The Covid-19 virus is slowly making its way around the world and hospitals pregnant women and families are worried about birthing at hospitals that might be treating infectious patients.

In many countries are cancelling non-essential surgeries to make space for a possible influx of infectious patients. This rational response will save resources, healthcare staff and space for patients that may be very sick over the next few weeks. But what about non-essential hospital births? Should the public health response include moving care for women with normal pregnancies outside of the hospital setting, to homes, birth centres and community health facilities where there risk of exposure to Covid-19 is lower? 

Changes over the past fifty years

Emergencies like global pandemics, natural, humanitarian and other crises magnify the vulnerabilities in our healthcare systems – this was clear during the Ebola outbreak and epidemic in West Africa (Jones et al., 2017) and during the 2004 earthquake and tsunami in Indonesia and other countries in South-East Asia (Carballo, Daita and Hernandez, 2005). Sweeping changes in maternity care systems in high- and mid-resource countries have embraced high-intervention methods and technology without the balance of midwifery (Renfrew et al., 2014), and are more vulnerable as a result. 

Facility-based birth

In many countries, public health messaging and funding has emphasised hospital facility-based obstetric care as the most important solution for improving maternal health and survival, although the evidence has shown that the safest and most sustainable type of care for the majority of women and babies is a midwifery-led service with timely access to emergency services as necessary (Miller et al.,2016). By moving the majority of births to hospitals, midwifery care and birthing at a community facility, birth centre or at home has come to be seen as an “alternative” instead of the norm. Governments have been closing rural and community maternity services and putting up barriers to the work of midwives in an attempt to save money by centralising care (Andrews, 2016), effectively creating “maternity care deserts,” even in high-resource countries like the United States (Porter, 2020). In emergency situations like the outbreaks of contagious diseases, women may not want to attend hospitals to give birth for fear of infection – for example, during the Ebola epidemic, facility births decreased by 20% in Sierra Leone (Carballo, Daita and Hernandez, 2005). All the while, the government ignored what was going on and continued encouraging “safe births in healthcare facilities” as opposed to investing in outreach or community programs (Carballo, Daita and Hernandez, 2005). 

While there are women that do need specialised care at some point or throughout their pregnancy, birth and postpartum journey, evidence has shown that interdisciplinary care integrated across hospitals and community settings that includes midwifery provides the best outcomes for mothers and babies (Renfrew et al., 2014). More than this, midwifery-led services with access to emergency services as needed have proven to give the best outcomes and lowest rates of intervention, for the lowest cost (Miller et al.,2016), especially important to consider during an emergency where resources are limited and rationed.

Too much, too soon

The overuse of technology and interventions has ballooned over the past two decades and case studies from Brazil, China and India have shown that health systems that are quickly developing are more likely to adopt maternity care systems that rely heavily on medical interventions, without balancing them out by integrating midwifery (Renfrew et al., 2014). In countries as diverse as Greece, Egypt, Turkey, Iran, Brazil and Mexico one in two women give birth through surgery, and a rate of one in three women has become normal in high-resource countries (McCarthy, 2018). With so much technology and so many surgical births, effective low-tech skills that were once common, like palpating a woman’s belly to feel where her baby is, or helping a woman bring twins, or a breech baby into the world vaginally, are lost. 

The drawbacks of these short-sighted policies and changes in practice become clear in emergency situations – when resources  or staff are severely rationed or not available, when there is no electricity. During a natural disaster or epidemic having midwives available to serve women with normal pregnancies and births in their homes or in community or improvised facilities can free up beds and resources in hospitals that find themselves overwhelmed or under-resourced. 

Workforce shortages and sustainability

In 2013, the World Health Organization estimated that there is a global shortage of 350,000 midwives (More midwives needed to improve maternal and newborn survival, 2013) – this is evident in high and low resource countries alike (Campbell, 2017; Williams, 2018). In emergencies, this is more obvious – during the 2004 tsunami in South-East Asia, the region lost 30% of its midwives (Carballo, Daita and Hernandez, 2005). Countries like Haiti, with severe midwife shortages, need to train 2200 midwives over the next few years and are implementing innovative solutions to achieve this. These  include opening satellite schools to educate midwives that will work in dedicated birth centres located throughout the country and accessible to women in rural and urban areas (Williams, 2018).

No matter the outside circumstances there will always be pregnant and birthing women –

and we can’t postpone our births until the crisis is over. 

The Way Forward

Midwifery care has been proven effective in extraordinary and disaster situations – in Indonesia, after the 2018 earthquake (Cooper, 2018), during the refugee crisis in Greece (Andrews, 2016), providing care to uninsured refugees in Canada (Handa, 2017).  Midwives also provide other essential reproductive health services, from abortion to management of miscarriage, contraception and sexually-transmitted disease treatment. Maintaining a strong, skilled and well-supported midwifery workforce, working in communities, at birth centres and in homes is vital as part of a response to every emergency situation. Some ways we can do this include:

• Increasing and retaining the global midwifery workforce using innovative, evidence-based methods;
• Introducing evidence-based midwifery education programs in smaller cities;
• Including midwives in planning, developing and implementing midwifery training, human resource and education programs;
• Engaging the expertise of midwives in planning, developing, implementing and evaluating emergency and disaster services, but also in rebuilding health systems after disasters;
• Including maternity care in emergency planning;
• Ensuring that midwives have the regulatory framework and skills to work autonomously in hospitals, community facilities and in the home;
• Policy and healthcare planning that ensures the existence of small maternity services and home birth, with an ambulance system to be used when needed.

Special thanks to Nicholas Rubashkin and Heidi Dahlborg for their input and comments on this piece.

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