birth. Instead, women should be trusted to make their own medical decisions based on what is best for them. However, there should be laws (or lack thereof) that ensure that women have access to a variety of types of care during birth. Thus, hospitals should be regulated to ensure that women of all income and geographic settings could access them. Also, currently, 28 states prohibit the practice of Certified Professional Midwives, who most often attend homebirths (http://mana.org/about-midwives/legal-status-of-us-midwives). In addition to legal advocacy, it is important to advocate for a larger change to the system that tells women that 1) they are not competent enough to choose where and how to give birth and 2) medicalized (hospital) birth is the only way to give birth.

Sources and additional information:

http://www.cdc.gov/nchs/data/databriefs/db84.htm

Summary and statistics about home birth in the US

http://mana.org/about-midwives/legal-status-of-us-midwives

An explication of the legal status of midwives in the US

http://www.theatlantic.com/health/archive/2014/10/why-american-babies-die/381008/

I recently read this article and found it very pertinent to our class, and to what I want to use in presentation. The article states how the United States is ranked 56 in the world in infant mortality and sandwiched between Serbia and Poland, which I personally found surprising as I figured the US would be lower, but I didn’t think that low.

The article states however that the US has lower neonatal death rates than Finland and Austria (two countries with low infant mortality rates) but relatively high postneonatal rates. So the problem is not when a child is born and is in the hospital and when they immediately get home, but later on.

But the one paragraph I found most interesting was this:

“The effects of socioeconomic status on health have been well-documented, and infant mortality is no exception: Unsurprisingly, the states with the highest rates are also among the poorest. “IfAlabama were a country, its rate of 8.7 infant deaths per 1,000 would place it slightly behind Lebanon in the world rankings,” Christopher Ingraham recentlynoted in The Washington Post, while “Mississippi, with its 9.6 deaths, would be somewhere between Botswana and Bahrain.””

The comparison to Botswana and Bahrain really puts the global problem of infant mortality in perspective in that it is a global problem which includes the United States. This article ultimately suggest how one must look critically at health statistics, but certainly for something as complex infant mortality.

The viewpoints offered in  Born in the USA  and A Walk to Beautiful are important to understanding the underlying factors that contribute to health outcomes for women and their children in different settings. Perhaps the starkest contrast in these films is access to medical care available to the mothers. The young mother’s in Ethiopia had to travel many hours to reach a hospital. It is likely that most women in these areas are not receiving any type of prenatal care, and have probably not received much medical care for most of their lives. This compounded with the fact that many of these girls are stunted due to lack of access to necessary nutrition, and the young age of many of the mothers the first time they give birth creates a perfect storm of risk factors. A study conducted in 2010 found that the major contributing factor to maternal death in rural southwest Ethiopia was a lack of referral care for mother’s in distress during pregnancy. This was due to the fact that families often did not understand the severity of certain situations because conditions such as fever, dizziness, and pain are considered normal during pregnancy.. Of the 94.4% of births that occur in the home in Ethiopia, 67.5% are attended by untrained neighbors, 20.5% untrained relatives, and 4.7% traditional birth attendants (Deribe et al, 2010). On a policy level, many of these issues could be addressed through the extension and improvement of the capacity of frontline health workers and midwifes. These individuals could attend to women and provide prenatal care, catching warning signs in early stages when they can hopefully be attended to without the amenities of a large hospital. They would also be present to help the mother’s during birth, better equipped to respond to difficulties in labor than an untrained neighbor or family member may be. They could also lead educational efforts focused on maternal and newborn health care. If mother’s and communities have a deeper knowledge of their bodies and their needs during pregnancy they will hopefully be empowered to have a healthier pregnancy. Extension of education on newborn care would hopefully promote better nutrition for newborns which could help to prevent stunting and lead to better health in the future.

The U.S. seems to be confronting the opposite end of the spectrum, over medicalization of the process of child birth. Opposite to what I expected when I first learned about infant and maternal mortality rates in the U.S., the over emphasis on medical care has not led to better outcomes. Despite spending more on medical care than any other country in the world, the U.S. ranks 50^th in maternal mortality and the rates have increased 25% since 1998 (Amnesty International, 2010). According to a report released by the Foundation for the Advancement of Midwifery, many women in the U.S. do not understand the options available to them when giving birth. A hospital is seen as the safest place other options are not explored. Many American women are taught to be afraid of the natural pain that accompanies childbirth. Epidurals to treat pain slow labor, leading to the use of pitocin to push the labor along (Foundation for the Advancement of Midwifery, 2013). These conflicting events push many women to expensive and invasive cesareans that may not be necessary. The high cost associated with child birth in the U.S. has another affect. African American women are four times more likely to die in child birth than any other race. A study done by Amnesty International showed that many African American women cannot afford the care they need during pregnancy and childbirth. Insurance companies turn these women away, and many doctors don’t take Medicaid (Amnesty International, 2010). The first and what I believe the most important policy that needs to be implemented are programs like the Affordable Care Act that will ensure that women have guaranteed lifelong access to quality health care. Policies that support the advancement of the visibility of midwifes could help alleviate many of the problems that are faced. Extending midwifes would cut down on hospitalization, the use of unnecessary cesareans, and provide excellent care at a fraction of the price.

Amnesty International. (2010) Deadly Delivery: The Maternal Health Care Crisis in the USA. http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf

Kebede Deribe, Sibhatu Biadgilign, Alemayehu Amberbir, Tefera Belachew, Kifle Woldemichael. The Road to Maternal Death In Rural Southwest Ethiopia. Ethiopa J Health Sci. 2010 March; 20(1): 71–74.

Foundation for the Advancement of Midwifery. (2013). The Pregnant Elephant in the Room:The U.S. Maternity Care Crisis.  http://www.gih.org/files/FileDownloads/US_Maternity_Care_Crisis_FAM_October_2013.pdf