Childbirth care in affluence and poverty : maternity routines in Sweden and Zambia

Abstract

The general aim of this thesis is to explore maternity practices during normal childbirth, both in an industrialised and in a low-income country, and to increase the knowledge about how these practices affect mother/newborn interaction and health. The studies have been carried out in Sweden and Zambia. The spontaneous behaviour of 21 healthy term newborn infants, placed skin-to-skin on the mother's chest, was studied during the first hours of life, using non-participant observation. It was found that the infant displays an organised sequence of behaviours and orients itself to the breast, finds the nipple and starts to suck the breast about one hour old (paper I).

Newborn infants were video recorded during the first hours of life (n=28) (papers II, III) and maternal oxytocin release was measured during the same period (paper II). It was found that the infant made massagelike hand movements on the mother's breast before the first breastfeeding, used its hand to explore the breast and assisted itself to attach to the nipple. Oxytocin levels were found to rise already in response to the massagelike hand movements and to sucking (paper II). In infants whose mothers had received labour analgesia it was observed that the infants' massage like hand movements were less frequent and significantly fewer infants made hand-to-mouth movements, touched the areola, made licking movements and sucked the breast within 2.5 hours of life. In addition the skin temperatures were significantly higher in infants, whose mothers had received analgesia during labour (p=0.03) and the infants also cried more (p=0.05) (paper III).

Fifty-nine women with uncomplicated vaginal deliveries at the University Teaching Hospital (UTH), Lusaka, Zambia, were studied with regard to maternity care during antenatal period and during delivery. The results indicate a low degree of application of recommended maternity care routines, positive correlation between application of these routines and the mothers' educational level (paper IV).

A total of 408 mothers who had a normal delivery and gave birth to a healthy term infant at UTH, Lusaka, Zambia were randomised to a midwife home-visiting programme with individual health education or not during the puerperium. There were no differences in the two groups regarding maternal health problems at 42 days after birth as identified by the mother, obstetrician and midwife. But there were significantly more infant health problems (p< 0.05) in the non home-visited group. The mothers in the home visited group took more action to solve the infants' health problems. Significantly more mothers in the non home-visited group experienced insufficient milk production and gave supplementary feeding (p<0.01) (paper V).

Three hundred and seventy six (376) parturient women were interviewed about their family planning practices before and after childbirth. Sixty-six percent of the women knew about contraceptive methods. Twenty-one percent had ever used modern contraceptives. Women with eight or more years of education used modern family planning methods more often than women with less education. One year following birth 64 percent were using modern or traditional family planning methods. Of those who did not use any contraceptive method 39 percent indicated that their husbands did not allow them. More than half of the teenagers stated that they had no knowledge of family planning methods (paper VI).

The routine care of women during normal labour and delivery and the immediate care of the newborns were observed in 84 women at different levels of health care in urban and rural Zambia. It was found that these women were confined to bed during the whole labour and delivery period. No food or drink were given and none of the women were allowed to have a companion present during labour. Foetal monitoring was inconsistent and partograph not used or lacking. There was a general lack of support for early mother-infant contact and early initiation of breastfeeding (paper VII).

Conclusion: Maternity care should support the biology of mother-newborn interaction and breastfeeding. Labouring women should be supported by a companion. Particular attention should be paid to primipara and socially vulnerable women, teenagers and single mothers. Review of midwifery curricula and continued education to midwives are needed for them to continuously evaluate the quality of care and maternity practices they implement.