Policymakers can contribute to promoting safe, healthy birth and should therefore:
Establish an appropriate healthcare system. Key indicators by which countries are compared in terms of health and healthcare system performance are: life expectancy at birth, healthy life years, infant mortality, maternal mortality, vaccination coverage, and regional health disparities.
Life expectancy in Slovenia has exceeded 80 years and is one year above the EU-28 average, with highly educated residents living longer and in better health than those with the lowest level of education.
Infant mortality is an indicator that reflects the accessibility and quality of healthcare in general. In Slovenia, it is among the lowest in OECD countries, at 1.6 infant deaths per thousand live births. Slovenia also ranks among the more successful countries in terms of maternal mortality for the period 2009 to 2011 (the three-year average rate is 1.5 maternal deaths per 100,000 live births).
Vaccination coverage for childhood diseases is an indicator of population participation in preventive programs and is equal to the EU average in Slovenia, with 96 percent of the population vaccinated against diphtheria, tetanus, and pertussis (same as in the EU), and 95 percent against measles (94 percent in the EU).
Indicators showing regional health disparities, along with other health determinants, also reflect accessibility to preventive and treatment programs. According to OECD data, Slovenia has the lowest share among all EU countries of people who could not afford healthcare due to financial or other reasons. We are among 17 European countries that provide healthcare to all their residents. However, due to the crisis and resulting unemployment, health inequalities between different population groups and regions have begun to deepen in Slovenia as well. At least in part, these differences can be attributed to reduced accessibility to healthcare (Ministry of Health of the Republic of Slovenia [MZ RS], 2015a).
Nevertheless, Slovenia lacks research on the satisfaction of women who give birth with a chosen midwife at home, in a maternity hospital, or in a birth center compared to the existing care provided in the Slovenian healthcare system. The practice in most Slovenian maternity hospitals is that a woman gives birth with the midwife who is currently on shift. Only Kranj Maternity Hospital offers the option of giving birth with a chosen midwife who has a contract with the Kranj Hospital for Gynecology and Obstetrics. Women contact this midwife themselves, and she comes to deliver with them at BGP Kranj (Hospital for Gynecology and Obstetrics Kranj [BGP] ND). Trbovlje General Hospital has also listened to women in labor who want their birth to be led by a midwife they trust and choose themselves. They offer a self-pay service where the woman chooses her own midwife (Trbovlje General Hospital [SB Trbovlje], 2015). There are also women who decide to give birth at home with a chosen Slovenian or foreign midwife. Slovenia lacks separate statistics on labor augmentation, labor induction, perineal injuries, and preterm birth in physiological pregnancies compared to pathological pregnancies. To obtain relevant statistics, tertiary centers would need to maintain separate statistics, as only then would they be competitive with smaller maternity hospitals, which generally deal only with physiological cases and refer all pathological pregnancies to tertiary centers (e.g., Ljubljana or Maribor).
Increase access to healthcare that most reliably supports the physiology of birth, i.e., midwives, birth centers, and birth companions. Pregnant women in Slovenia have very good access to healthcare. Their pregnancies are managed by gynecologists, and when necessary, they are referred to tertiary centers. This provides dual care, making gynecologist visits more frequent and pregnancy management more thorough and precise. However, it can be seen that gynecologists and obstetricians are those who deal with pathological pregnancies and participate in childbirth. Midwives, who are responsible healthcare professionals for managing physiological births and also support the most physiological births possible, are somewhat marginalized in Slovenia. In Slovenia, every pregnant woman is entitled to 10 systematic examinations and two ultrasound scans, as well as individual consultations. The purpose of preventive examinations is active health monitoring of the pregnant woman and fetus. If the pregnancy is not progressing normally, the gynecologist decides on additional examinations. The first examination is performed by a gynecologist within 12 weeks of pregnancy. Subsequent systematic examinations are approximately in weeks 24, 28, 35, and 40 of pregnancy. The other five systematic examinations in weeks 16, 32, 37, 38, and 39 of pregnancy are performed by a registered midwife or a registered nurse trained for independent work. If the gynecological team does not employ a registered midwife or a registered nurse trained for independent work, these examinations are performed by a gynecologist (MZ RS, 2015b). Since Slovenian gynecological clinics (within maternity hospitals, health centers, or independent gynecological clinics) do not employ midwives/registered nurses trained for independent work who could perform these examinations (nursing staff are mostly for administration only), all examinations are performed by gynecologists. According to the Regulations for the Implementation of Preventive Healthcare at the Primary Level from 1998, last amended in 2015, Slovenia should work to ensure that women have greater access to midwives during pregnancy and receive midwifery care. Research below shows that contact with a midwife during pregnancy positively affects pregnancy and birth outcomes, even in cases of pathological pregnancy. At last year’s fourth birth conference in Maribor titled Ancient Wisdom and Modern Science of Birth, Jesenice Maternity Hospital also presented. Among other things, they mentioned that every first Monday of the month they hold a discussion about physiological birth with a gynecologist, pediatrician, and midwife. Since the beginning of 2015, midwives have also been running a clinic where they perform the 5 midwifery examinations prescribed by the Regulations for the Implementation of Preventive Healthcare at the Primary Level for healthy pregnant women in weeks 16, 28, 35, 37, and 38 of pregnancy. They also check urine, and if they detect changes, they refer the pregnant woman to a gynecologist. Otherwise, they talk to her and give her further instructions. After physiological births, they also perform rounds themselves. This way of working requires the support of system leaders, employees, and users of healthcare services. This requires more staff with appropriate knowledge and experience and additional spaces where this midwifery activity could be carried out. As healthcare professionals with easy access to knowledge, we must ensure that we (re)design our existing systems to positively influence the culture of birth and thus change practices that will be demonstrably better and safer choices for pregnant women, women in labor, newborns, and others involved in the birth process. However, staffing shortages must first be addressed.
Support the quality of work of all involved in the birth process, support initiatives to improve the quality of maternal and child care and for physiological processes in healthy women and newborns and, when safe, in those with special needs. For example, routinely enable skin-to-skin contact even during cesarean sections or, if the mother is unable, enable this for the father.
Develop and implement experiences with care, birth outcomes, and women’s opinions on the quality of care. Surveys should be prepared on women’s satisfaction with care during pregnancy, birth, and the postpartum period.
Develop and publish safe website options that provide pregnant women with access to relevant information. This is also the goal of the author of this master’s thesis, who collects and organizes relevant articles on pregnancy, birth, the postpartum period, and midwifery through the Facebook network under the name Moja Babica and on the website www.mojababica.si.
Promoting breastfeeding and maintaining the Baby-Friendly Hospital designation. Through the Baby-Friendly Hospital Initiative, the National Committee for the Promotion of Breastfeeding encourages breastfeeding for the good health of mothers and children (UNICEF, ND).
Support public education and information for women, the public, journalists, and others about the value of physiological birth processes for the health of women and newborns.
Zadok (2016) uses a board in her birth preparation classes where participants write down associations related to birth. Positive words appear on the board, such as: child, anticipation, blessing. But more typical are words like: pain, fear, loss of control, death. These associations stem from childhood, as birth is always presented to us as suffering and the media portray it that way. Awareness, humility, patience, and dedication are four interconnected elements that help women in birth preparation to begin trusting their bodies, gain appropriate knowledge, and build confidence. A woman who does not feel safe or perceives danger will likely have a long and painful birth. We as healthcare professionals are the ones who must enable women in the delivery room to feel safe and trust us. Support and a sense of security make birth faster. Fear and anxiety slow it down and make it more painful. During birth, emotions and environment affect the release of hormones that have a major impact on labor. A woman who does not feel safe will release a lot of adrenaline, making labor slow and painful. Muscles contract under the influence of adrenaline, and all energy goes to our limbs. The body is also more sensitive to pain. Adrenaline release helps us avoid danger, and we must ensure that as little as possible is released during birth. A woman who feels safe in the environment where she is giving birth will release oxytocin and endorphins, which will help her labor progress well. Muscles are relaxed under the influence of these hormones, and energy is sent to the uterus, which further increases oxytocin release (Durham, 2016). To prevent adrenaline release in the delivery room, we must ensure that the woman feels safe, loved, and protected, that she has a sense of control and people around her who provide support. We must also provide her with privacy.
Source: Nastja Pavel – Six Areas in the Delivery Room for Better Birth Practice (2016); master’s thesis under the mentorship of Assoc. Prof. Dr. Darja Arko, MD, and co-mentorship of Asst. Prof. Dr. Jadranka Stričević
