Birth, Womanhood, Value

I was reading one of the original publications on the three delays to care in childbirth emergencies this morning, and was struck with an unpleasant thought.

First, let me acquaint any readers who have not heard of them with the three delays. It is a framework for thinking about and dealing with the problems that lead to increased maternal mortality.  It has generally been applied to women living in low resource settings.

  • The first delay is the wait time between the problem occurring and the woman or those with her recognizing there is a problem. This generally has to do with lack of education and trained birth workers. In areas where poor outcomes are endemic due to multiple effects of poverty, women and their families may consider the signs of a problem to be normal because this happens to nearly everyone.
  • The second delay is the wait time between identifying the problem and seeking help. This generally has to do with the costs of seeking care, the low value of women to a society (and her ability to decide for herself to seek care), and the perception of the health system’s ability to provide help.
  • The third delay is the wait time between arriving at the place where help is available and receiving that help. This generally has to do with under funding health systems causing lack of staff, supplies and necessary resources to handle emergencies.

What stuck me today was that although this framework was designed for use in low resource settings, I can see reflections of some of the causes of delays in conversations with home birth in the US. I understand that in the US, the maternal mortality rate is not driven by women not having access to care in obstetric emergencies. Yet, I can’t help but wonder if some of the push back against home birth comes from the successful implementation of this framework into the international obstetric community.

I want to explain why this framework was adopted. Prenatal care was supposed to have solved maternal mortality by identifying women at risk and referring them to appropriate resources.  While this might work for hypertension issues, that is only one small chunk of the maternal mortality pie-chart. Once the research started to show the failure of prenatal care to predict obstetric emergencies, the momentum changed to improving access to emergency care by making sure facilities with obstetrical services were well distributed, properly staffed, provided with adequate supplies, and able to be accessed when an emergency occurred.

In the United States, most of the country has the emergency services available (but there are geographic pockets with low population levels that are simply under served in all areas of health care). In the minds of  decision makers, the existence of  emergency obstetric care is evidence the third delay has been dealt with, and it is only the first two delays that could cause problems.

If you look back on the first two problems, these relate to poor decision making by unskilled labor attendants.  In the developing world this was most often family members of the woman. In most of the United States, registration or licensing helps to ensure minimum competency of birth attendants for home birth. To some, this serves as evidence that the first two delays have also been dealt with.

So what was the unpleasant thought? When viewing birth from two different paradigms, it is easy for sides to see very different courses of action as appropriate. While homebirth supporters may feel they are expressing faith in the natural process, I can see how practitioners who view birth from a different paradigm could hear something very different in the comments I hear.

So a comment about how it took two days of labor, but the baby finally came out might be seen as evidence the midwife is not trained in the partograph to help identify obstructed labors.

A comment about how a woman had to birth unassisted because she didn’t want a cesarean might be seen as evidence of an inability to recognize risk.

These are just examples.  I’m sure you could come up with additional ones.  The point is, a paradigm can make a comment be received very differently than it was intended. It makes me wonder what the best way to bridge the various birth paradigms may be.


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Jennifer Vanderlaan CNM MPH is the author of the website. She has been working with expectant families since 2000, training doulas, childbirth educators, and midwives. She has worked with midwives in Central America and Sub-Saharan Africa. Her interest in public health grew in 2010, and she is now a PhD student learning to become a producer of knowledge.

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