Birthing and the birthing transition in Thailand: Penny Haora and Streerut Thadakant examine current birthing issues in a country where midwifery is not yet an autonomous profession but maternal deaths have been reduced.

The processes and practices surrounding birthing in Thailand and the factors determining maternal health have changed considerably in recent decades. A significant contribution to the transition in birthing outcomes was the effectiveness of population control policies introduced in the 1960s. The total fertility rate was 1.7 in 2004 and the national contraceptive prevalence rate 79.2% in 2001. In 1998 there were around 850,000 live births and around 640,000 annually by 2003.

Historically, birth attendants called hmor tam yae dominated the care of Thai pregnant women. Most of them were women who had seen or experienced childbirth at least once before and thus they provided care from a basis of experiential knowledge. The delivery usually took place in or around the woman's home, and often involved the attendant physically supporting and encouraging the labouring woman, as well as providing immediate postnatal care to mother and baby. Postnatal food restrictions were common, and the practice of yue fai or 'staying by the fire' was prevalent in some areas. An auxiliary midwife training programme of 18 months duration was offered in parts of Thailand until the 1990s. However, these personnel became viewed as 'inferior' to the nurses formally trained in the higher education sector, where a higher entry requirement was also expected.

The World Health Organization (WHO) promotes the midwife as the lead carer for normal pregnancy and birth. However, at present, there is virtually no model of midwife-led care practised in Thailand, where instead, along with the hospitalisation and medicalisation of birthing, a model of obstetric nursing has been adopted.

In some parts of Thailand, institutional practices such as routine episiotomy, originally influenced by western countries but long since abandoned there, are still in regular use. Notions of 'woman-centred care' are yet to be adopted and women are denied intrapartum support from their partners or female relatives, in spite of this being the usual practice historically. The loss of these personal benefits seems to be regarded by women as little price to pay for the 'safety' afforded by the hospital and doctors, and the assurance of a 'healthy, happy and smart' baby. Such passivity seems to be reinforced by a 'system' and patriarchal society, where women have little input to political or high-level decision making.

Caesarean section rates in Thailand have been studied, and concern expressed regarding rates of up to 51.45% in the private hospitals in 1996, with a national average around 20% in that year. As in many contexts, the data demonstrate a public-private disparity. At the other end of the spectrum some women's access to formal birthing services has been problematic due to cultural or geographical constraints.

Maternal mortality

Available data have shown a dramatic reduction in maternal mortality ratio (MMR) since 1960. Notably, since before the introduction of hospitalisation and 'delivery by skilled carer' policies, a declining trend was underway. The most recent quality data were published after a Reproductive Age Mortality Study in 1995-1996, which showed an MMR of 44.1 per 100,000 live births. This figure was almost three times that of the official Ministry of Public Health statistics for the same period, a finding that triggered a review of maternal death classification and reporting, which subsequently brought about improved reporting and an increase in the documented MMR. However, for 2003, a ratio of 20.63 was documented, though it is important to note that no mandatory data-reporting requirement exists for health service providers. Thus these data are conspicuously incomplete, especially with regard to the private system.

The 'Millennium Development Goals Plus' plan for Thailand targeted the northern and southern regions in the area of Goal #5: Improving Maternal Health. These regions have exhibited higher than national MMRs, and have unique challenges: the northern terrain includes mountainous and difficult-to-access areas, along with at-risk population groups such as ethnic minority hilltribe populations as well as migrant and refugee women. The southern region presents other challenges, due to language, cultural and religious differences. Awareness of these issues has increased: additional resources as well as creative 'problem solving', are being applied.

The medical causes of maternal deaths have changed little over the years, haemorrhage still being a predominant factor. The proportion of deaths from 'indirect causes' increased with prevalence of HIV; however, aggressive action has since created a downward trend in the prevalence of HIV among pregnant women.

Midwifery in Thailand--current practice

Since 1986, midwifery in Thailand has had its own definition, codes and regulations of practice defined by the Thailand Nursing Council (TNC). Thai midwifery has also adopted definitions and guidelines from the Standards of Midwifery Practice for Safe Motherhood in South East Asia from WHO. These 25 standards clearly delineate midwifery practice including procedures that midwives are permitted to, and should be able to, provide for pregnant women and newborns. They also set the scope of practice to include family planning and initial management of abnormal situations, which may threaten delivering women's and babies' lives, in the absence of a medical professional. Midwifery practice in Thailand is expected to be provided within the scope of practice framed by these documents. However, the scope of practice defined by the TNC is narrower than that of WHO: for example, performing forceps and vacuum extraction deliveries is strictly prohibited by the TNC.

The current organisation of midwifery services in Thailand has puzzling aspects. Student nurses about to be registered receive a midwifery licence, but only some provide maternity services. The roles of those nurse-midwives who are providing care for pregnant women are often obscured by the perceived role of the obstetrician. Nurse-midwives whose work involves obstetric and maternity care, and often work exclusively in maternity care areas, are not called midwives. The term nurse-midwife is used for these practitioners, as it is for those not working in areas related to midwifery practice. The term obstetric nurse is also used in most hospitals.

A recent study Exploring Current Midwifery Practice in Thailand by Streerut Thadakant identified factors that are shaping the scope of Thai midwifery practice.

Structure and level of care influenced by the setting

Current midwifery practice appears to be shaped by the health care structure as defined by the Thai government, rather than the scope of midwifery practice as defined by international and national health and midwifery organisations. The structure of care is distinguished in two main types: the health centre setting where care is provided for outpatients; and the hospital setting for both in- and outpatients. The differing structures impact on midwifery practice, e.g. the health centre setting does not facilitate the provision of a continuum of midwifery care for pregnant women as there are no delivery rooms. Nurse-midwives at health centres therefore provide care mainly during the antenatal period, rather than the intranatal and the postnatal phases. In the hospital setting, nurse-midwives do not provide any degree of continuity of care, as they are usually fixed by their employment in one unit or one area of care. This fragmented approach to the organisation of practice may result in the loss of skills and a diminished range of midwifery practice.

The structural organisation of care also affects practice. In the community-level setting, easily accessible care is offered for minor diseases and normal maternal and childcare in high volume situations. Technologies such as ultrasonography and electronic fetal monitoring are not provided at this level. The nurse-midwives are not involved with the use of advanced technology for assessing the progress of pregnancy and the fetal health status. Thus the scope of midwifery practice in the community is limited for the management of complicated cases. By contrast, in the hospital, nurse-midwives are more involved in complicated pregnancies and abnormal situations and appear to engage in using medical technology to assess the fetal status as advanced medical instruments are available.

Lack of midwifery identity and midwifery models of care

The following are prevalent issues, which have potential implications for midwifery:

* Lack of continuity of caregiver

* Limited promotion of normal birth

* Limited provision of information to women/couples

* Reduced 'partnership' in decision-making

* No affiliated professional body representing Thai midwives (only the Thai Nurses Association)

* Limited opportunity to participate in international professional development events for midwives and to contribute to the international body of midwifery knowledge.

While researching midwifery practice in Thailand, Thadakant found that most nurse-midwife respondents lacked a strong professional identity as midwives, and had only a weak affiliation with the midwifery profession. Some also had a confused understanding of the roles of a midwife and a narrow view of the scope of midwifery practice. There was a perception that midwives are of low status within the health care system. Nevertheless, in the same study, nurse-midwives were able to identify a model of continuity of carer, and their interest in independent practice was evident. Thai nurse-midwives thus recognised and valued the broader roles and scope of practice as described by the International Confederation of Midwives. They indicated a preference for providing a wider range of midwifery care throughout pregnancy and a desire to practise independently in relation to normal pregnancy. However, lack of empowerment to seek the preferred models was apparent, as they also indicated satisfaction with the existing patterns of practice.

Reducing maternal mortality vs. improving maternal health

A preoccupation with maternal mortality ratios in the international community has arguably led to a distortion of priority setting in birthing services in many developing countries, including Thailand. The fact that the MMR is notoriously problematic to measure and monitor has been overlooked until recently, when it has been acknowledged that data about 'near misses', and quality improvement indicators such as case fatality rates, can be more usefully applied. No mandatory requirement exists in Thailand for the routine collection and reporting of birthing data. Thus, data collection and analysis lacks standardisation, and the utility and availability of data is limited. Lack of accountability regarding birthing interventions and outcomes within the lucrative private system is apparent.

The author's current research study aims to inform health policy and contribute to practice development in Thailand. Historically, a variety of international sources have contributed to policy development in the various sectors related to birthing and within stakeholder organisations (e.g. the Royal Thai College of Obstetricians and Gynecologists); thus a combination of strategy approaches has been applied for the reduction of maternal mortality. Additionally, the Ministry of Public Health policy has been specifically targeted to this end. The policy of hospitalisation for birthing, as well as the parallel medicalisation, has been researched in the current study. Dramatic population, social and economic changes have also contributed to the changing outcomes, and these 'social determinants' are also under investigation.

Penny Haora RN, RM, MPH (International Health), PhD Candidate, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia, [e-mail]

Streerut Thadakant RNM, MSc (Public Health: Nutrition), MSc (Midwifery). PhD, Lecturer, Department of Nursing, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

For a full list of references please contact Penny. Penny Haora's PhD project is part of the 'Thai Health Risk Transitions' Study. The aims of the study are: to understand the main factors behind the impressive reduction of maternal mortality in Thailand; to identify potential future Steps for further reducing mortality; and to identify prospective strategies for reducing morbidity and improving maternal health, especially among women of population sub-groups e.g. rural, migrant, refugee women. An additional aim is to 'learn lessons', which may be adopted by other countries of the region where maternal deaths still occur frequently.