1.6 The Caregiver in Normal Birth

The birth attendant should be able to fulfil the tasks of the caregiver, as formulated earlier. He or she should have a proper training and a range of midwifery skills appropriate to the level of service. At the least, these should permit the caregiver to assess risk factors, recognise the onset of complications, perform observations of the mother and monitor the condition of the fetus and the infant after birth. The birth attendant must be able to perform essential basic interventions and to take care of the infant after birth. He or she should be able to refer the woman or the baby to a higher level of care if complications arise which require interventions which are beyond the caregiver’s competence. Last but not least, the birth attendant should have the patience and empathetic attitude needed to support the woman and her family. Where possible, the caregiver should aim at providing continuity of care during pregnancy, childbirth and post partum period, if not in person then by the way that care is organised. Various professionals can be considered to fulfil these tasks:

· The obstetrician-gynaecologist: these professionals are certainly able to deal with the technical aspects of the various tasks of the caregiver. Hopefully they also have the required empathetic attitude. Generally obstetricians have to devote their attention to high-risk women and the treatment of serious complications. They are normally responsible for obstetric surgery. By training and by professional attitude they may be inclined and indeed, are often required by the situation, to intervene more frequently than the midwife. In many countries, especially in the developing world, the number of obstetricians is limited and they are unequally distributed, with the majority practising in big cities. Their responsibilities for the management of major complications are unlikely to leave them much time to assist and support the woman and her family for the duration of normal labour and delivery.

· The general physician and the general practitioner: the theoretical and practical training in obstetrics of these professionals varies widely. Certainly there are well-trained practitioners who are able to fulfil the tasks of the caregiver in primary care obstetrics and thus in normal birth. However, for general practitioners obstetrics is usually only a small part of their training and daily duty, and therefore it is difficult to keep up the skill and to remain up-to-date. General physicians working in developing countries often devote much of their time to obstetrics and are thus quite experienced, but may have to give more attention to obstetric pathology than to normal childbirth.

· The midwife: the international definition of the midwife, according to WHO, ICM (International Confederation of Midwives) and FIGO (the International Federation of Obstetricians and Gynaecologists) is quite simple: if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife (Peters 1995). Generally she or he is a competent caregiver in obstetrics, especially trained in the care during normal birth. However, there are wide variations between countries with respect to training and tasks of midwives. In many industrialized countries midwives function in hospitals under supervision of obstetricians. Usually this means that the care in normal birth is part of the care in the whole obstetric department, and thus subject to the same rules and arrangements, with little distinction between high-risk and low-risk pregnancies.

The effect of the International Definition of the Midwife is to acknowledge that different midwifery education programmes exist. These include the possibility of training as a midwife without any previous nursing qualification, or “direct entry” as it is widely known. This form of training exists in many countries, and is experiencing a new wave of popularity, both with governments and with aspiring midwives (Radford and Thompson 1987). Direct entry to a midwifery programme, with comprehensive training in obstetrics and related subjects such as paediatrics, family planning, epidemiology etc. has been acknowledged as both cost-effective and specifically focused on the needs of childbearing women and their newborn. More important than the type of preparation for practice offered by any government is the midwife’s competence and ability to act decisively and independently. For these reasons it is vital to ensure that any programme of midwifery education safeguards and promotes the midwives’ ability to conduct most births, to ascertain risk and, where local need dictates, to manage complications of childbirth as they arise (Kwast 1995b, Peters 1995, Treffers 1995). In many developing countries midwives function in the community and health centres as well as in hospitals, often with little or no supervisory support. Efforts are being made to promote an expanded role of midwives, including life-saving skills in several countries in many parts of the world (Kwast 1992, O’Heir 1996).

· Auxiliary personnel and trained TBAs (traditional birth attendants): in developing countries which have a shortage of well-trained health care personnel the care in villages and health centres is often committed to auxiliary personnel, such as auxiliary nurse/midwives, village midwives or trained TBAs (Ibrahim 1992, Alisjahbana 1995). Under certain circumstances this may prove inevitable. These persons have at least some training and frequently provide the backbone of maternity services at the periphery. The outcome of pregnancy and labour can be improved by making use of their services, especially if they are supervised by well-trained midwives (Kwast 1992). However, for the fulfilment of the complete set of tasks of the caregiver as described above their education is frequently insufficient, and their background may mean that their practice is conditioned by strong cultural and traditional norms which may impede the effectiveness of their training. Nonetheless, it should be acknowledged that it is precisely this close cultural identification which often makes many women prefer them as caregivers for birth, especially in rural settings (Okafor and Rizzuto 1994, Jaffre and Prual 1994).

From the above account, the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications. Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:

· To make it more accessible to women in greatest need, each function of maternity care should be carried out at the most peripheral level at which it is feasible and safe.

· To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively.

· In many countries, midwives and assistant nurse-midwives, located in small health centres, require a higher level of support if maternity care is to be effectively provided for and with the community.

These recommendations point to the midwife as the basic health care provider in obstetrics delivering care in small health centres, in villages and at home, and perhaps also in hospitals (WHO 1994). Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth. However, in many developed and developing countries midwives are either absent or are present only in large hospitals where they may serve as assistants to the obstetricians.

In 1992 the House of Commons Health Committee report on maternity services was published in the United Kingdom. Among other things, it recommended that midwives should carry their own caseload and take full responsibility for the women in their care; midwives should also be given the opportunity to establish and run midwife-managed maternity units within and outside hospitals (House of Commons 1992). The report was followed by the Expert Maternity Group report “Changing Childbirth” (Department of Health 1993) with comparable recommendations. These documents are first steps towards increased professional independence for midwives in Britain. In a few European countries midwives are fully responsible for the care of normal pregnancy and childbirth, either at home or in hospital. But in many other European countries and in the USA almost all midwives (if present) practise in hospital under the supervision of the obstetrician.

In many developing countries the midwife is considered the key person in the provision of maternity care (Mad 1994, Chintu and Susu 1994). However, that is not the case in all: some face a shortage of midwives. Especially in Latin America, schools of midwifery have been closed down, on the assumption that physicians would cover the tasks. In some countries the number of midwives is declining, and those that are present are maldistributed: the majority work in hospitals in towns, and not in the rural areas where 80% of the population lives and consequently most of the problems lie (Kwast and Bentley 1991, Kwast 1995b). It is recommended that more midwives be trained, and that consideration be given to the location of the training schools so that they are easily accessible to women and men from rural areas who are thus more likely to stay in the community they come from. The training should be such that midwives can meet the needs of the communities they are going to serve. They should be able to identify complications which require referral, but if referral to a higher level of care is difficult they should be able to perform life saving interventions.