[Русская версия]

Imagine you (your partner, close relative or a friend) are pregnant or just planning a pregnancy and now are puzzled about what will happen next. If we focus on the period between the decision to continue with the pregnancy and the necessity of taking care of the newborn, it is obvious that childbirth is a prime area of interest. Sooner or later you will figure out that there are different conditions (hospital or home childbirth, paid or provided by health insurance, in an individual or shared delivery room, etc), different formats (with a partner, with a doula or with a medical team on duty), and different methods of delivery (vertical, conservative, surgical, “natural”, with or without anesthesia and so on). If you are in Russia and live in a regional center, you probably have some options to choose; indeed these depend considerably on the different resources you possess – in this way you can enter the so-called “market of obstetric services” (Temkina 2016).

Suppose you live at some distance from the regional center. In that case, your options become considerably reduced. There is only one maternity department at the Central Hospital in your district, and if you do not have certain materials available (a personal car at least) or social resources, you will have to give birth in only this department. And now imagine there is no maternity department in your district at all, or that you live in a village, say 40 kilometers (or much more) from it. In case birth is on term, you probably would just spend a bit more days in a hospital, but in the case of urgent delivery, you would go with an ambulance and then just rely on luck to reach a hospital in time.

ambulance_LO2

These hypothetical situations illustrate only one thing: the system of “birth supply” is heterogeneous and distributed unevenly across the country. Moreover, there are more or less developed fragments of this system within each region. Such a systemic view allows the investigation of the obstetric system in Russia as one of many other infrastructures, providing the work of any organized practices (Star 1999: 380). On the one hand, usage of this infrastructure seems to be quite rare and limited – according to statistics, each woman in Russia uses it only 1.7 times [according to the data of ‘Rosstat’ for the 2015 year]. On the other hand, any breakdown in this infrastructure demands completely different symbolical and physical expenses, as opposed to a plumbing problem such as damaged tap.

If we, in spite of all probable counterarguments (like for example, why we can analyze childbirth as an organized practice), consider the obstetric system to be an infrastructure, several non-obvious features can be detected. According to Susan Leigh Star’s definition, infrastructure serves as such as long as it stays invisible (Ibid); it becomes appreciable only in case of breakdown, when its work stops being unnoticeable. In this sense, facility-based childbirth in Russia is often a ‘broken’ infrastructure: its usage implies either continuous and intended processes of choice, or is accompanied by social, symbolic, or transport challenges. Moreover, some recent reforms in the field of obstetrics management and regulation sometimes cause even deeper fragmentation of the quality, development and access to maternity services.

perinat_centr

The facility-based childbirth system in Russia, represented by healthcare institutions and providing obstetric services for women and neonathological services for newborns, has been considerably transformed for the past several decades. Services of maternity and childcare, provided by the branched network of obstetric hospitals, FAPs (nursing-level institutions), and maternity wards in district hospitals located even in remote places, have been rearranged. The main goal of reforms in this field was to decrease the maternal and infant mortality rates, and the improvement of technically developed healthcare. In order to reach this goal, the construction of perinatal centers (large and technically the best equipped institutions) has resumed since 2006.

Moreover, since 2009 (but more appreciably since 2012), facility-based childbirth has been organized as a three-level system within each region. The smallest and the least equipped maternity institutions (less than 500 births per year) were assigned first level status, not allowing work with complicated or pathological cases of pregnancy and delivery. The second level institutions in this system usually represent larger and more equipped maternity wards in central district hospitals, while the third level – independent maternity hospitals and perinatal centers, are located in regional centers. Coordination between all these levels is regulated by so-called ‘marshrutizatsia’ (routing) – a particular order that prescribes hospitalization of pregnancies with different risks of complication to the appropriate level of maternity care.

Such measures have actually decreased the levels of maternal and infant mortality rates during the past few years. Besides, statistics have revealed that the most unfavorable cases occur in the first level institutions – the most remote and the least equipped. Hence, one of the measures enacted by regional administrations was the redistribution of institutional capacity between different levels. In practice this was realized through the growth and expansion of perinatal centers at the expense of the smallest first level institutions: through the reduction of their beds, services and staff, and in some cases through their complete closure. For example, due to this ‘optimization’ the neonatologist’s round-the-clock duties can be curtailed or abolished, in which case the doctor has to come overtime if childbirth happens at night. The positions of infant nurses can be reduced or eliminated, in which case midwifes should perform their duties. Further reductions include the list of medicines and technical devices used for urgent delivery. Because of this, the decrease of birth rates in certain institutions leads to economic deprivation (fewer insurance payments), as maternity wards become economically unprofitable for hospitals – consequently such wards appear at risk for closure.

rodzal

In this way one of the unintended consequences of the leveling and routing measures in the facility-based childbirth was the decrease of those maternity wards located in the most remote areas. And now let’s turn to the hypothetical cases of childbirth that we imagined at the beginning of the text. Usually, women with pregnancies without any complications or other health problems do not know to which level a maternity institution is assigned, and neither do their partners, friends, parents or even midwifes. They probably do not read the statistics of the Ministry of Health and are not aware of the bed and staff capacity of their particular department. It is much more important for them just to pack the necessary items for childbirth and postpartum, and to reach the facility on time. But if any of them live not in a regional or district center, their usage of the obstetric system becomes all the more problematic.

Suppose a pregnant woman lives in a small town located 150-250 km from the regional center. There is probably a first level maternity ward in this area. Moreover, during the pregnancy some medical complications are revealed, according to which this woman should be routed to the regional center. Or this particular maternity ward was ‘optimized’ and closed. In reality this means that one or more weeks before the date of birth, the patient should go to regional hospital on her own and spend this entire period hospitalized. On the one hand, the technical equipment at this maternity institution, as well as the doctors’ qualification and some other circumstances, provide more safety of the childbirth in this case. On the other, the location of this institution does not take into account those social and transport challenges which pregnant woman must face: how can she reach the perinatal center if, for example, there is no car in the family? How should she come back home with a newborn already? What if she already has other small children? What if, finally, labor begins before the due date? And what if a snowstorm has started and it takes much more time to travel?

The reformation of the obstetric system in Russia and the existing routing model do not consider these and other important questions. Practical changes of the system streamline its management but complicate its usage by both patients and healthcare practitioners. In other words, conceptualizing the obstetric system as infrastructure allows us to detect some problems in its functioning that would be invisible to statistics. This same system does not appear to be an infrastructure for those who project or service it (Star 1999: 380) – it should be unnoticeable for its user. However, the recent changes in the facility-based childbirth’s regulation and resource allocation emerge not to simplify its usage by pregnant women and their relatives, but to optimize its work for economic and statistical reasons.

References:

Star S.L. (1999) The Ethnography of Infrastructure. American Behavioural Scientist, 43: 377-391.

Темкина А. (2016) Оплачиваемая забота и безопасность: что продается и покупается в родильных домах? Социология власти 28(1): 76-106.

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