BIRTHING BARRIERS ACROSS THE GLOBE

Authors

Perinatal healthcare is plagued by various systemic and individual barriers both in low income countries (LIC) and high income countries (HIC).

Though barriers manifest differently based on varying health settings, perinatal health outcomes are hindered universally. It is imperative to identify and examine the current landscape to prime suggestions for the future to ensure satisfactory levels of safe, accessible healthcare during childbirth.

Personal Finance

Perinatal financing is arguably the greatest hurdle in LIC. In Sub-Saharan Africa, Caesarean sections (C-section) cost families over 10% of their average yearly income, whilst vaginal births are deemed affordable, costing approximately 1% [1].

In up to 47% of Malian households in which the mother succumbs to obstetric complications, the family incurs “catastrophic” expenditures, threatening the household’s ability to meet its needs [2]. In the United States, a country without universal health coverage, over 2 million people fall into a ‘coverage gap’ in which they do not qualify for either publicly funded Medicaid insurance nor receive Marketplace coverage through their workplace [3]. Those finding themselves uninsured predominantly live in states which have not opted into the expanded

Medicaid program - these states also offer lower minimum wages, fewer social welfare programs, and laws against abortion, further challenging pregnant women. 1 in 3 uninsured women have untreated hypertension, a risk factor for preeclampsia, intrauterine growth restriction, and other serious perinatal complications [4].

Health Literacy

Living in remote and disadvantaged areas predisposes women to poor health literacy, contributing to challenges understanding prenatal care. For example, 8.8% of Australian women smoked cigarettes during their first trimester with the vast majority of these women living in remote or disadvantaged areas [5]. Poor health literacy may also interfere with the ability of women to communicate with healthcare providers, recognise when to access healthcare services, and make informed decisions throughout their pregnancies [5].

In an attempt to improve health literacy, the USA has developed the ‘Centering Pregnancy’ program (CPP), which is a model whereby a pregnant person receives group-based care from a primary healthcare worker, such as an obstetrician or a midwife, throughout the duration of their pregnancy. The benefits of CPP are mainly derived from its group setting design, as it provides a safe space that encourages sharing of experiences and learning. This model resulted in reduced rates of preterm birth, low birth weight and maternal depression, as well as increased satisfaction with prenatal care felt by patients [6].

Tearing the Tiered System

Most LIC operate under a two-tiered model of childbirth care whereby “low risk” pregnancies are directed to primary care facilities whilst the “high risk” pregnancies are referred to advanced obstetric and neonatal services [7]. As a result, between 33-50% of births from the highest maternal mortality countries occur in community clinics where there is little recourse to lifesaving services (e.g. surgical and transfusion services) should the need for them arise [7].

Unstable Foundations

While the two-tiered model of care seems efficient in theory, it is grounded by the assumption that risk stratification is reliable. In reality, 30% of pregnancies stratified as "low risk" translate to complications in HIC; this is further exacerbated in LIC as detection of antepartum risk factors is limited by poor quality antenatal care [8].

Furthermore, the model relies on having an effective emergency referral response to hospitals in the event of a complication during childbirth [9]. Intrapartum transport in high income countries itself is challenging and reserved for necessary cases, despite travelling on reliable roads in ambulances equipped with advanced life support. The ability to refer complicated births to a hospital in a LIC setting is increasingly more risky due to the poorer infrastructure [9].

While the two-tiered system worked to minimise the barrier of access previously, recent urbanisation and reductions in travel time has enabled LIC communities in Haiti, Malawi, Nepal and Tanzania to be within 2 hours of an advanced healthcare facilities, providing better access to hospitals and consequently less reliance on primary facilities [10].

Reforming the Landscape

De-tiering the current two-tier system and concentrating all obstetric and neonatal service advancements to fewer facilities allows for the development of high-delivery volume providers who are skilled in managing rare complications. Moreover, health system reform will naturally diminish the inequalities that currently exist as wealthier women bypass the twotiered system by acquiring higher quality care at an additional cost.

Redesigning the health system is a long term objective, however, there is scope for improving community care during the transition period. One such initiative is Malawi’s ‘Birthing Companions’ program (BCP) which incorporates volunteers from the community to provide emotional, verbal and practical aid during childbirth [11]. Non-healthcare specific supports and initiatives such as the BCP cements holistic care in primary facilities, providing a better maternal experience.

Overmedicalisation of Childbirth

The private healthcare system of HIC is vulnerable to over medicalisation during childbirth, as seen in the rates of elective C-sections, which consequently hinders evidence based practice. Though the World Health Organisation (WHO) states that C-section rates should remain between 10-15% [12], it is 37% in Australia with 43-56% of planned C-sections before 39 weeks having no clinical indication [13]. Overmedicalisation of C-sections commonly leads to maternal complications (haemorrhage, excessive bleeding, endometritis, or wound infections, and newborn morbidities (impaired lung function metabolic issues, and immunosuppression) that can have longterm or life threatening consequences [14,15].

The increased C-section rates may be driven by poor health literacy regarding childbirth or coercion from the treating team for their own convenience or financial gain. In the United States, the elective caesarean section rate for African Americans is significantly higher at 36.8% compared to 32.7% for non-African Americans [16]. Although grossly over generalised, African-American women are more likely to have narrower and shallower pelvises which may complicate normal vaginal deliveries [17,18]. However, many obstetricians are prejudiced by this and push for women to elect for C-sections without individual assessment [18].

Though there are several social and structural factors contributing to poor maternal care, protecting and improving the healthcare landscape is not insurmountable. As discussed, there are several innovative initiatives that have been implemented to address particular barriers which can be further developed and adopted globally to improve the perinatal experience.

REFERENCES

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