According to official data, in 2021, 17 cases of maternal mortality per 100,000 births were recorded in Ukraine, compared to 4 cases in the Netherlands or Germany. The perinatal mortality rate in Ukraine was 9.2 cases per 1000 newborns, while in the Netherlands, it was 5, and in Germany, 5.9. One of the factors that may contribute to such high mortality rates compared to European ones is the lack of a continuous care model in Ukraine that focuses on low-risk pregnant and birthing women.
Even before the full-scale invasion began, Ukraine was facing a demographic crisis. This is evidenced by a nearly twofold decline in the birth rate: from 511,070 births in 2012 to 258,483 in 2021. The full-scale invasion of Russia has led to a significant deterioration in these indicators. According to OpenDataBot, 209,393 children were born in Ukraine in 2022, which is 28% less than in 2021.
According to the UN Population Fund, the number of preterm births, stillbirths, and perinatal pathologies has increased significantly during the full-scale war. Many women had to give birth in hospital basements, subway stations or other shelters, during air raids or even under fire. There have been cases when childbirth had to be done via mobile phones or online due to the risk of transfer. Unfortunately, birth attendants in Ukraine have little or no experience and skills to provide emergency care outside of a medical facility, which can be disastrous in a full-scale war.
These and other challenges have highlighted problems in the organization of care in childbirth in Ukraine.
Among the main problems:
- Almost all women, regardless of their perinatal risk group, give birth in high-tech perinatal centers and second- and third-level maternity hospitals, which are designed to provide care to women with high-risk pregnancies. This can lead to unnecessary medicalization of normal births and diverts specialists from women with high-risk pregnancies and births. The use of perinatal centers for low-risk pregnant and birthing women is also economically inexpedient. This is evidenced, for example, by the practice of the Netherlands, where low-risk pregnant and birthing women receive care from qualified midwives as the primary level of care in childbirth, and only in cases of high-risk conditions is responsibility transferred to an obstetrician.
- Women with low-risk pregnancies and births face a large number of unnecessary medical interventions and manipulations. According to a 2021 study, the over-medicalization of low-risk pregnancy and childbirth, which is characteristic of the obstetric (obstetrician-led) model of care, may be associated with increased rates of cesarean sections. At the same time, 21.1% of women in Ukraine among more than 7000 persons who took part in the national survey would like to have a natural, comfortable and safe delivery, which can be provided in midwifery centers.
- The closure of maternity wards in small towns leads to a lack of specialists in communities who can provide continuous, qualified care during pregnancy and childbirth at the place of residence. This contradicts the decentralization reform, and is also critical for women with low-risk pregnancies who have no indications for hospitalization or constant medical supervision and would like to give birth in their community.
- Devaluation of the midwifery profession and an effective removal of midwives from care for low-risk pregnancy and childbirth. The actual scope of practice and responsibilities of Ukrainian midwives has been reduced to the equivalent of the profession of nurse-midwife or OB-GYN assistant in EU countries. This creates a monopoly for OB-GYNs to manage all pregnancies and deliveries, including low-risk ones, and leads to a lack of qualified professionals in communities who specialize in providing midwifery care to low-risk pregnant women. Numerous studies, including the most recent systematic review and meta-analysis published in PubMed in 2023, have shown that a model of care in which a skilled midwife provides comprehensive care for low-risk pregnant women during pregnancy, labor and the postpartum period, as well as for newborns, has a positive impact on preventing preterm birth, reducing the need for interventions and improving clinical outcomes.
- Women who choose to give birth outside of a medical facility put themselves and their babies at risk due to the lack of medical professionals who can provide qualified care at the place of their choice and the lack of integration of home births into the maternity care system in Ukraine. According to official data from the Ministry of Justice, in 2020, excluding data from Dnipro, Rivne, Odesa, Volyn, and Chernivtsi regions, 317 registrations of children born outside of a medical facility were made in Ukraine. This creates additional challenges in the realities of martial law, when giving birth outside a medical facility may be a forced measure due to the security situation in a particular region. Since, on the one hand, home births are not regulated by any norms, there are no qualification conditions for them, no policy of transfer to a medical facility; and on the other hand, since existing birth attendants are not authorized to provide care outside a medical facility and do not have the appropriate skills, the risks to mother and child in the event of a birth outside a medical facility increase significantly. It is important to note that in most European countries, home births are part of the public maternity care system. According to a 2020 systematic review and meta-analysis, among low-risk women who plan to give
- The absence of licensing and personal responsibility of medical professionals creates a dependence of doctors and midwives on a medical institution. Without registering as an individual entrepreneur and obtaining a medical practice license, specialists cannot legally work with pregnant and birthing women. To obtain such a license, individual entrepreneurs or institutions must have premises and a significant amount of equipment, which is not expedient for low-risk pregnancy management. Specialists also do not bear any professional responsibility when they work with clients in the shadows. This is due to the lack of professional licensing in the medical industry in general. In addition, competition for pregnant women among medical institutions is linked to funding from the National Health Service of Ukraine, and among doctors — through monetary “gratitude” to the doctor, which often translates into an unofficial mandatory fixed payment without paying taxes.
- A prescriptive and manipulative approach to interacting with women in childbirth, inherited from the Soviet era, returned during the full-scale invasion. This happened for a number of reasons: the impact of long-term stress on the mental health of medical staff, the lacking culture of support and prevention of mental stress among medical professionals, excessive workload due to forced displacement, curfews, and the closure or destruction of maternity hospitals. This situation turns us from a woman-centered, client-oriented approach based on dignity and human rights to aggressive and prescriptive management of pregnancy and childbirth. Obstetric violence, non-compliance with existing protocols, non evidence-based practices, unnecessary harmful medical interventions, intimidation and manipulation of the life and health of unborn children are often recorded during childbirth, as evidenced by numerous media reports and published stories of many women. It is important to note that WHO recognizes the central role of the professional midwife in providing quality care during pregnancy and childbirth and other reproductive and sexual health services. In a supportive environment, midwives trained to the standards of the International Confederation of Midwives (ICM) can provide almost all the care women and newborns need.The midwifery model of care (midwifery-led care) provides for the professional autonomy of midwives; a partnership approach to working with clients and the proactive role of pregnant women and families in decision-making; continuous care during pregnancy, childbirth, and the postpartum period; informed choice in all aspects of care; the right to choose the place of delivery and to receive professional care; an integrated approach to working with other healthcare professionals; and an approach based on evidence-based medicine and researchirth at home compared to low-risk women who plan to give birth in a hospital, the former group has fewer medical interventions during labor and fewer adverse maternal outcomes. At the same time, the risk of stillbirth, neonatal morbidity and mortality among low-risk women does not differ depending on the planned place of birth (home or hospital).
It is important to note that WHO recognizes the central role of the professional midwife in providing quality care during pregnancy and childbirth and other reproductive and sexual health services. In a supportive environment, midwives trained to the standards of the International Confederation of Midwives (ICM) can provide almost all the care women and newborns need.
The midwifery model of care (midwifery-led care) provides for the professional autonomy of midwives; a partnership approach to working with clients and the proactive role of pregnant women and families in decision-making; continuous care during pregnancy, childbirth, and the postpartum period; informed choice in all aspects of care; the right to choose the place of delivery and to receive professional care; an integrated approach to working with other healthcare professionals; and an approach based on evidence-based medicine and research.
In summary, we argue that:
In order to reduce maternal and perinatal mortality in Ukraine, given the new challenges posed by Russia's full-scale invasion, due to the economically unjustified use of the resource of perinatal centers and high-tech hospitals for low-risk pregnant and birthing women, in order to shift the worldview paradigm of childbirth from a pathological-medical process (as a disease) to a physiological one (as a norm), and to bring care during pregnancy, childbirth and postpartum closer to EU standards, in particular the EU Directive on the Education and Practice of Midwives, we consider it necessary to introduce a midwifery model of care in Ukraine.
It is important to introduce the profession of midwife, a professionally autonomous, qualified birth attendant who provides continuous care to low-risk pregnant and birthing women.
A characteristic feature of the organization of medical care during pregnancy and childbirth in the EU is decentralization. Midwives autonomously provide care to women of NGO Family Development Center "Semytsvit"
NGO Association of Natural Parenting Specialistsreproductive age, including low-risk pregnancy and childbirth at community-based birth centers. We are convinced that in Ukraine, there should be an opportunity for safe, continuous care during low-risk pregnancy and childbirth in communities with the participation of a qualified midwife with the possibility of receiving consultations, joint care and transfer to perinatal centers with multidisciplinary teams (obstetricians, gynecologists, neonatologists, anesthesiologists) if necessary.
The introduction of the midwifery model of care in Ukraine will have a positive impact on perinatal outcomes and ensure that low-risk pregnant and birthing women can receive services in the primary care setting.
Persons with a midwife specialty will be able to attend childbirth in a place of a woman's choice, which is especially important under martial law, when transportation to a medical facility may be difficult or limited.
It is important to introduce professional licensing for independent medical activity in the field of midwifery and at the same time to review approaches to licensing of economic activity in medical practice, changing approaches in general. This will make it possible, in particular, to legally provide personalized midwifery services that are not covered by the medical guarantees program, but guarantee safety for women through a comprehensive control system and professional responsibility.
To train midwives and effectively implement the midwifery model of care in Ukraine, it would be appropriate to create pilot projects at maternity hospitals using training programs from leading countries.
It is also necessary to develop appropriate legislation and regulations for the implementation of the midwifery model of care as an integral part of the midwifery system in Ukraine.
The resolutions were signed by the following NGOs and activists by filling out a Google form:
Organizations:
NGO Association for the Prevention of Traumatic Childbirth
NGO Lviv Academy for Human Rights
NGO Doulas of Lviv
NGO Ukrainian Midwives’ Union
NGO Natural Rights Ukraine
NGO Docudays
Perinatal specialists, professional lawyers, human rights defenders, public activists:
Olena Hnidec - midwife
Olga Syomina is an obstetrician-gynecologist
Svitlana Kalyukh - midwife, perinatal psychologist
Tatyana Panasiuk - midwife
Yulia Oleh is a public activist
Anna Marich is an obstetrician-gynecologist
Alina Dunaevska is an obstetrician-gynecologist
Lyudmila Vedmid - midwife, Perinatal Center
Alla Lobas - midwife
Tetyana Fesenko is a midwife
Maryna Magdenko is a midwife
Farida Mirzoyeva - midwife, Ukrainian Medical Center of Obstetrics, Gynecology and Reproduction of the Ministry of Health of Ukraine
Svetlanka Kresina is a doula
Iryna Cherednychenko is a doctor
Zoya Turkovska is a perinatal psychologist
Tatyana Britan - doctor, doula, mentor
Victoria Pavlova is a doctor
Olena Rozhenko is a midwife student
Oleksiy Golovin is a lawyer
Anna Petrovska is a pregnancy consultant, a doula, and a human rights activist
Yevgenia Kubakh is a human rights activist, an expert on women's rights during pregnancy and childbirth
Mariana Vladimirtsova is a biologist, midwife, and OB-GYN consultant
Hanna Leshchenko is a doula
Sofia Brytkova - obstetrician-gynecologist, osteopath
Julia Fesniak is a doctor
Marina Cherednyk - psychologist, doula
Iryna Ferko is a perinatal psychologist
Tetyana Kostenko is a doula
Zhanna Mazyukova is a doula
Anastasia Shcherban is a doula
Oleksandra Basko - doula
Anastasia Chromey is a psychologist
Hanna Tyutyunnik - doula, childbirth preparation instructor
Olga Merkulova is a lawyer
Anastasia Kozachok is a doula
Veronika Kupchenko is a doctor
Tamara Dyka is a midwife
Iryna Kryshtal is a doula
Yuliya Rudyak - perinatal psychologist, psychotherapist
Oleksandra Tymoshenko - doula
Natalia Bohonko is a doula
Olena Zvir - public activist, communicator
Olena Ryabitska is a doula
Marina Pustovit is a psychologist
Kateryna Petruk is a psychologist
Anna Sinkina is an obstetrician-gynecologist
Oleksandr Kobasa is an obstetrician-gynecologist
Olga Stepenko - midwife
Natalya Myronyshina is a postpartum recovery specialist
Olesya Sydorenko is a psychologist
Tatiana Brazhnyk is a public figure
Oksana Kuklina - a consultant in food and supplementary feeding; trainer of childbirth preparation groups
Olena Yakymenko is a midwife
Olena Chernyaeva-Dovgalenko - doula
Anastasia Barykina - doula, perinatal psychologist
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- Obstetrician-led model
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