From safe motherhood to a positive birth experience – times are a-changin’

More then 30 years ago, World Health Organization (WHO) defined “safe motherhood” as a safe, healthy pregnancy and childbirth for all women in the world. The key elements of safe motherhood were set in 1987 in Nairobi, and they guided the WHO reproductive health philosophy for the next three decades: family planning, community-based maternity care, obstetric care for life-threatening complications, and social equity for women.

Romania was more or less part of this movement, and after 1989 a tremendous reduction of the huge maternal mortality (mostly due to unsafe abortion) was registered. In November 2018, the Euro-Peristat collaboration published a new European Perinatal Health Report, based on national-level indicators of mothers’ and babies’ health from 2015 in current EU member states along with Iceland, Norway and Switzerland, a total of 31 countries with over five million births^(1,2). Euro-Peristat indicator set includes 10 core and 20 recommended indicators of fetal and newborn health, maternal health, characteristics of the childbearing population, and healthcare services⁽³⁾. Member of the European Community since 2007 and the seventh largest European country, Romania is part of this report, and we are able to systematically compare our data with those from other countries.

According to this last Euro-Peristat report, in Europe stillbirth rates ≥28 weeks of gestation per 1000 total births ranged from <2.3 in Cyprus, Iceland, Denmark, Finland and the Netherlands to >3.5 in Slovakia, Romania, Hungary and Bulgaria. Greece, France, Sweden, Belgium and UK (England and Wales) registered between these extremes with rates around 3 per 1000 total births⁽¹⁾. Neonatal mortality at ≥24 weeks of gestation ranged from <1.3 per 1000 live births in Slovenia, Iceland, Finland, Norway, the Czech Republic, Luxembourg and Estonia to around 2 in The Netherlands, Lithuania, France and Latvia, and >3.2 in Northern Ireland, Malta, Romania and Bulgaria⁽¹⁾.

The 2015 report confirms previous Euro-Peristat findings, revealing marked disparities in preterm birth rates and trends in Europe⁽⁴⁾, and stresses the need to understand these differences between countries. In this regard, the European median preterm live birth rate in 2015 was 7.3%, but ranged from <6% in Finland, Latvia, Estonia, Sweden and Lithuania to >8% in Belgium, Scotland, Romania, Germany, Hungary, Greece and Cyprus⁽¹⁾. An apparent small 2% difference is in fact substantial, representing over 77,000 fewer preterm children, if all European countries were able to reduce their preterm birth rates to at least 6%.

Euro-Peristat data suggest that change is possible. Overall, preterm birth rates in 2015 did not differ from those in 2010, but this obscures significantly lower rates in six countries (The Netherlands, Austria, Czech Republic, Spain, Sweden and Germany), and significantly higher in others (Italy, Portugal, England and Wales, Poland, Ireland, France, Cyprus and Scotland)^(1,4). Understanding what drives these changes is an important public health priority.

Caesarean rates are another hot point in the Euro-Peristat report. Disparities in caesarean section incidence have widened, with rates reaching very high levels in some countries, including Romania. The European median caesarean birth rate in 2015 was 27%. It ranged from <18% in Iceland, Finland, Norway and The Netherlands to >30% in Slovakia, Ireland, Malta, Germany, Scotland, Luxembourg, Portugal, Switzerland and Italy. The highest rates were in Hungary (39%), Poland (42.2%), Bulgaria (43%), Romania (46.9%) and Cyprus (56.9%)⁽¹⁾. On average, the rates in 2015 were 4% higher than in 2010, but this includes larger increases in Romania (from 36.9% to 46.9%), Poland (from 34% to 42.2%), Hungary (from 32.3% to 39%) and Scotland (from 27.8% to 32.5%), and decreases in Lithuania, Latvia, Portugal, Estonia, Italy and Norway⁽¹⁾. The Romanian caesarean rate (46.9%) must be regarded as huge by any standards, and a comprehensive analysis of all the factors involved is mandatory as soon as possible.

On the other hand, the 2018 United Nation Global Strategy for Women’s, Children’s and Adolescents’ Health seeks to ensure that not only will women survive childbirth complications if they arise, but also that they will thrive and reach their full potential for health and life⁽⁵⁾. In line with this objective, this guideline brings together existing and new recommendations that address not only the clinical requirements for a safe labour and childbirth, but also meet the psychological and emotional needs of women. It aspires to ensure that women give birth in an environment that, in addition to being safe from a medical perspective, also allows them to have a sense of control through involvement in decision making and which leaves them with a sense of personal achievement.

Adopting a woman-centred philosophy and a human-rights based approach opens the door to many of the care options that women want, such as the right to have a companion of choice with them throughout the labour and birth, as well as the freedom to move around during the early stages of labour and to choose their position for birth. These recommendations are all evidence-based, optimize health and well-being, and have been shown to have a positive impact on women’s experience of childbirth⁽⁵⁾. In addition to providing the clinical care specific to labour and childbirth, healthcare facilities also mean making sure that women are treated with respect and that they have the very basics of oral fluids and food during labour and childbirth. The continuity of care, the regular monitoring and documentation of events, as well as clear communication between medical practitioners and clients are essential, along with ensuring a referral plan when more advanced medical care becomes necessary. All these are essential elements of good quality labour and childbirth care that every woman and her baby should receive⁽⁵⁾.

We can conclude that in 2019 in Romania motherhood and childbirth are as safe as in other European countries. But times are a-changin’, and we must move forward from “safe” to the next level of care, based on best available medical evidence and on our patients’ values.  

Conflict of interests: The authors declare no conflict of interests.