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Midwifery centres – the what, the how, the why

Women across the globe (in low-, middle- and high-income countries) are concerned about misuse of medical intervention, and disrespectful or abusive treatment during labour and birth (World Health Organization, 2014). For example, in Mexico where the caesarean section rate is 50%, 30% of women report they have experienced ‘obstetric violence’ (Alonso et al., 2018). Whereas the poorest women in Sub Saharan Africa usually give birth at home either unattended (56%) or with a traditional birth attendant (41%), because they lack access to a skilled birth attendant, or do not think one is needed (Montagu et al., 2011). Midwifery centres – also known as birth centres – are sought by women who want to experience safe, respectful, and satisfying birth in a facility, while avoiding unnecessary intervention (Stevens & Alonso, 2020).

What is a midwifery centre?

A Midwifery Centre is a home-like healthcare facility that is guided by a midwifery philosophy of care, centred on the woman’s experience, specialising in physiological birth, with access to basic emergency care, and fully integrated within the healthcare system (Stevens & Alonso, 2020). Midwifery centres operate all over the world in over 56 countries – see map here. While midwifery centres could be key to achieving quality maternal and newborn care, there are negative perceptions about their capacity, limited understanding of what midwives do, and lack of access globally.

Midwifery centres in high-income countries

In high-income countries (e.g., Australia, Canada, United Kingdom, United States) highest-level evidence demonstrates women who plan to birth in a midwifery centre have a higher chance of normal birth, with a lower chance of obstetric intervention, and no difference in infant mortality (Scarf et al., 2018). Approximately 3% of women in Australia give birth in a midwifery centre. A study in one Australian state determined that 34% of women having their first baby, and 12% of women having a subsequent baby, were transferred from a midwifery centre and gave birth in hospital (Scarf et al., 2019). While there has been a near doubling of demand for midwifery centres in Australia over the past two decades, access has remained limited and birth numbers in midwifery centres have been static (Adelson et al., 2021).

Midwifery centres in low-income countries

In low- and middle- income countries, less is known about the outcomes associated with midwifery centre care. In these settings, there are challenges including lack of equipment, supplies, medication, blood, electricity and water; combined with difficulty transferring women to higher level care when needed either through lack of transport or women’s unwillingness to access hospital care (Munabi-Babigumira et al., 2017). Furthermore, midwifery centres in low- and middle- income countries tend to operate outside the healthcare system. Safe and respectful care, with seamless access to higher level services when required, is key to increasing access to skilled birth attendants in low- and middle-income countries; and therefore, addressing maternal and infant mortality in these settings.

How standards contribute to quality care

Without international standards, including a consensus definition of what a midwifery centre is (and is not), it is difficult to implement, monitor, evaluate and scale up.  Rigorously developed international standards guide funders, policy makers, managers and maternity advocates. It is important to be able to measure and compare outcomes between midwifery centres within and between countries, while accounting for variation in the population.

Development of international standards

Researchers Stevens & Alonso (2021) wanted to develop clear guidance through international standards to ensure the quality of care provided in midwifery centres. To do this, they initially gathered midwifery centre operation standards from the United States and Europe and compared these with international guidance on quality of maternal and newborn care, rights of childbearing women, and respectful maternity care (Stevens & Alonso, 2021). The research team analysed the documents to determine commonalities and to develop draft international standards. Next, international experts in low-, middle- and high-income settings provided feedback on the draft standards. The researchers then piloted 52 standards at 8 midwifery centres in 8 countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda, and Trinidad) (Stevens & Alonso, 2021). Discussions with the pilot sites helped determine the final list.

Assessing how midwifery centres meet international standards

The Operational Standards for Midwifery Centers are freely available here. There are 43 process standards in three domains: Dignity, Quality, and Community-Facility (Stevens & Alonso, 2021). Each standard includes indicators which can be used to measure and assess whether, and how, the standard is met. Dignity includes 13 standards that are focussed on the woman. For example, Standard 10 Every mother is informed about the benefits of supporting physiological processes, includes indicators like policy, and woman’s health record. Quality includes 13 standards that are focussed on the maternity care providers. For example, Standard 24 At every birth, there are at least two staff currently trained for emergency management of common birth complications, can be assessed through staff education logs and birth documentation. Community-Facility includes 17 standards that are about administration. For example, Standard 31 The facility has functioning, reliable, safe, and sufficient systems for each of the following: clean water, dependable energy, facility sanitation, hand hygiene, general waste disposal, and medical waste disposal, can be assessed through availability of policies and procedures.

Primary midwifery care is the solution

Some argue that universal access to high-quality obstetric care and facility-based birth is the path to address maternal and infant mortality in low- and middle-income countries (Bohren et al., 2014). From this perspective, midwives are seen as an ‘add on’ to provide emotional support during obstetric-led birth (Austad et al., 2021). An alternative solution, that would address women’s expressed desires to birth close to home, with minimal intervention, and avoid disrespectful care, would be to rapidly scale up midwifery centres that meet international standards. Primary midwifery care should be the foundation of any maternity system. Midwives need to be supported in systems and health services to deliver care and outcomes for women and babies.

Scale-up of midwifery centres

Using the term ‘midwifery centre’ instead of ‘birth centre’ may help reorient thinking about how best to organise and provide quality maternal and newborn care. In high-income settings, a midwifery centre is not a room with an armchair and a birth pool within an obstetric-led unit. Midwifery centres are midwifery-led, woman-centred – designed to promote physiological birth and enable midwives to work to their full scope of practice. In low- and middle-income settings, a facility outside the hospital that offers birth care, but is not fully integrated to enable consultation, referral and transfer to higher level services, is also not a midwifery centre. The consensus definition and operational standards can be used in any global setting to establish, monitor and scale-up midwifery centres.

Highlighted research

Stevens, J. R., & Alonso, C. (2021). Developing operational standards for Midwifery Centers. Midwifery, 93, 102882. https://doi.org/10.1016/j.midw.2020.102882

References

Adelson, P., Fleet, J. A., McKellar, L., & Eckert, M. (2021). Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016. Women and Birth34(1), e84–e91. https://doi.org/10.1016/j.wombi.2020.05.005

Alonso, C., Storey, A. S., Fajardo, I., & Borboleta, H. S. (2021). Emergent change in a Mexican midwifery center organization amidst the COVID-19 crisis. Frontiers in Sociology6, 611321. https://doi.org/10.3389/fsoc.2021.611321

Austad, K., Juarez, M., Shryer, H. et al. (2021). Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy and Childbirth, 21, 425. https://doi.org/10.1186/s12884-021-03842-1

Bohren, M.A., Hunter, E.C., Munthe-Kaas, H.M. et al. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health, 11, 71.

Montagu D, Yamey G, Visconti A, Harding A, Yoong J (2011) Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLOS ONE, 6(2): e17155. https://doi.org/10.1371/journal.pone.0017155

Munabi-Babigumira, S., Glenton, C., Lewin, S., Fretheim, A., & Nabudere, H. (2017). Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. The Cochrane Database of Systematic Reviews11(11), CD011558. https://doi.org/10.1002/14651858.CD011558.pub2

Scarf, V. L., Viney, R., Yu, S., Foureur, M., Rossiter, C., Dahlen, H., Thornton, C., Cheah, S. L., & Homer, C. (2019). Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012. BMC Pregnancy and Childbirth19(1), 513. https://doi.org/10.1186/s12884-019-2584-0

Scarf, V. L., Rossiter, C., Vedam, S., Dahlen, H. G., Ellwood, D., Forster, D., . . . Homer, C. S. E. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis. Midwifery, 62, 240-255. https://doi.org/10.1016/j.midw.2018.03.024

Stevens, J. R., & Alonso, C. (2020). Commentary: Creating a definition for global midwifery centers. Midwifery, 85, 102684. https://doi.org/10.1016/j.midw.2020.102684

World Health Organization. (2014). Prevention and elimination of disrespect and abuse during childbirth. Retrieved from: https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/