Centralization of Birth Settings: Worrying Developments Affecting the Role of Midwives in the Social Organization of Maternity Care

Authors: Bourgeault, I., Benoit, C., DeClercq, G., De Vries, R., Sandall, J., van Teijlingen, E. and Wrede, S.

Conference: 31st ICM Congress Midwives making a difference in the world

Dates: 18-22 June 2017

Journal: http://www.midwives2017.org/scientific-programme

Place of Publication: The Hague, the Netherlands


Overview/Outline: In 2005, we wrote about midwifery as a ‘touchstone’ for understanding the diversity of maternity care systems worldwide [1]. In this symposium, we examine the changes over the past decade to the social organization of maternity care in Canada, the US, England and the Netherlands with a particular focus on the increasing centralization of birth in large hospitals and how this affects the role of midwifery in these centralising health systems. Across four country presentations, the role and changing nature of the social organization of maternity care and its impact on midwifery practice, policy and education will be highlighted. The symposium will encourage participants to think in a more complex manner about the evolving role of the midwife in 21st century maternity care, being attentive to changing client demographics, but also to the increased corporatization, medicalization and consumerism of care.

The Symposium Leader, Bourgeault, will provide an introductory overview of the framework tying together the four country presentations and will lead a cross-cutting discussion at the end before opening up for audience participation and Q&A.

Each of the presentations will focus on key dimensions affecting the evolution of the role of midwives in the social organization of increasingly centralized maternity care systems: 1) what are the evolving trends in the centralisation of maternity care? 2) what is the evolving role of midwives in centralising systems, especially with regard to: their autonomy, their relationships to other caregivers, and their relationships to women and the community; 3) what is the effect of centralization on client perspectives of birth care and attitudes among the new generation of midwives?

In the first presentation by Benoit, it will be detailed how Canada, host of the ICM, has witnessed in the last two decades a one-third decrease in eligible hospitals for birth and a parallel increase in birth taking place in large academic hospitals. While this centralization trend has been paralleled by a painfully gradual increase in the number of births attended by midwives in hospital, home and birth centres, the caesarean section rates (currently 27.3%) have continued to rise. This is a persistent trend even in jurisdictions where midwives are attending a substantial minority of births.

[1] Benoit, C., Wrede, S., Bourgeault, I., Sandall, J., van Teijlingen, E., &. DeVries, R. (2005) Understanding the social organization of maternity care: Midwifery as a touchstone. Sociology of Health and Illness, 27(6), 722-737.

Part1: In the second presentation on the US, Declercq will reveal how hospital mergers and closures have been increasingly centralizing maternity care across the country. This has had a limiting effect on the role of midwives in attendance at birth. Specifically, despite growth in the profession, midwife-attended birth remains the exception -- 9 percent of all births and 13 percent of vaginal births in 2014. Continued high caesarean rates (32%) also limit opportunities for midwife attendance at birth.

Part2: In the third presentation on England by Sandall, it will be clear how policies have supported the role of the midwife as primary carer in hospital and community settings for all women. There has been policy support for provision and choice of birth settings, centralisation of obstetric services combined with care close to home and an increase in midwife led units.. However, the C-section rates have continued to rise to 26.5% in 2014.

Part3: In the fourth presentation on the Netherlands, van Teijlingen will detail that although once considered the ‘mecca’ of midwifery, the last decade has witnessed a gradual undermining of the autonomy of midwives,. With a steady decline in the proportion of home births from about one third of all births throughout the period 1980-2000 to about one in six in 2014, and a slow(small) decline in the number of hospitals. However, the C-section rates remain relatively low at 16-17%

Source: Manual