Sustainable Birth in Disruptive Times

Springer (Verlag)
  • erschienen am 9. Januar 2021
  • |
  • XVI, 296 Seiten
E-Book | PDF mit Wasserzeichen-DRM | Systemvoraussetzungen
978-3-030-54775-2 (ISBN)
This contributed volume explores flexible, adaptable, and sustainable solutions to the shockingly high costs of birth across the globe. It presents innovative and collaborative maternity care practices and policies that are intersectional, human rights-based, transdisciplinary, science-driven, and community-based. Each chapter describes participatory and midwifery-oriented care that helps improve maternal and newborn outcomes within minoritized populations. The featured case studies respond to resource constraints and inequities of access by transforming relations between providers and families or by creating more egalitarian relations among diverse providers such as midwives, obstetricians, and nurses that minimize inefficient hierarchies within maternity care. The authors build on a growing awareness that quality and respectful midwifery care has lower costs and improved outcomes for child bearers, newborns, and providers. Topics include: Sustainable collaborations including transfers of care among midwives and obstetricians in India, The Netherlands, Germany, United Kingdom, and DenmarkMidwifery-oriented, femifocal, indigenous, and inclusive models of care that counter obstetric violence and gender stereotypes in Mexico, Chile, Guatemala, Argentina, and India Doula care and midwifery care for women of color, previously incarcerated women, indigenous women, and other minoritized groups in the global north and southPractices and metrics for improving quality of newborn and maternal care as well as maternal and newborn outcomes in disruptive times and disaster settings Sustainable Birth in Disruptive Times is an essential and timely resource for providers, policy makers, students, and activists with interests in maternity care, midwifery, medical anthropology, maternal health, newborn health, obstetrics, childbirth, medicine, and global health in disruptive times.
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Kim Gutschow, is a Lecturer in Anthropology and Religion, and affiliated with Public Health, Asian Studies, and Women's, Gender, & Sexuality Studies, at Williams College in Williamstown, Massachusetts, where she has taught since 2003. She has published over 35 articles on maternity care, maternal death reviews, and counting maternal mortality in India and the United States; as well as on the gender dynamics and discourses of Buddhist monasticism, Tibetan medicine, community-based irrigation, and land use practices in the Indian Himalayas. She is the author of Being a Buddhist Nun: The Struggle for Enlightenment in the Indian Himalaya (Harvard 2004), which won the Sharon Stephens Prize for best ethnography (2005). Her collaborative research projects with Ladakhi teams have received several awards including a Humboldt Fellowship for Experienced Researchers (2009) for Birth: From Home to Hospital and Back Home Again; a National Geographic Explorer Award (2019) for Climate Change Adaptation: By the People, For the People, as well as funding from the Harvard Society of Fellows (1997-2000) and the German Research Council (Deutsche Forschungsgemeinschaft). She raised $100,000 to fund appropriate technology, passive solar design, and other projects with and for Zangskari women via the Gaden Relief Zanskar Project between 1991-2015.
Robbie Davis-Floyd, PhD, is Senior Research Fellow in the Department of Anthropology, University of Texas at Austin, and Fellow of the Society for Applied Anthropology. She is a well-known medical anthropologist, midwifery and doula advocate, and international speaker and researcher in transformational models in maternity care. Robbie is author of over 80 journal articles and 24 encyclopedia entries, and of Birth as an American Rite of Passage (1992, 2003) and Ways of Knowing about Birth: Mothers, Midwives, Medicine, and Birth Activism (2018); coauthor of The Power of Ritual (2016); and lead editor of 13 collections, including the award-winning volumes Childbirth and Authoritative Knowledge (1997) and Cyborg Babies (1998); and the "seminal" Birth Models That Work (2009). Her most recent collection, co-edited with Melissa Cheyney, is Birth in Eight Cultures (2019). Birthing Models on the Human Rights Frontier: Speaking Truth to Power, co-edited with Betty-Anne Daviss, is in press. As a Board Member of the International MotherBaby Childbirth Organization, Robbie served as Lead Editor for the International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care (a joint IMBCO/FIGO global initiative). She presently serves as Lead Editor for a Routledge series called "Social Science Perspectives on Childbirth and Reproduction," and as Senior Advisor to the Council on Anthropology and Reproduction.
Betty-Anne Daviss, MA, BMJ, RM (Registered Midwife), has served as a midwife for 45 years practicing in various countries on six continents, and as a researcher in the social sciences and clinical epidemiology for over 25 years. She is an Adjunct Professor in Gender and Women's Studies at Carleton University, Ottawa, in Ontario, Canada, and has taught since the 1980s on reproductive issues and the politics of gender and health, while working towards midwifery legislation in North America and abroad. She co-authored the large prospective home birth study of Certified Professional Midwives in North America published in the BMJ (2005) that continues to be accessed 500-800 times a month; the World Report on Postpartum Hemorrhage, when she worked for the International Federation of Gynecology and Obstetrics (FIGO) (Lalonde et al 2006), which continues to be used with updates; and was the co-principal investigator and principal writer for the Frankfurt study comparing vaginal breeches born with the mothers on their backs vs. in upright positions (Louwen et al. 2017). The only midwife in Canada in the last two decades to have achieved official hospital privileges to attend breech births without a transfer to obstetrics, Betty-Anne has been involved with over 170 planned vaginal breech births, and provided workshops, rounds, and/or plenaries on vaginal breech in Europe, Africa, North and South America, China, India, Australia, and Turkey. She has testified for 10 midwifery hearings/court cases and 11 state and 3 provincial legislative processes.
Foreword Sustainable Reproduction Marcia Inhorn, Yale University Departments of Anthropology & Global HealthInhorn situates the volume in the emergent literature on how sustainable birth ties into broader efforts to make reproduction more sustainable, accessible, and founded in human rights. The Foreword situates a focus on sustainable birth within broader efforts to increase access to reproductive rights maternity care and reproductive rights.

Introduction -- will need to be Ch. 1 Sustainable Birth Across the Globe: Solutions, Obstacles, and Challenges Kim Gutschow, Robbie Davis-Floyd, and Betty-Anne Daviss, eds. This chapter introduces the Editors' concept of sustainable birth and explores how their models of maternity care avoid the unsustainable human and financial costs of our current obstetric model of care. The Editors examine many models of sustainable birth that promote hybrid midwifery/obstetric models to improve maternal and newborn outcomes and increase provider and maternal satisfaction. They consider a continuum of care that includes more sustainable models of surrogacy, abortion, and newborn care across very different parts of the world. They illustrate how each and every chapter offers an example of "evidence-based activism," in which consumers, clients, and clinicians push to change their protocols and institutional practices in ways that benefit mothers, newborns, providers, and their wider communities.

Glossary of Terms & Acronyms

SECTION 1: SUSTAINABLE BIRTH IN HIGH-RESOURCE SETTINGSThe first section describes sustainable and compassionate models of care in the US and other high-resource countries that overcome the obstacles raised by technocratic obstetric models of care. The Authors detail the principles of sustainable midwifery care; sustainable transfers of care between home and hospital settings in the US; the Dutch obstetric indications list that specifies when patients are to move between three levels of providers; an innovative model of doula care for low-income or previously incarcerated women in the US; an analysis of metrics for maternal health that have been promoted across the US after the Affordable Care Act; and a hybrid model of breech care that promotes flexible compromises between midwifery and obstetric models of care in very different high-income countries, an analysis of the well-known collaboration between midwives and obstetricians in the Netherlands, and a formula for sustainable surrogacy that contrasts case studies of surrogacy in the US and Israel.

Ch 1. Sustainable Midwifery in the US. Elizabeth Davis (Former Director of the Midwifery Education and Certification Council (MEAC))This chapter explores the key elements that make midwifery care more sustainable, cost-effective, and humanized than obstetric care. It analyzes the enduring skills that have enabled midwives to produce far better maternal and neonatal outcomes than standard obstetric care. Davis describes holistic models of midwifery education and care that are collaborative, egalitarian, flexible, and receptive to the dynamic energy of birth, as opposed to the technocratic obstetric model that is consumed with control, intervention, and hierarchies. We learn how midwives interact with their clients and key tools they use to promote holistic and transparent care. We see how midwives promote self-care, authenticity, and trust between themselves and their clients, while enhancing the birth experience and minimizing provider burnout, as is so common in the obstetric paradigm of care. Critically, the holistic midwifery model of care described in this chapter can be practiced in teams or individually, at home or in hospitals, and in public or private institutions-making it a truly universal model of care that can be scaled up or adapted to any setting.
Ch 2. Disrupting the Obstetric Imaginary and the Home-Hospital Divide: Toward a US Maternity Care System Worth Emulating. Melissa Cheney (Oregon State University) This chapter explores the growing dissatisfaction with the unsustainable and exorbitant cost of maternity care in the US ($100 billion annually). Cheney argues that this situation is shaped by what she calls the obstetric imaginary and the home-hospital divide. She defines the "obstetric imaginary" as an unsustainable push towards facility-based births alone, a push that is always accompanied by an overuse of obstetric technologies and skills, ignoring the fact that these measures increase costs without improving maternal and newborn outcomes as consistently as once believed. She shows that the home-hospital divide in the US currently deprives women of low-cost, humanized midwifery care, while perpetuating increased medicalization and rising costs of low-risk deliveries in the US, mostly due to the territorial and financial motives that prevent US obstetricians from ceding power and autonomy to midwives.
Ch 3. Getting from Here to There: Sustainable Transfers of Care in Childbirth in the US. Bria Dunham (Boston University) and Sara Hall (Massachusetts General Hospital Institute of Health Professions)This chapter outlines five features needed to create a sustainable model for transfers of care to a hospital from homes or birth centers in the US. Dunham and Hall raise the challenge of surmounting the pervasive competition and distrust between obstetricians and midwives working at very different levels of care, during a high-pressure transfer that may or may not be an emergency. They outline a clear list of mechanisms that could make transfers of care more sustainable and humanized than they currently are in the US: better communication between providers engaged in the transfer, maintaining continuity among the mother's support personnel, avoiding replication of tests and procedures via electronic record transfer if possible, limiting obstetric interventions to those medically indicated, and reducing the fragmentation of care during the transfer. Sustainability in transfers of care can be integrated in a humanized approach that eliminates redundancies, recognizes the expert knowledge contributed by the original care provider, and works to accommodate the woman's desires for birth within the new setting.
Ch 4. Structures for Collaboration between Midwives and Physicians in the Netherlands. Rachael Bommarito (University of Minnesota)This chapter explores the remarkable collaboration between midwives and obstetricians in the Netherlands that has produced an Obstetric Indications List proven valuable in helping to determine where a birth should take place and which kind of providers should Netherlands far exceeds that found in most other industrialized countries, including the US, this chapter offers a rare look at the shifting priorities and negotiations between midwives, obstetricians, and GPs who practice obstetrics in the Netherlands today. Bommarito shows that the Obstetric Indications List is a guide and not a definitive set of rules, thereby allowing some flexibility in the management of care. Yet in practice, all of the maternity care providers work very hard to follow the List and avoid ambiguities about who is responsible for care. We learn that while midwifery is still powerful, its dominance in the Netherlands is being eroded by the collusion of obstetricians and for-profit enterprises, such birth "hotels" where women can pay for a home-like birthing atmosphere. While the Netherlands model has been sustainable for centuries, the author raises the concern of how sustainable this model still is and what is needed to promote increasing cooperation between autonomous midwives and obstetricians in a country that already displays one of the highest degrees of collaboration between these two professions.
Ch 5. Sustainable Models of Breech Care. Shawn Walker (City University, London) and Anke Reitter (Sachsenhausen Hospital, Frankurt)This chapter explores several joint midwifery/obstetric models of care that focus on breech deliveries in the US, Australia, Germany, and the UK. The authors argue that these new models of breech care focus on collaboration between providers and clients, midwives and obstetricians to emphasize skilled knowledge of the normal physiology of labor, rather than prediction and control. They briefly describe the recent decline in vaginal breech delivery across the globe, arguing that this decline cleared space for new innovative, flexible models of care that arose from the ashes of older, now defunct models of breech care. Walker and Reitter show how these new models center the mother-baby dyad as the locus of embodied knowledge. They also show how these new models are being made more sustainable by self-propagation through clinical training of providers who leave the original practices to start their own breech clinics in various settings.
Ch 6. Re-Envisioning Birth Work: Doula Training for Low-Income and Previously Incarcerated Women in USA. Rebecca Bakal and Monica McLemore (University of California, San Francisco)This chapter considers a model of doula care that has the radical potential to improve maternity outcomes among some of the most marginalized women in the US, while enabling reproductive justice, employment opportunities, and community empowerment. The originators of this model trained low-income and previously incarcerated women of color in the East Bay area of San Francisco to work as birth doulas within their communities. The pilot project proved hugely successful for both the doulas and their clients, who speak eloquently of their increased awareness of birth justice, reproductive justice, and self-actualization. Bakal and McLemore learned that a doula's support can extend far beyond birth support into broader issues of family, self-worth, and community health, as both doulas and their clients were able to pursue goals they had considered unreachable before the project. While the project was supported by grants, the doulas are actively working to make this model more sustainable across California by having doula work subsidized by Medicaid and funded by the savings incurred from healthy mothers and newborns needing less invasive and costly care than is presently available.
Ch 7. Sustainable Maternal Health Metrics in the USA. Katie Pine (Arizona State University) and Christine Morton (California Maternal Quality Care Collaborative)This chapter focuses on the development of quality measures in the US that improve maternity care, and quantifies the actual progress that individual interventions and practices are making towards improved maternal outcomes. These quality measures were instituted after 2010, when the Affordable Care Act (ACA) required that the 40% of US births reimbursed by Medicare meet quality standards. The authors also present a core set of perinatal standards including vaginal and cesarean rates, antenatal steroids for preterm labor, newborn sepsis rates, and newborn breastfeeding rates that all hospitals with over 1100 births/year were required to adopt in 2014. Pine & Morton explore the effects of these quality standards in shifting care towards healthier outcomes and fewer interventions. They analyze the challenges of "gaming the system" of metrics that try to manage expectations that metrics will solve all problems, in part by balancing broader standards with local constraints. The chapter illustrates how metrics can slowly, sustainably shift maternity care towards more evidence-based practices and better maternal and newborn outcomes.
Ch 8. Sustainable Surrogacy Practices in Israel and the USA. Elly Teman (Ruppin Academic Center, Israel) and Zsuzsa Berend (Dept of Sociology, UCLA)This chapter contrasts two models of surrogacy regulation, in Israel and the US, to illustrate how to make surrogacy practices more sustainable and accessible, and at the same time, protect the agency and well-being of surrogates, intended parents, and providers. Teman and Berend explicitly contrast how very different surrogacy looks in two high-income settings that lie at the polar ends of the regulatory spectrum--with Israel one of the most closely and carefully regulated surrogacy markets in the world, and the US one of the most highly deregulated surrogacy markets. They explore the attitudes and experiences of those in the American surrogacy market, where both surrogates and intended parents choose each other with the help of agencies that are not always upfront about the psychological and financial costs, or prioritizing the health of the baby and surrogate mother. In contrast, in Israel the state promotes and subsidizes surrogacy as a last resort for infertile couples by carefully screening all parties, ensuring that they understand the psychological, legal, and financial implications of the process. The result is a more constrained market that is inaccessible to many (non-Israelis, gay and lesbian couples, unmarried people) who desire to be parents, even as it is more affordable and accessible for Israeli families with proven infertility. By contrasting these two sets of surrogacy practices, the authors are able to point the way toward developing more sustainable, ethical surrogacy policies around the world.

SECTION 2: SUSTAINABLE AND HUMANIZED CHILDBIRTH IN LATIN AMERICAThe second section of Sustainable Birth describes a set of case studies from Latin America that harness a radical movement against obstetric violence and abusive care. While the term obstetric violence was first coined in Venezuela, the movement against obstetric violence quickly spread to neighboring Brazil, Chile, Argentina, Mexico, and Guatemala, as we learn in this section. The authors explore local and grounded efforts to make birth more respectful and less coercive for women while also increasing access for marginalized and indigenous women across Latin America. Critically, this section describes how the fight against abusive care and obstetric violence has extended beyond Latin America to become a key policy agenda within maternal and reproductive health after 2015.
Ch 9. Winds of Hope: The Return of Physiologic Childbirth in Chile. Michelle Sadler Spencer (Dept. of Anthropology, University of Chile), Gonzalo Leiva, and Ricardo Gomez (Center for Perinatal Diagnosis and Research, La Florida Hospital, Chile)This chapter describes a dramatic movement of "evidence-based activism" in Chilean childbirth that began in 2000 with an international conference on humanizing childbirth in Fortaleza, Brazil that began a region-wide movement to humanize childbirth and eliminate obstetric violence and disrespect. Sadler and co-authors relate this movement to political changes in Chile, including a law against obstetric violence. The chapter also details the roles of consumers and providers in organizing a systemic and integrated shift towards humanized birth in public maternity units across Chile. They focus on one public hospital where a single maternity unit dedicated to humanized birth reduced the cesarean rate from 40% to 5% and reduced episiotomy rates from 50% to 12% within its first year of operation. The chapter closes by describing the growing movement toward homebirths in Chile, in which midwives are seeking recognition and regulation from the state to make transport and referrals to facilities more integrated and effective.
Ch. 10. The Maternity Hospital Estela De Carlotto in Buenos Aires, Argentina. Celeste Jerez (University of Buenos Aires)This chapter describes the history and model of care developed at the Maternity Hospital Estella de Carlotto (MEC), named for a famous defender of human rights who founded the Abuelas de Plazo de Mayo-a widely-respected group whose members agitated against the violence and "disappearances" of thousands of people during the Peron dictatorship. While the name positioned the hospital as adhering to the principles of reproductive justice, it also enabled the MEC staff to transition from a technocratic to a humanistic model of childbirth. Jerez elucidates how medical staff developed a new model of birth that departs sharply from the invasive and often abusive maternity care that is practiced across Argentina. Jerez shows how staff were trained to be protagonists in their own transformation as they adopted an evidence-based, sustainable birth model that promotes gender equality and diversity in sexual orientation. The chapter describes the behavior changes that reduced rates of cesareans and other interventions like NICU admission within one hospital while offering recommendations about how this model of care could be sustainable across Argentina.
Ch. 11. Luna Maya Birth Centers in Mexico: A Network for Femifocal Care. Cristina Alonso, Jenna Murray, Alison Lucas-Danch, & Janell Tryon (Luna Maya, Mexico).This chapter describes innovative community-based midwifery care developed by the Luna Maya collective, beginning with a description of the landscape of maternal mortality in the Chiapas highlands, where the state has been unable to lower very high rates of maternal mortality for decades. Alonso et al. explain how the Luna Maya model of care is "femifocal" and family-centered by placing women at the center of care and empowering them to have the agency to choose the type of care and provider that best serves their needs. The chapter recognizes that women are always already embedded in family and community relations that can have a positive or negative impact on their health and wellbeing, as well as the need for negotiation with each woman around her needs and her relationships. Luna Maya provides a full spectrum, continuous, holistic, humanized, integrated, and family-centered model of care that privileges indigenous women's rights, their informed consent, and the continuity of care that they need in their chosen communities. Its ambitious aim is to combat a technocratic model of care that has perpetuated obstetric violence and abusive or disrespectful care for generations of indigenous Maya women via a more sustainable model with profound psycho-social benefits for mothers, families, and providers.
Ch 12. Reconstructing Referrals: Overcoming Barriers to Quality Maternity Care for Maya Women in Guatemala Through Care Navigation. Kirsten Austad, Anita Chary Peter Rohloff (Brigham and Women's Hospital & Maya Health Alliance), Jessica Hawkins, Nora King, & Boris Martinez, (Maya Health Alliance, Guatemala)This chapter explores a program of obstetric patient "navigators" that is helping Mayan women to overcome the pervasive obstacles to accessing emergency obstetric care and facility-based deliveries in Guatemala. The authors show how local patient navigators with sufficient cultural capital-Spanish fluency, technical savvy, knowledge of hospital-based bureaucracies and protocols--are better able to accompany Mayan women who are referred to facilities than traditional midwives. Despite laws that insist upon the rights of traditional midwives to enter hospital-based labor and delivery rooms, many Mayan midwives are routinely denied entry to hospitals (as are their clients) due to language barriers and racial bias. The patient navigators are beginning to precipitate change in the providers, helping them to better communicate with their Mayan clients and examine the roots of their own biases. They also work to increase sustainable and positive birth experiences that can mitigate the well-founded aversion and stigma associated with health facilities within Mayan communities, which have made government efforts to improve birth so ineffective and unsustainable.
Ch 13. Medicalized Childbirth in a Middle-Income Country: A Qualitative Study with Providers at Public Hospitals in Two States in Mexico. Betania Allen-Leigh (Center for Population Health Research, National Institute of Public Health, Mexico) Maria Teresa Dominguez, and Karen Andes (Dept of Global Health, Rolling School of Public Heath), Lillian Bravo, MPHThis chapter illustrates the range of providers' views on shifting childbirth in public hospitals across Mexico away from a medicalized, obstetric model of care towards a humanized midwifery model of care. The authors summarize a range of interviews with providers at different hospitals across Mexico who inadvertently show their biases for technology and for routine interventions that are not evidence-based nor recommended by WHO, despite the Mexican government's push to humanize birth and promote more evidence-based care in institutions. The provider interviews betray their wish to control birth, limit the autonomy and informed consent of mothers, and their broader lack of knowledge about the harmfulness of the routine interventions they are promoting. By focusing on provider attitudes, the essay charts the path towards understanding why providers do what they do and how best to change clinical behaviors that are harmful to mothers and newborns in sustainable ways.

SECTION 3: FLEXIBLE SOLUTIONS IN LOW-RESOURCE SETTINGS WITH GLOBAL IMPLICATIONSThis third section of Sustainable Birth explores more evidence-based interventions within low-resource settings that have a dramatic ability to improve outcomes and experiences for mothers, newborns, and providers. The chapters in this section argue against an overly technocratic approach to birth in favor of the low-cost benefits of traditional midwives who are following global midwifery and WHO standards (India and South Africa, Ch 14 and 15), an innovative program for improving neonatal resuscitation and community based antenatal care (Ch 16 on Newborn Survival), better policies that support and protect women's access and right to abortion (Ch 17), new metrics and accountability for maternal and newborn health interventions (Ch 18), and a more careful focus on quality and continuity from routine to emergency obstetric care (Ch 19).
Ch 14. Giving Birth at Home in India: Developing A Women-Centric Approach. Bijoya Roy (Center for Women's Development Studies, India), Imrana Qadeer (Council for Social Development, India), Janet Chawla (MATRIKA), Mira Sadgopal (Centre for Health and Social Justice, New Delhi, India), and Sandhya Gautam.This chapter illustrates why 65% of women in four study districts in India choose to deliver at home with a traditional dai or midwife at their side, who offers respectful, collaborative, and empowering care, while the poorly staffed and under-resourced primary care facilities continue to provide poor quality and abusive care to the most marginalized groups of women, including those from poor, low caste, or tribal communities. Roy et al. carefully detail the intrapartum and postpartum skills of the dais in their study area, as well as the nurturing care they offer to mothers in the form of labor massage, verbal encouragement, herbal decoctions, and traditional foods, and a sense of companionship that is sorely lacking in the minimal and often sub-standard care offered at primary health centers in the same regions. The study describes how dais are able to successfully and sustainably overcome complications such as cord malposition or prolapse, breech position, and retained placental fragments that affected between one-fifth and one-fourth of the births in the study area.
Ch 15. Tranquil Birth: Revising Risk Definitions to Sustain Spontaneous Vaginal Delivery. Kathleen Lorne McDougall (Cape Town, South Africa)This chapter describes the landscape of public and private obstetric care in post-Apartheid South Africa, where a midwifery model of care is combating the pervasive medicalization, abusive care, and high rates of cesareans prevalent across public and private facilities in Cape Town. McDougall considers how this midwifery model of care can transcend the public/private and racial divides in South Africa, where "private" means higher quality of care but also higher cesarean rates for mostly White women, while overcrowded and under-resourced public facilities provide lower standards of care and dangerously low rates of cesareans for mostly Black women. The author closes by considering a radical midwifery practice that is promoting homebirth in the townships where privacy, maternal agency, community involvement, and the natural physiology of labor are supported by skilled midwives who can transcend the racial and class divisions that currently plague maternity care within private and public hospitals, asking "Is that model sustainable?"
Ch 16. It Takes More Than a Village: Building a Network of Safety in Nepal's Mountain Communities. Vincanne Adams (University of California, San Francisco), Sienna Craig (Dartmouth University), Arlene Samen (OneHeart), and Surya Bhatta (OneHeart). Adapted from Maternal and Child Health Journal, Vol 20, Issue 12, December 2016, Springer.This chapter describes one small maternal health NGO working in rural villages in Tibet and Nepal to establish a model of integrated maternal and newborn care delivery that it calls a "network of safety." The authors show both the challenges that were faced and overcome by both the NGO and the rural communities where its personnel worked to implement this model and reduce maternal, newborn, and infant mortality. They explicitly show how the model is responsive to local needs, cultural beliefs, social infrastructure, and existing sociopolitical dynamics within the community that could hinder or advance maternal and newborn healthcare. This model scales across communities rather than scaling up, thereby prioritizing local knowledges and power, and trust between householders and referral units within the mountainous Nepali and Tibetan landscapes. The "network of safety" can be flexibly adapted to differing cultural beliefs around birth within Hindu and Buddhist villages and adapted to different regions of Nepal and Tibet that may have very different rural health infrastructures. Finally, the authors consider how small-scale interventions by NGOs can provide valuable metrics and policy insights that complement the data obtained from large-scale RCTs within global health.
Ch 17. Preterm Birth and Neonatal Care: A Case Study From Ladakh, India.
Kim Gutschow (Williams College), Padma Dolma (Leh District Hospital, India), and Spalchen Gonbo (Leh District Hospital, India).This chapter describes the successful creation of a Special Newborn Care Unit at Leh District Hospital in the Ladakh region of the Indian Himalayas. Co-authored by an anthropologist along with the obstetrician and neonatologist who developed the newborn care unit, the chapter describes how two doctors were able to acquire the clinical skills, the technological equipment, and the support of their district hospital to develop one of the few Special Newborn Care units in one of the most remote and rural districts of India's war-torn state of Jammu & Kashmir. The chapter describes the remarkable progress in maternal and newborn outcomes during the last 40 years at the Leh District Hospital in relation to the wider efforts across India to improve neonatal and maternal obstacles.
Ch 18. Sustainable Newborn Care and Outcomes in Low-Income Settings. George Little (Dartmouth Hitchcock Hospital) and Chiamaka Aneji (University of Texas Medical School in Houston).This chapter analyzes the major causes of neonatal mortality across the globe before explaining how simple low-tech interventions like newborn resuscitation, kangaroo care, antibiotics, and hand washing could save millions of newborn lives across low income settings. In particular, Little and Aneji focus on the rapid spread of a sustainable neonatal resuscitation toolkit known as Helping Babies Breathe (HBB), developed in 2010 for both high- and low-resource settings. Their chapter offers an easily teachable newborn resuscitation method as a sustainable step toward improved newborn outcomes - sustainable because it is low cost, efficient, provider-friendly, replicable, and adaptable to local contexts, with a minimum of technology. It also shows how HBB is especially effective for preterm babies, whose lungs are more compromised and for whom low-tech resuscitation and assistance have proved far more beneficial, less costly, and less linked to further complications than traditional intubation.
Ch 19. A Sustainable Model of Improving Maternal Quality of Care in Low-Income Settings. Mary McCauley and Nynke van den Broek (Centre of Maternal and Newborn Health, Liverpool School of Tropical Medicine, UK).This chapter examines efforts to improve quality of care, given the ongoing persistence of preventable maternal mortality. It explores the prevailing gaps in quality and institutional accountability that prevent the delivery of basic emergency obstetric care (BEmOC), even though first-line providers or nurses can be trained to provide this care. The authors find solutions in clinical quality audits, as well as in a renewed focus on continuity of care, including quality antepartum, intrapartum, and postpartum care that follows a basic checklist of recommended interventions. The chapter emphasizes that both routine obstetric care and emergency obstetric and postpartum care are often missing in rural, low-income settings, along with referral systems that shift patients with complications from primary to secondary and tertiary facilities. The authors find that midwifery models of care can provide the "six signal functions" of BEmOC and newborn care, thereby helping to save lives across Africa and South Asia.
Ch 20. Sustainable Abortion: Stigma, Safety, and Legality.
Bayla Ostrach (Boston University Medical Center). Adapted from Frontiers in Women's Health 1(1), 2015.This chapter seeks to identify the factors that interfere with access to safe, high-quality abortions performed by skilled, respectful providers in sterile settings with appropriate instruments, medications, and follow-up care. It addresses "bidirectional factors" in abortion access that stem from and contribute to abortion-related stigma, and thereby limit access. It describes a global reality in which half of all pregnancies are unplanned, 20% end in abortion, and half of those abortions are unsafe, contributing significantly to high maternal mortality rates. Ostrach explores cultural, political, and social constraints that influence the legality and accessibility of abortion, as well the degree of abortion-related stigma in various countries. She shows that cultural or moral prohibitions against abortion and the role of patriarchy in defining children as property of the father inhibit women's access, or shape the extent to which women will seek clandestine but risky abortions. The chapter explores the gendered power dynamics and structural violence that shape women's reproductive agency across the globe and its effects on maternal health outcomes.
Conclusion Moving Forward: What We Have Learned About Sustainable Birth Models. Kim Gutschow, Betty-Anne Daviss, and Robbie Davis-Floyd
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