Birth at home and in midwifery-led birth centres in Indonesia: risk selection, trends and neonatal mortality

Abstract

The inequitable application of the human right to healthcare is the basis for two conflicting and interrelated problems in childbirth care globally: under- and over-intervention at birth. These have been labelled "too little, too late", where inadequate maternity care results in avoidable death and disability, and "too much, too soon", describing the growing overuse of interventions like unnecessary caesarean sections, causing negative health impacts and higher costs. In high-income countries, home or midwifery-led birth settings for low-risk women are safe and involve fewer interventions, but the safety of such births in low- and middle-income countries such as Indonesia remains untested as studies rarely consider risk-status. In Indonesia, a strong midwifery profession means most women receive pregnancy and birth care, and they give birth in a wide variety of locations, including midwifery-led birth centres (MLBC) hospital and at home. My thesis aimed to evaluate whether birth at home with a skilled attendant, or in an MLBC in Indonesia is safe and associated with a reduction in over- and under-intervention when compared to birth in hospital for low-risk women. First, I analysed World Health Organization guidelines on childbirth care to ascertain recommendations related to birth outside of hospital. Second, I utilised three waves (2007, 2012, 2017) of representative Indonesian Demographic Health Survey (IDHS) data including 45,953 births, to define low-risk pregnancy and determine trends in birth settings and caesarean sections. Finally, I quantified via logistic regression, neonatal mortality rates for birth in different settings adjusting for risk-status and potential confounders. World Health Organization guidelines do not provide clear, evidence-based direction on which risk factors should result in a recommendation of birth in a hospital, or how to support birth at home safely. Utilising a definition of risk developed by combining existing guidelines, 24.4% of Indonesian women reported risk factors in pregnancy. More women with risk factors gave birth in hospital than any other setting, however one in five women who gave birth at home also had risk factors. Over the 15 years of data, homebirth declined from 49% to 16%, hospital births more than doubled (17% to 35%) and births in MLBCs remained steady at around 30% of all births. Caesarean sections were the mode of birth for 10% of all women who had antenatal care with a midwife (8% low risk, 17% with risk factors), and over 30% of all women who had antenatal care with an obstetrician (34% low risk, 43% with risk factors). First day neonatal mortality was 7.35 per 1000 live births among women with pregnancy risk factors compared to 2.21 among low-risk women. The odds of first day neonatal death were lowest for those who gave birth in a MLBC, and highest at home (aOR 2.50, 95% CI 1.26-4.96). Women who gave birth at home were more likely to report barriers to accessing care than any other setting. These analyses show that the presence of risk factors in pregnancy is associated with increased neonatal mortality. World Health Organization Guidelines provide inadequate guidance for care for the millions of home and MLBC births annually. Homebirths in Indonesia were associated with "too little, too late" being linked to high neonatal mortality, and barriers to accessing care. MLBC births, however, were associated with neither over- nor under-intervention, and no increase in risk of neonatal death for low-risk women, whilst maintaining enduring acceptability in Indonesia over time. Further research to improve categorisation of risk would support effective management of birth in all settings. Human rights, especially gender equity, demand that no matter where they are in the world, women receive safe, accessible, acceptable perinatal care which does not over- or under-intervene and, in Indonesia, midwifery-led birth centres meet this demand, but birth at home does not. Show more