Doctor or midwife? Effectiveness of midwifery-led maternity care in Nepal

Maternity services in Nepal are led by doctors, who supervise the work of midwives. The Patan Hospital Birthing Centre (BC) uses a different approach: midwives have sole responsibility for the care of women in low-risk labour. Researchers compare BC’s efficacy with that of the Hospital’s Consultant-Led Maternity Unit (CMU).

Skilled attendance at delivery is vital for safe motherhood. The maternal mortality ratio in Nepal is 539 per 100 000 live births. Two thirds of maternal deaths happen at home and a further 11% on the way to hospital. Health professionals are present at only 13% of deliveries. Are midwifery-led services an effective way to increase the presence of skilled attendants at childbirth and to reduce maternal mortality?

The aim at the Patan Hospital is for women with uncomplicated pregnancies to deliver at BC, while those with complications will deliver at CMU. The researchers looked at the outcomes of 550 deliveries at BC and 438 at CMU to assess relative safety and efficacy.

They found that:

• 12.9% of women at BC and 14.8% at CMU develop complications during labour. The commonest problems are failure to progress, prolonged rupture of membranes and foetal distress.
• Looking at obstetric procedures, artificial rupture of membranes is more likely to occur at BC than at CMU, but use of oxytotic drugs to augment labour and episiotomy are less common.
• The incidence of meconium-stained liquor at delivery (a sign of foetal distress) is lower at BC than at CMU.
• The results are similar at the two sites for length of labour, type of delivery, birth weight and admission to the special care baby unit.
• Women at BC are more likely than those at CMU to use post-natal clinics and family planning services after their pregnancies.

Midwife-led care seems to be no less safe than physician-led services for women at low risk of obstetric complications. Many women who choose to deliver in maternity institutions have simple deliveries. The researchers suggest developing more midwifery-led Birthing Centres with facilities for referral and transfer of complicated cases to hospitals. This would cut the workload of specialist hospitals, which could then provide a better service for high-risk cases. Midwife-led care would also be suitable for other areas of the country where delivery at health facilities is uncommon. However, the Patan Hospital BC is underused. Health policy-makers could tackle this problem by:

• providing low cost, high quality services
• promoting delivery at health facilities
• developing links with the local and national Safe Motherhood programmes
• encouraging dialogue between health providers and clients.

Source(s):
‘Comparison of midwifery-led and consultant-led maternity care for low risk deliveries in Nepal’, Health Policy and Planning 18 (3): 330-337, by T. G. Rana, R. Rajopadhyaya, B. Bajracharya, M. Karmacharya and D. Osrin, 2003
'A systematic review comparing continuity of midwifery care with standard maternity services', British Journal of Obstetrics and Gynaecology 105: 1160­1170, by U. Waldenstrom and D. Turnbull, 1998
'Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?', Tropical Medicine and International Health 3: 771­782, by V. De Brouwere, R. Tonglet, W. Van Lerberghe, 1998

id21 Research Highlight: 11 February 2004

Further Information:
Geetha Rana
Health Section, UNICEF
United Nations Building
PO Box 1187
Kathmandu
Nepal

Fax: +977 1 527280/535395
Contact the contributor: gerana@unicef.org.np