BLOG: Why prevention lies at the basis of a sustainable quality care during birth

I was so lucky to be one of the one in six people globally born in a high-income setting. This meant that my first thought, when I realised I was pregnant, was one of joy.  My biggest problem was about having nausea, and I looked forward to the forthcoming birth and the idea of bringing up a healthy child. As a midwife, as well as having lived and worked in various low-, middle- and high-income settings, I am painfully aware that for many fellow women globally their first thought is not care-free as mine was. Their realistic chance of life-long injuries, psychological trauma, death of their child or their own death is very real. It happens within their community, amongst neighbours, friends or family virtually every day.  

My understanding of the importance as well as my personal passion for investing in prevention has grown with my experience and age. And to be clear, this does not mean I see it as more important than (emergency) interventions. It’s all about the right balance between investing in prevention as well as in intervention. Yet prevention needs to always stand at the foundation, and we need to be vigilant not to lose it out of sight during often more visible and sometimes even heroic (emergency) interventions, because without prevention we won’t truly move the needle forward on reducing maternal morbidity and mortality globally in a sustainable way.  

For this reason, it was such an honour to co-author a Commentary in the November issue of the Lancet Global Health ‘Prevention first, preparedness always: a holistic approach for managing postpartum haemorrhage’ (PPH), together with other thought leaders in the global maternal and newborn health space.  

PPH is the leading cause of maternal death, accounting for around 20% of all maternal deaths globally.  The statistics associated with maternal death and injury are hard to fathom. The fact alone that maternal mortality is an indicator of overall health system performance and social development is indicative of deep global inequities. So, while my chance of dying due to complications during pregnancy and birth was 4 in 100,000, the risk rises 100-fold for women in low-income settings to an average of 430 in 100,000. And evidence shows that up to 20 to 30 times more women experience lifelong injury, such as obstetric fistula, urinary incontinence, sexual dysfunction, etc. 

So why was my chance of pregnancy or birth related trauma or death so low? Why was I able to feel so safe? Was it due to the availability of quality lifesaving (emergency) interventions at birth such as caesarean sections, resuscitation of my baby or myself, or stopping excessive bleeding after birth? Part of the answer is yes, indeed these actions are necessary, they are lifesaving, and easy to measure and report. This is the reason why we often connect the maternal mortality rate to the availability of these types of interventions.   

However, when I gave birth, my chance of needing an (emergency) intervention was significantly lower than that of women living in low-income settings at the onset of my birth.  This was because of a complex combination of factors that extended further than the quality midwifery care I was able to receive before, during and after my pregnancy. For example, I enjoyed primary, secondary as well as university education and was therefore able to inform myself, I had an independent income, I had a good balanced diet before and during my pregnancy, as did my mother when she was pregnant of me, I had clean water, I was able to plan my pregnancy because I had access to contraceptives, the list of factors continues.   

Added to this I attended 12 antenatal care visits during my pregnancy. I received quality respectful care from a small team of midwives, whom I got to know and trust. My pregnancy and health were monitored, my blood pressure and haemoglobin level were checked, I knew when to call upon a midwife and was able to get to a healthcare facility that was well stocked, including quality medication. This myriad of interacting factors makes it hard to ascertain which factor contributed to what extent to my overall lower risk of harm or even dying at birth. This makes the measurement of the impact of prevention is more complex and nuanced making it harder to measure and less ‘sexy’ to communicate. This however does not make it less important. There is much wisdom in the words of W. Edwards Deming ‘The most important things can’t be measured!’ 

In simple terms you can liken the difference of the impact of prevention and (emergency) intervention like this: When there is a bumpy hazardous road that needs to be navigated, you can either organise an emergency team at the end of the road to give emergency treatment to the damaged persons at the end of the road (intervention). Alternatively, you can invest in a safer road and better navigation skills (prevention). If all attention is given to emergency intervention, the number of people that need to be treated will always remain the same. It is costly as well as traumatic for all involved. An investment in a better road, as well as better navigation skills will lower the incidence of accidents, lowering long-term costs of emergency interventions as well as the accompanying trauma.  And of course, better still is to invest in a safer road and better navigation skills as well as in an emergency team to provide quality care for the few people who will still have accidents and need emergency care. 

Not investing in a safer road and the required navigation skills seems foolish. Yet even though we know that the majority of emergencies at birth can be prevented, long term investment in prevention often comes as a second thought or gets less systematic attention, recognition and funding than investments in (emergency) interventions.    

The WHO recommends eight antenatal visits during pregnancy in the 2023 Roadmap to Combat Postpartum Haemorrhage. And in the recently published consolidated guidelines for prevention detection and treatment of PPH (ICM, FIGO, WHO), several pages are devoted to prevention. However, as the Editor in Chief of the Lancet Global Health points out in her Editorial, it assumes women receive these eight recommended antenatal visits, while most women in low-income settings are lucky to even receive one antenatal visit. And chances are that the quality of care they receive is suboptimal, because the midwives or other healthcare professionals providing care are not educated or updated to evidence based guidelines, they are often underpaid and the facilities not stocked with the quality commodities needed to provide quality care.

And this is why I will continue to plea for a comprehensive and holistic approach to care during pregnancy and birth. Every implemented intervention needs to go hand in hand with holistic preventative measures as a standard. The evidence shows that investing in midwives will provide us with this needed balanced approach, because comprehensive and holistic care is inherent to midwives. Educating more midwives as well as providing Continual Professional Development (CPD) to all midwives will be a worthwhile investment of which the return is said to be 16-fold.  

While my motivation to play my part in contributing towards positive change is only growing through time, I have also grown less willing to compromise on what I know the evidence shows, what makes such good common sense and is morally the right thing to do. Investing in maternal and newborn health is investing in future generations. We know that a good start in life for a mother and her child will support communities globally to thrive. For this to be possible we need to be bold and smart. We need to use the latest technology and integrate it with the necessary human touch.  

That is what Maternity Foundation does, and why I feel fulfilled when I come home from work. Maternity Foundation offers a free global good, by midwives, for midwives: the Safe Delivery + programme with at the core the Safe Delivery App (SDA). It supports midwives to improve their quality care for women and their babies, wherever they work. It provides evidence based micro-learning, adapted to local context such as language, and visuals. It can be used on and off-line, and most important of all the current 20 modules have a perfect balance between prevention and intervention. We have now reached 500.000 midwives and other healthcare professionals globally through our app and programme, so there is clearly a need. The SDA dashboard data, which gives insight into how, when and where the Safe Delivery App is used, speaks louder than words. This data clearly indicates that midwives themselves see the need of combining their micro-learning about interventions, such as management of PPH, with modules about prevention, such as perinatal mental health, antenatal care and contraception. Midwives on the ground understand which modules will be most impactful for them to deliver quality care. Our data shows that across the 30+ language versions, the most frequently used modules by midwives are postnatal care, antenatal care and infection prevention. Hereby I rest my case!