Delivering the goods: Sweden's midwives stand test of time

October 2, 2013 by Camille Bas-Wohlert

Only one ultrasound in nine months and no need to see the doctor or obstetrician: at first glance, Sweden's pregnancy care appears rather simplistic.

But while it may be far from the medical approach to seen in most Western countries, where mothers-to-be have loads of doctor's appointments and tests, the Swedish system, where reign supreme, has proven its merits.

According to the organisation Save the Children, Sweden is the second-best country in the world to become a mother, behind Finland.

Neonatal mortality is low, at 1.5 deaths per 1,000—the second lowest in Europe behind Iceland—as is maternal death in childbirth, at 3.1 per 100,000 births, according to the European Perinatal Health Report from 2010.

In Sweden, midwives are entrusted with caring for the health of the expectant mother and the foetus. It is the only pregnancy care available to women, and is free for the patient, falling under state health care benefits.

"A doctor can be called in at the 's initiative as soon as she notices that something is not right," says Sofie Laaftman, a midwife in central Stockholm.

For those accustomed to intensive medical care during pregnancy, the Swedish way may seem rudimentary: a few blood and urine tests are done to detect vitamin deficiencies or anomalies, the mother's blood pressure and the heartbeat of the foetus are checked, and a little nutritional advice is doled out.

During a normal pregnancy without complications, just one ultrasound will be done over the whole nine months—and not a single gynaecological exam.

Meanwhile, in France for example, a 2011 report from the health ministry showed 20 percent of expectant mothers had more than six ultrasounds and four percent had more than 10—without any obvious benefit.

"Pregnancy is a normal condition" and not an illness, says Marie Berg, professor in health and care sciences at Sahlgrenska Academy at Sweden's University of Gothenburg.

Laaftman echoed that notion, saying most women under 40 did not need more medicalised care since their bodies were healthy and capable of giving birth, which is after all a natural process.

Lonely, but in good hands

A scientific study published in August by the Cochrane Collaboration, an organisation of practitioners, concluded that "most women"—those who have no complications in pregnancy—would benefit from seeing a midwife during pregnancy rather than a doctor.

Care by a midwife can actually reduce the number of premature births, the study's authors say. In Sweden, only five percent of babies are born prematurely.

But the lack of contact during pregnancy can be tough for some expectant mothers.

Christina Singelman, a 31-year-old expecting her second child, recalls the sense of loneliness she felt during her first pregnancy: from the time she registered at the clinic until her first ultrasound, some 10 weeks went by without a single appointment.

But if the woman is under the age of 40, has no prior medical conditions and has fallen pregnant by natural methods, "there's no reason to have more frequent checks in the beginning", insists Laaftman, the Stockholm midwife, who cares for about 100 at a time.

Adina Trunk, 33, saw two different midwives for her two pregnancies.

"They were both very competent but the system puts them in a very passive position. It's always up to the expectant mother to take the initiative, to ask questions and possibly ask to see a specialist," she says.

"And since this is a culture where people don't like to make a fuss, it keeps costs down," she adds.

Midwives also take care of the delivery, although that is with an entirely different team than the one that has followed the mother throughout her pregnancy.

A doctor will only intervene if there are complications during the delivery, or if the woman in labour asks for an epidural, which is the case in about half of all deliveries.

Entrusting pregnancy and delivery care to midwives to such an extent is unique in the world.

Midwives in Sweden have been in charge of pregnancy care since the 18th century.

While the rise of the modern medical profession meant midwives in much of Europe were forced to yield at least part of their responsibilities to doctors, Sweden's midwives held onto their traditional role thanks to doctors' consent and, in recent times, a strong union.

The system has never been called into question, owing primarily to its strong track record.

The number of Caesarian sections is relatively low in Sweden, at around 17 percent of births in 2011, and only 10 percent of women undergo episiotomy, an incision to widen the opening for delivery.

"It's an efficient system in terms of cost management," says University of Gothenburg professor Berg.

In countries where care for pregnant women, she says, the number of "tests and ultrasounds often multiply, which opens the way to easy money".

Explore further: Women who receive midwife care throughout their pregnancy and birth have better outcomes

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