Challenging the reliance on facility-based childbirth to prevent maternal mortality in low and middle-income countries

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By: Bethany Kotlar, MPH, Associate Directer of the Maternal Health Task Force


The burden of maternal mortality in low- and middle-income countries (LMICs) remains high, notwithstanding heavy investment in maternal healthcare. Historically, these strategies have prioritized increasing facility-based birth. However, emerging evidence has challenged facility-based birth as an appropriate or effective strategy for reducing maternal mortality.

Human rights groups highlight prevalent disrespect and abuse during childbirth and low-quality facilities as factors in the failure to increase uptake of facility-based birth and improve birth outcomes. Yet, there has been little analysis of the ethics of public health campaigns to improve facility-based birth, despite their widespread use and potential for harm. While the goal of increasing facility-based childbirth is based on good intentions, it fails to consider race-based violence plaguing health systems, exposing racialized minorities to harm. To achieve further reductions in maternal mortality, health professionals must place justice at the heart of these efforts by recognizing and learning from the past and working with racialized communities to envision and implement new strategies.

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Emerging evidence has challenged facility-based birth as an effective strategy for reducing maternal mortality. Photo credit: Pexels/Sai-Viswanath

The World Health Organization (WHO) has placed the reduction of maternal mortality as a high-priority health goal for decades. Investment in this goal, largely focused on increasing access to facility-based birth, led to a 38% reduction in the maternal mortality ratio worldwide between 2000 and 2017. However, reduction in maternal mortality has not been equitable. While increases in facility-based birth in high-income countries has been beneficial, in LMICs emerging evidence suggests higher facility-based birth has null or even potentially harmful effects on maternal health outcomes. Within LMICs groups marginalized due to race or ethnicity have poorer maternal health outcomes compared to dominant groups.

These disparities in outcomes are rooted in injustices in how maternal health is promoted. The most striking evidence for this injustice is the violence perpetrated against birthing people, broadly termed “disrespect and abuse during childbirth.” This violence includes physical assault or derogatory language from healthcare providers as well as institutional practices such as policies preventing the use of traditional birthing practices, requiring unnecessary medical preventions, and forcibly keeping postpartum people for failure to pay for the birth of their child. Disrespect and abuse during childbirth is a strong deterrent for seeking medical care during childbirth and a direct contributor to poor maternal health outcomes.

While there has been little quantitative research outside of socioeconomic disparities in abuse, qualitative work suggests that healthcare providers and health systems consider multiple axes of identity as well as historic conflicts and political factors when considering how to treat a patient, including race and ethnicity, and are more likely to abuse those belonging to racialized minority groups.

Promotion of facility-based childbirth that is blind to race or ethnicity constitutes structural violence. Given lack of concrete evidence that facility-based birth in LMICs leads to better outcomes and overwhelming evidence that facility-based birth exposes marginalized groups to harm, reliance on increasing facility-based birth as a frontline public health tool is fundamentally unethical.  Furthermore, health systems that allow structural violence to occur create inequitable health outcomes by benefiting high-status racial groups and actively harming low-status groups. The next frontier in reducing maternal mortality in LMICs will be to eliminate race and other socially-based disparities. To do this, we must end the reliance on broad strokes public health campaigns such as the promotion of facility-based birth and develop new tools. These tools will require a strong grounding in the principle of justice.

First, strategies must recognize that racial biases are not ahistorical. Rather, they are based in a long history of attempts to erase the cultures of marginalized racial and ethnic groups and subordinate them to dominant groups. As Richard Matthews argues, these attempts are not only interpersonal, but also embedded in institutions such as the healthcare system and can be seen as an extension of purposeful erasure of the culture of marginalized groups by those in power. In maternal healthcare, this can be seen most clearly in policies that prohibit cultural birthing practices. Achieving justice in maternal healthcare requires an examination of how healthcare systems reinforce the erosion of marginalized cultures in each context in order to envision strategies that are equitable.

More recently, some maternal health proponents have instead shifted towards improving an uptake in skilled birth attendance, rather than facility-based birth. This is a positive step towards a more just strategy, but may be too little to move the needle on disparities in birth outcomes. Envisioning new strategies must also include centering the lived experiences and voices of racialized minorities. In qualitative assessments of barriers to facility-based care birthing participants clearly identify the harms of facility-based birth. However, this approach to understanding birthing people’s preferences is inadequate. We must move beyond investigations into “barriers to facility-based birth” and towards opportunities for culturally affirming, equitable care. Researchers must investigate the desires of birthing people as a first step towards equity and maternal health leaders must then work collaboratively with leaders from racialized minority groups to design and realize maternal health strategies based on these desires.

It’s time to abandon facility-based birth as the “gold standard” in maternal healthcare. The invasive presence of structural violence in healthcare systems makes facility-based birth campaigns both harmful and unjust. We are called to envision alternative strategies for equitable maternal health outcomes, strategies that consider histories of oppression and center the desires of subordinated groups. Only then can justice in maternal health be achieved.