‘In high-income countries, women’s pregnancies are over-medicalised’

19 Feb 2020

Dr Marit Bovbjerg, OSU. Image: Fulbright

Dr Marit Bovbjerg is researching the realities of community births and the implications on healthcare systems around the world.

After completing her master’s degree in health evaluation sciences at the University of Virginia, Dr Marit Bovbjerg worked as a clinical researcher at the university’s medical centre for four years. She completed a PhD in epidemiology at the University of North Carolina at Chapel Hill in 2010 and is now a member of the faculty at Oregon State University (OSU).

She was most recently a Fulbright scholar at the National Perinatal Epidemiology Centre at University College Cork.

‘We hope that our work can perhaps lead to some systems-level reforms that will improve outcomes for women and infants’

What inspired you to become a researcher?

I was always interested in clinical research. My mother is a clinician, and while seeing patients never appealed to me, figuring out why they were sick in the first place struck me as very exciting.

Can you tell us about the research you’re currently working on?

My work focuses on maternity care in the US, and now in Ireland. With my colleagues, I use data from pregnancy and birth medical records to try and figure out how to get the best outcomes for women and their infants.

When I began working at OSU a decade ago, I was lucky enough to start a collaboration with Dr Melissa Cheyney, who focuses on community birth (home and birth centre) outcomes.

Since generally only low-risk women plan community births, studying these women is a great way to figure out what should be done to manage the vast majority of pregnancies and births, because more than 90pc of women have low-risk pregnancies.

Courtesy of my Fulbright scholarship, I have been lucky enough to live and work in Ireland for the past six months. There, I have been collaborating with Dr Sarah Meaney to look at maternity care and home births in Ireland.

It is comforting to know that my colleagues and I have found exactly the same things, in terms of how pregnancy and birth is best managed for most women, whether we use data from the US or from Ireland.

In your opinion, why is your research important?

Maternity care globally is characterised by many places having ‘too little, too late’ – women in many parts of the world do not have access to prenatal care, skilled midwives for their births or to contraception. However, in the US, Ireland and other high-income countries, we instead have ‘too much, too soon’ – women’s pregnancies and births are over-medicalised, rather than being allowed to unfold as part of a normal biological process.

Unnecessary use of medical technologies such as induction of labour or caesarean section is associated with poorer outcomes for women and infants. This is not to say that these and other interventions are never necessary – in parts of the world that do not have ready access to caesareans, people die.

However, both Ireland and the US have rates of caesarean that are more than double the maximum rate recommended by the World Health Organisation.

Above this ideal rate of between 10pc and 15pc, the risks of this major surgery outweigh the benefits. With rates above 30pc in both countries, Ireland and the US are subjecting women and their infants to harms without benefit. By studying people birthing in community settings, where these interventions happen at a much lower rate, we work to shed light on how we can improve maternity care for all women.

What are some of the biggest challenges you face as a researcher in your field?

The biggest challenge we face is public perception of risk. Most people are more concerned about being killed in an airplane crash than a motor vehicle accident, despite the fact that, by any measure, cars are riskier.

Perception of risk associated with childbirth is no different. “But what if something goes wrong?” is the most common response a pregnant woman will hear when she tells her friends and family that she is planning a community birth.

The reality, however, is that most pregnancies are low risk. The best outcomes will be achieved if the medical team minimises intervention, and instead watches and monitors the labouring mother and her foetus, waiting for birth to unfold naturally.

Provided that a hospital is nearby, however, there is currently excellent evidence from high-income countries around the globe that, for most women and infants, their outcomes will actually be better if they plan to birth in a community setting.

Are there any common misconceptions about this area of research?

Despite what some of our critics say, we do not advocate planned community birth for everyone. Indeed, we do not advocate for any particular position.

Instead, we hope that our work provides useful information that childbearing families and their care providers can use when making important decisions like place of birth. If a woman with a perfectly straightforward, low-risk pregnancy would be more comfortable having her baby in a hospital, then by all means she should.

What are some of the areas of research you’d like to see tackled in the years ahead?

There is a trend, at least in the US, of some women with higher-risk pregnancies choosing community births because of restrictive policies at their local hospitals. For example, many obstetricians advocate automatic caesarean births for any woman pregnant with twins, whose foetus is breech, or who has had a caesarean in the past.

There is some evidence of better outcomes with planned caesarean for breech, but little such evidence for women with a history of caesarean. The evidence for twins lies somewhere in the middle.

Regardless of what the evidence does or does not show, pregnant women are autonomous individuals, and legally they have the right to refuse a medical procedure such as caesarean. At some hospitals, women will unfortunately be told that they do not have this choice, and that hospital policy dictates that they ‘must’ consent to the caesarean.

Collectively, we hope that our work can help to inform these policies and perhaps lead to some systems-level reforms that will improve outcomes for women and infants.

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