Midwife-assisted planned home birth: an essential component of improving the safety of childbirth in Sub-Saharan Africa

Introduction

A home birth is childbirth in a nonclinical setting that takes place in a residence. Most home births in developed countries are attended by a midwife or lay attendant with varying experience in managing deliveries. Until the advent of modern medicine at the beginning of the last century, the de facto method of delivery globally was home birth. In fact, lying-in hospitals developed so that homeless women would have a place to deliver other than the street at a time when more well-to-do women delivered at home.

Since the beginning of the twentieth century, but mainly from 1930s onward, home birth rates have drastically fallen in most developed countries generally to less than 1% of all births. Even in the Netherlands where home birth rates are high, home births have fallen to below 20% from 60% several decades ago [1]. Over the same period, perinatal and maternal mortality have also decreased significantly.

There is however an emerging trend of women choosing to deliver at home in a few countries of the developed world such as the US, UK and Australia. Among the reasons women have for home birth are the desire to deliver in familiar surroundings and to avoid what they consider to be unnecessary interventions. This has created ethical challenges for obstetricians, health care organizations and policy makers, because studies especially in the US have shown increased perinatal death and injury [2], [3], [4].

The American College of Obstetricians and Gynecologists (ACOG) accepts the reported findings that there is a twofold to threefold risk from planned home birth versus hospital birth [5]. ACOG takes the view that pregnant women should be informed about this risk [5]. In contrast, the Royal College of Obstetricians and Gynaecologists and Royal College of Midwives joint statement claims that planned home birth is a safe option for many women [6]. These differences demonstrate that home birth remains controversial in the developed world [4].

Conditions in Sub-Saharan Africa (SSA) are quite different from those in developed countries. Indeed, the picture in SSA is quite gloomy: maternal and perinatal mortality are the highest compared to those in other parts of the world; there are not enough skilled health care professionals; health facilities are inadequate; most deliveries occur at home unattended; and poverty and illiteracy are rampant. Some cultural beliefs consider that hospital delivery is unnatural and alien to traditional norms and practices. Therefore, at this stage it is impossible in developing nations to immediately replace all home births with hospital births. A realistic alternative for improving the safety of childbirth is to increase the frequency and quality of attended home birth and to establish at least four basic emergency obstetric care facilities and one comprehensive emergency obstetric care facility per 500,000 inhabitants as recommended by the World Health Organization (WHO) [7].

In the 1980s, observational studies from the US, the UK and Australia all demonstrated the safety of home deliveries in a well-organized and supervised setting [8], [9], [10], [11]. In a commentary on several articles concerning the place of delivery and obstetric interventions published in 1986, it was concluded that all available evidence suggests that in carefully selected and well-supervised low risk deliveries the extra risk to the mother and baby attributable only to the absence of hospital facilities is low and the satisfaction of a successful delivery is high [12]. These studies may give impetus to the effort of finding a way to optimize the safety and quality of home birth in selected cases in SSA where circumstances may not permit hospital birth due to the many challenges described above.

Improving the safety of childbirth

Of the world’s estimated 130 million births, nearly half of the births occur at home [13]. The vast majority of home births occur in developing countries and are unattended. Systematic reviews of Maternal Newborn and Child Health (MNCH) services in developing countries have not been able to provide explanations for why usage rates of facilities remain low [14], but it is evident that the primary reasons include impact of costs, access, perceived quality and cultural preferences for home deliveries [15]. More than 70% of deliveries in developing countries are home births for economic reasons, difficulties with access to appropriate health services or cultural preferences [16]. For example, in Burkina Faso, only 34% of home births are assisted by skilled health personnel [17]. This means women give birth alone or are assisted by unskilled attendants such as untrained midwives, friends or relatives [18]. In Ethiopia, about 90% of childbirths occur at home and most are not assisted by skilled attendants [19]. This situation is much the same in other SSA countries.

Many programs were initiated and put in place such as the “Safe Motherhood Initiative” and the “Millennium Development Goals”, which are meant to screen women suitable for home births and to shift the location of births to hospitals when indicated with the aim of reducing maternal and perinatal mortality and morbidity. However, these programs have to a large extent failed to achieve a significant reduction in home births and thus a concomitant significant reduction in maternal and perinatal mortality and morbidity. Other factors militating against reduction in home births in SSA are the absence of an adequate number of health facilities in most communities and inaccessibility to existing facilities due to poor or non-existent means of transportation. Even if facilities are present and reachable, women only use them in case of severe complications [20].

In 2016, two main policy responses addressed the high numbers of unattended home births. The first is to increase facility-based services; the second is to increase skilled attendance at birth [18], [21]. Available data provide little evidence for the impact from increased supply of facilities [22] because, even where facility-based services exist, usage of those facilities remains low [14]. In this region, where targeting investment is of paramount importance to improving health outcomes, analysis of reasons for delivering outside of facilities may be primarily social and cultural [16]. Such motivations are not easily addressed through improved access to, or lower cost of delivery in, facilities [16]. Socio-cultural norms may shift over time and long-term investments in facilities may accelerate this. Meanwhile, the issues of costs and access remain important barriers to the use of facilities for giving births [16]. Three delays are analyzed to understand the barriers to achieving institutional birth: the first delay occurs with care-seeking and proper screening of women at risk, the second to arrive at a health facility (transport) and the third to receive appropriate care [23].

It has therefore been suggested that, at least in the short term, efforts to reduce maternal and neonatal deaths should prioritize community-based interventions aimed at making home births safer [16]. Such interventions include proper risk screening and those that improve the frequency and quality of attended deliveries [16]. Systematic reviews have shown that training traditional birth attendants in screening and proper methods of delivery and neonatal care can reduce perinatal and neonatal deaths and stillbirths [22]. A recent study in Tibet found that community health workers could, in fact, be effectively trained to perform uterine massage, as well as appropriate neonatal resuscitation techniques [24]. Results from a recent Global Network trial suggest that training home birth attendants (HBAs) in newborn resuscitation might reduce the number of births formally characterized as stillbirths [25]. Examining the results of controlled trials of traditional birth attendant training, the authors of a Cochrane Review summarized the limited data available by stating that there is a potential to reduce perinatal mortality through HBA training, especially when done in conjunction with building a stronger linkage to the health care system [23], [25]. Another viable approach is to train skilled birth attendants such as midwives and nurses and use them in communities with high home birth rates. Thus, in the short term at least, in those countries where women mostly give birth at home, reducing maternal mortality is likely to require expanding, strengthening and improving community-based approaches [16]. These data suggest that trained midwives and traditional birth attendants can be given special training, such as risk screening, delivery methods, postpartum care and neonatal management, and be integrated in a well-coordinated program with active community participation and a strong linkage to health care facilities to conduct delivery at home in carefully selected women.

Recommended model for midwife-assisted planned home birth to improve the safety of home births

Full community involvement should increase the acceptability and cooperation by community members. Strong linkage with nearby hospitals should enable a seamless continuity of care whenever needed. By using well-trained community midwives and traditional birth attendants to supervise deliveries at home and selecting appropriate cases for referral before or during delivery, maternal and perinatal outcomes might be improved. A trained midwife is a birth attendant who had received formal training to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications. Traditional birth attendants have no formal training in conducting deliveries and are members of the community. Community midwives should be members of the community they serve or at least understand the language and culture of the community. Registration of all pregnant women early in their pregnancies will facilitate access in the time of need. There must be a comprehensive system of proper documentation of each case to create a database to support and improve the efficacy and safety of the model.

The first stage of the proposed model involves the evaluation and risk screening of pregnant women by qualified health personnel, ideally in a hospital but also at home or a community-based center, in the first part of the pregnancy. Women with risks and contraindication for home birth should be identified in a timely manner and planning initiated for hospital birth. The evaluation will involve identification of medical diseases such as malaria, diabetes, hypertension, renal disease, sickle cell disease, heart disease, anemia and retroviral disease; obstetric conditions such as placenta previa, multifetal pregnancy and congenital fetal anomalies; previous obstetric history such as previous cesarean section, previous intrauterine fetal death, previous difficult labor, prior hemorrhage or any other condition that will increase risks during and after vaginal home birth. Basic antenatal tests should be carried out to determine maternal blood group, hemoglobin genotype, hemoglobin level, screening for retroviral disease and hepatitis. A basic physical examination of the pregnant women should be performed to determine their heights and weights and pelvic size. Prenatal ultrasound should be performed in the mid-second trimester to diagnose complications such as multiple gestations, congenital anomalies and placenta previa.

On the basis of this comprehensive clinical evaluation, pregnant women should be counseled about risks and complications and their clinical management. Women should then be educated about danger signs in pregnancy, for example, vaginal bleeding, preterm premature rupture of membranes and symptoms of preeclampsia. They should also be educated about birth preparedness and complication readiness before the onset of labor or complications occur. In addition, potential blood donors should be identified and plans for transportation should be made well in advance of the expected date of delivery.

The second aspect of the model involves scheduled home visits by trained midwives for further evaluation and, when appropriate, referral to a nearby hospital for those women who develop complications that cannot be safely managed in the home setting. These midwives should have basic equipment, such as dipsticks for testing urine, a thermometer, a sphygmomanometer, a stethoscope and a Pinnard fetal stethoscope, to enable them carry out basic patient evaluation in the course of their scheduled home visits. They should also carry with them uterotonics such as oxytocin and misoprostol and also surgical gloves and basic equipment for conducting delivery at home. Access to midwives in the community should be available 24 h a day, 7 days per week.

Even in the context of home birth, it is helpful for the attending midwife to know the relevance and utilization of the partograph. The partograph is an important tool which can be used to identify cases of prolonged labor and arrested labor. Prolonged labor adversely affects the maternal and fetal well-being. When labor is prolonged, the mother becomes exhausted and dehydrated and maternal metabolic activity is switched to utilization of fat which leads to ketosis. This in the fetus will lead to fetal distress which if prolonged may result in fetal brain damage and delivery of an asphyxiated neonate and in some cases cerebral palsy in later life. Identifying prolonged labor and arrested labor is thus paramount even in cases of home births.

To make the model effective, birth attendants should be trained to manage emergencies such as neonatal resuscitation, simple genital lacerations and postpartum hemorrhage (PPH). PPH is the leading cause of maternal death; every 7 min a woman dies of PPH worldwide [26]. All midwives and birth attendants must therefore be taught to prevent, identify and treat PPH with simple measures such as uterine massage and use of uterotonics. Approximately 25% of all maternal deaths are from PPH, a significant contribution to the burden of disease and mortality in the developing world [27], [28], [29]. Using misoprostol postpartum is an important strategy in the prevention of PPH and every midwife must know how and when to administer it. In numerous randomized trials, misoprostol given after birth has been associated with a significant decrease in acute PPH, including severe hemorrhage of >1000 mL, which is most often fatal [30], [31], [32], [33], [34]. Projects in a number of countries including Afghanistan, Bangladesh, Ethiopia, Ghana, Nepal, Nigeria, Tanzania, Zambia and others have demonstrated that antenatal care providers or community health workers can effectively distribute misoprostol late in pregnancy for PPH prevention and women can safely use misoprostol following childbirth at home [35]. A study in rural India concluded that misoprostol is a cost-effective intervention for home births [36]. A double-blinded control trial in Pakistan found a 24% reduction in PPH when trained traditional birth attendants administered misoprostol [37]. However, misoprostol can inadvertently be administered after delivery of a first twin with an undiagnosed second twin in utero. A global review of all programs that advocated postpartum misoprostol use at home birth showed that mistaken self-administration of misoprostol before birth or a serious error occurred in only seven of 12,615 (0.06%) women for whom follow-up visit data were collected. In addition, among 51 maternal deaths reported among all misoprostol users, none was attributed to misoprostol use [38]. To complement misoprostol use following delivery, women should be taught uterine massage as well as proper management of the third stage of labor, including when and how to deliver the placenta. Massage can potentially improve uterine contraction following birth thus reducing the risk of uterine atony and PPH. Community midwives can also be trained to administer the loading dose of magnesium sulfate intramuscularly at the onset of eclamptic seizures before referring the patient for further management in a hospital. It is known that at least 12% of maternal mortality is attributed to eclampsia [39]. Initiating magnesium sulfate treatment in a timely fashion can reduce maternal mortality and morbidity even when eclampsia starts at home. Other simple life-saving skills can be taught to midwives, such as the use of oral airways for patients with eclampsia before referral. Implementing the comprehensive measures of the proposed model should result in home birth that is of higher quality and therefore safer in communities where home birth rates remain very high and acceptability of hospital birth remains low.

Conclusion

During the past century, the developed world has been able to shift the location of birth from home to hospitals with dramatically improved maternal and perinatal outcomes. The developing world of less well-resourced countries has yet to achieve a similar improvement and births have remained largely confined to the home. Mainly in low-resourced countries, community-based approaches are needed to make home birth safer while effort is being made which will allow most women to deliver in hospitals in the future when conditions of both, transport, organization and professional medical care improve.

The model that we have proposed to improve the quality and safety of planned home birth in SSA does not in any way mean that hospital delivery should be discouraged but rather seeks to make home birth as safe as possible in SSA, to maximize the health benefits of limited resources and access to hospitals. The model is meant to involve communities, respect their cultural beliefs and practices and reduce maternal and neonatal morbidity and mortality by increasing the incidence of attended planned home birth and by careful case selection for home birth and referral of higher-risk cases to hospitals.

Implementing the proposed model will incur increased costs. This is a necessary expense for any low-resource country today, because there is an ethical imperative to protect the life and health of pregnant, fetal and neonatal patients [40]. In addition, such a program should be expected to result in a healthier population and increased economic productivity that should offset the cost of implementing the proposed model.