In safe hands

Some 1,500 women die every day from pregnancy or childbirth-related complications, and in 2005 an estimated 536,000 maternal deaths were recorded globally. The United Nations (UN) Millennium Development Goal number five, to improve maternal health, includes the aim of reducing maternal mortality rates (MMR) around the world by 75 per cent by 2015. Sweden registered the lowest rate of maternal mortality in Europe at the beginning of the 20th century — almost one-third that of the United States — andin 2005, the country's MMR stood at three deaths per 100,000 births.

In light of Sweden's prominent positionat the forefront of maternal care, the UN andthe World Health Organisation (WHO) now consider the country a model for other nations to emulate in their quest for the 75 per cent reduction in MMR by 2015.

Sweden's low MMR has long been recognised as a source of envy among other countries.A report in the American Journal of PublicHealth, published in 2004, studied Swedish MMRs from the early 1600s to modern times and concluded that a large part of the country's success was due to its reliance on a network of highly qualified, extensively experienced midwives, capable of acting in emergencies when doctors could not be reached.

National policy

The United Nations Population Fund (UNFPA), which says that midwives can prevent up to90 per cent of maternal deaths where theyare authorised to practise their skills and playa full role in pregnancy and birth, says historical records show significant reductions in Sweden's MMR during the 1800s. It credits this success to a national policy encouraging qualified birth attendants — Sweden's first professional midwives — at all births, along with the development of a set of standards regulating quality of care.

The early midwifery system dictated that each village or community had a properly trained and regulated midwife, while nowadays — although many women give birth in a medical institution — it is still the midwife providing the care, with an obstetrician only called if medically required or in cases where the birth may be classed as high-risk.

A reliable network

While the midwifery system has developed immeasurably since the early days, and the rapid advancement of modern medicine has no doubt contributed, it seems it is still reliant on the same network of highly qualified midwives and close co-operation between midwives and doctors at all levels.

Recently, qualified midwife M.L. Hedin spent a total of four and a half years studying and training for her sought-after qualification. Beginning with a compulsory three-year nursing degree, during which all aspects of general nursing were covered, Hedin then went onto undertake the 18-month midwifery programme incorporating 50 per cent theory,50 per cent clinical and practical work and aspects such as pre- and post-natal health care support, delivery, basicneo-natal care and topics �associated with gynaecology and obstetrics.According to Hedin, a number of factors have contributed to Sweden's enviable reputationfor quality health care and its impressivelylow maternal mortality rate. "9.2 per centof gross domestic product, or almost one-tenth of total annual economic activity, is investedin health care," she says. "High taxes enablethe government to fund and continuously improve health care and senior-level midwives are also involved with doctors to setpublic health policies."

Additionally, Sweden's natural landscape and the associated demands necessitate highly competent medical care from all involved, according to Hedin. "The Swedish population can be very rural, so the midwives needto be trained to take the role of doctors and consultants in emergencies in case they cannot be reached," she says. "For this reason, midwives have a broader medical knowledge in Sweden."

Sharing expertise

With such a successful midwifery systemin Sweden, it is no surprise to see the country willingly sharing its expertise and experience with countries struggling to reduce theirMMR. According to the WHO, 99 per centof all maternal deaths occur in developing countries; the MMR in such countries is450 deaths per 100,000 births, compared tojust nine per 100,000 in developed countries.In light of this information, the Swedish International Development Agency (SIDA)is currently undertaking a programme withthe UNFPA to support three Swedish midwives in UNFPA offices in countries with a particularly high MMR. One such country is India, where SIDA is working with midwives to provide training and support, in co-operation with the Karolinska Institutet — famous for its midwifery training — and the Swedish Associationof Midwives. SIDA is also active in co-ordinating conferences around the world to highlightthe benefits of a midwife-led system andshare best practice and advice.

While recent reductions in MMR havefallen short of the UN's targets, concerted efforts such as that undertaken by Sweden — and, accordingly, countries with a high MMR following Sweden's model — should meanthe goal of achieving a 75 per cent reductionin MMR by 2015 is realistic. n

Delivery diary 

Anna Lilja, from Malmo, had her five-month-old son Per in Lund hospital, an institution she says is known in Sweden for its maternal care. "I had a very uncomplicated birth with only a midwife in attendance," she says. "If there are any complications then there are always doctors around, but I felt good that I had someone with me who only [delivered babies] and if anything had gone wrong I knew there would be a doctor there in seconds."

Lilja finds midwives in Sweden take their jobs very seriously and know exactly what they are doing, which she feels contributes to the success of the midwifery system. "It's a combination of taking the approach that birth is a very normal, natural thing, but with doctors there to help if anything goes wrong," she says.

Karin Vasen, from Gothenburg, delivered her son Elmer by Caesarian section at Danderyd hospital. "I was very relaxed and confident, which I think had a lot to do with being in a hospitalas the doctors were there in case of anything going wrong," she says. "The midwives saw [a natural birth] wouldn't work and I was happy that the best care was taken." Vasen attributes the success of Sweden's delivery system to the superior skills and knowledge of the midwives, anda general acceptance of the value of non-medical approaches to birth.

"Midwives in Sweden are first nurses and then midwives, so they are more medically aware. Also, Sweden is quite far ahead in alternative medicines such as acupuncture and [equipment such as] birthing balls — they are very open to having alternatives, [to traditional medicine] so maybe, we are more relaxed," she says.