Organisation of maternity care and choices of mode of birth: a worldwide view.

Drawing on the findings from a Cochrane systematic review of midwife-led care vs. other models of maternity care, this article discusses maternity organisation of care, women's choice of mode of birth and a global trend in reducing normality of childbirth. The review included 11 trials involving 12,276 women. The results showed that women who received models of midwife led care were less likely to experience fetal loss before 24 weeks' gestation, less likely to have regional analgesia, less likely to have instrumental birth, less likely to have an episiotomy (with no significant differences in perineal lacerations), and were more likely to be attended at birth by a known midwife, more likely to have a spontaneous vaginal birth, initiate breast feeding and more stated to feel in control. In addition, their babies were more likely to have a shorter length of hospital stay. No statistically significant differences were observed in fetal loss/neonatal death of at least 24 weeks or in overall fetal/neonatal death between women who were allocated to the midwifery led care and those in the medical led care. In light of these findings, the interrelationship between social organisation of maternity care, philosophy of care and choice is explored using case examples with high and low rates of caesarean section rates. A worldwide overview of vaginal birth and caesarean section rates as indicators of normality (and lack of it) is also presented. Questions are raised with regard to the fast growing rate of caesarean section rates particularly among middle income countries. The rate of caesarean section is twice as much in private settings compared to public hospitals in these countries. In conclusion, the importance of sharing good practice among countries with particular attention to social location of midwifery, mobilisation of consumer groups as well as education of maternity health-care professionals and women, in facilitation of an effective 'informed choice', is highlighted. Areas for further global research on factors, which may influence women's choice of mode of birth are debated.