From home to hospital : 'safe motherhood', hospitalisation and the birthing transition in Thailand (1945-2006)

Abstract

This research explores Thailand's birthing transition (1945-2006), analysing socio-political contexts, identifying key determinants, describing change processes, outcomes and impact, including women's experiences. Maternal mortality decreased substantially from the mid-1900s, when lay-midwife-attended homebirth was usual. Nevertheless, following widespread hospitalisation, a caesarean "epidemic" transpired and birthing became dehumanised. What influenced this transition? Is birth 'safer'? To what extent does the contemporary maternity system support woman-centred, evidence-based, equitable, quality care? Using a multidisciplinary, mixed-methods approach, this study analysed qualitative and quantitative data from national datasets and in-depth interviews with diverse women and informants. Findings detail major changes in birthing ecologies, cultures, outcomes, and women's experiences. Historically, birthing incorporated holistic support from trusted caregivers, utilising rituals, empowering most women to birth successfully. Complications and deaths did occur, where cosmological influences were implicated. Maternal mortality was already 'low' before widespread hospitalisation. According to internationally-advocated 'safe motherhood' strategies; reduced fertility, and potentially 'skilled attendants', had the greatest impact, along with improvements in women's wellbeing. These assertions are supported by evidence of poorer health and outcomes among marginalised populations where health improvements have lagged, and access to reproductive services is problematic. The importance of pro-equity strategies addressing the social determinants of maternal health, are highlighted. Birthing has been redefined, now largely technocratic. The biomedical, obstetric care model predominates, influenced by perceptions of safety and comfort, while midwifery-led care is unavailable. Institutionalised birthing has accompanied the proliferation of policies and practices that are not evidence-based, have resulted in increased iatrogenic risks through overmedicalisation, produced minimal widespread outcomes improvements, and is rarely woman-centred, as women's rights are not often actualised. System-wide inequities were observed, where obstetric services are high-cost, privilege doctors and private providers, while poor, rural, and ethnic-minority women remain disadvantaged with limited access to resources for health. Significant parallels were found between industrialised-country transitions and that occurring in industrialising settings. Increased demand for biomedicalised birth occurred through a transference process. Despite a largely 'successful' care model, according to women's desires for safety and comfort, biomedical knowledge acquired authoritative status, while lay-midwifery care was subjugated. Biomedicine became culturally acceptable, as women believed their experiences could be improved, transferring trust from traditional care. Conversely, much about 'traditional' care is supported by current evidence, and modern-day childbirth does not always promote healthy outcomes. 'Traditional' knowledge could enhance contemporary care. Findings support a reorientation of maternity services, to offer quality midwifery-led care, thereby protecting and promoting humanised, normal and healthy birth, achieving broad health improvements. Findings are relevant to policy-makers internationally, seeking to improve maternal health, prevent deaths, and promote healthy experiences and outcomes. Following international health and rights definitions, I assert evidence supports the widespread acceptance of 'social' care models including midwifery-led care as a primary strategy, and these should be supported through international initiatives. I argue a reorienting of 'safe motherhood' is needed to put women first, since 'safety' is more than survival, that risk discourses be balanced with normalcy, that women's experiences be optimised through respecting their rights; to ensure care is woman-centred, evidence-based, quality, equitable and sustainable.