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Why family-friendly Sweden is talking about a maternity care crisis

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Why family-friendly Sweden is talking about a maternity care crisis
"All around Sweden I hear that prospective parents are worried," Sweden's Health Minister told The Local. Photo: Izabette Nordfjell/TT
16:32 CET+01:00
Sweden is regularly hailed as a feminist, family-friendly country, but in recent years pressure on maternity care has led to overworked midwives and closed-down clinics, while rates of injury during childbirth are above the OECD average. The Local explores the story behind the Swedish 'maternity care crisis'.

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By all accounts, Sweden is a wonderful place to raise children. Take lengthy paid leave if you want it, explore the many well-equipped public play areas, enjoy generous state benefits as the children grow up; the list goes on.

Sweden has the world's first self-proclaimed feminist government and was recently ranked by separate surveys as both the best place in the world to be a woman and the best place for expat families.

Yet despite the many positives to raising a family in Sweden, the country faces challenges in one extremely important aspect: maternity care. A Google search for 'förlossningskris' (maternity care crisis) brings up thousands of results, and Swedish media, including The Local, have reported for years on the problems facing the sector.

The term 'crisis' should be seen in perspective. Sweden is an extremely safe place to give birth. Healthcare is heavily subsidized by the state, and the country's midwife-led approach to maternity care has been credited with the fact that infant and maternal mortality rates are among the lowest in the world.

But that doesn't tell the full story.

There are "two sides" to Swedish maternity care, Annika Strandhäll, the minister for health and social affairs, tells The Local in an interview via e-mail.

"We have good care; however, we see that employees are too stressed and that the parents-to-be do not always feel security when about to give birth," Strandhäll explains. "Swedish midwives have had too tough a situation for a while."


Annika Strandhäll, right, joined a shift with midwives working at Stockholm's Karolinska Universitetssjukhuset, and said this was "perhaps my best experience as a minister so far". Photo: Ministry for Health and Social Affairs

"All around Sweden I hear that prospective parents are worried [about whether] they can expect a safe delivery, and the situation is in many ways strained in childbirth," the minister adds.

Though Sweden recently upped its spending on maternity care, she acknowledges that this should have happened earlier and that individual midwives are under huge amounts of pressure. What's more, Strandhäll says a long-term increase in funds is necessary in order to "give the midwives, and other personnel within this field, better conditions to do what they are good at".

Over recent years, maternity wards across the country have closed down due to a lack of funds and qualified staff.

In a 20-year period the number of total hospital beds across the country decreased by 10,000 according to one study, while the population grew by 13 percent during the same period. Among OECD countries, the number of hospital beds per capita in Sweden is the third lowest, ahead of only Mexico and Chile. While a lack of funding has affected the healthcare system as a whole, maternity care has been particularly hard hit, and between 2000 and February 2017, nine maternity clinics were closed down. 

READ ALSO: Swedish blogger films her entire childbirth and puts it on YouTube

The most recent of these closures, of a maternity ward in Sollefteå, northern Sweden, in January last year, prompted widespread protests. The county council said the move would save money and that they had struggled to recruit qualified staff for the clinic, but it left expectant mothers facing journeys of 100-200 kilometres to reach their nearest alternative.

Some argued that this was actually illegal: Sweden's Patients Act, which came into force in January 2015, states that all residents should have "easily accessible" healthcare.


A sign protesting the ward's closure reads "Are women's and children's lives not worth anything?" Photo: Izabelle Nordfjell/TT

Two healthcare professionals started a course to teach parents-to-be how to deal with a car birth, something they warned would be increasingly likely due to these long distances.

However, one of them, nurse Stina Näslund, later told The Local that authorities had banned midwives from teaching the course due to rules over working for competitors, and said that this move "could put people in danger". And less than a month after the ward was closed, the first woman to gave birth at the roadside on her way to her nearest hospital described the experience as "the worst thing I've been through".

The news of the car birth course was picked up by global media, intrigued by the seeming contradiction between the necessity of such a course and Sweden's image as a feminist, family-friendly country. But for those familiar with the context, it's a problem that has been in the making for years.

It's not only the rural north affected by the shortages. In 2014, a Swedish man helped his fiancée give birth in the back of a taxi after they were told that every maternity ward in the Stockholm region and sent south to the small town of Nyköping one hour away. In August 2017, a woman gave birth in the garage of a Gothenburg hospital after being sent away from their local hospital.

In other cases, pregnant women have been sent out of the country altogether, with multiple families from the Uppland province flown to Finland to give birth.


Östra sjukhuset in Gothenburg. Photo: Tomas Johansson/TT

One factor putting pressure on the wards is a lack of midwives to work in them. As the national population rises steadily, the number of pregnant women in Sweden is increasing much faster than the number of midwives. And estimates suggest that in the next seven years, one in three working midwives will retire.

Many others opt to work abroad, particularly in neighbouring Norway, where wages are higher and workloads often lighter.

Others still are quitting midwifery altogether. Eight midwives in Växjö, Småland, resigned over the space of just a few months last year, citing the stressful workload as well as cancelled maternity leave and vacation time. At a clinic in Huddinge, south of Stockholm city centre, staff say 47 of the 128 midwives have quit (though managers say the figure is lower, with only 39 resignations in 2017 and 16 new recruits) since management changes in autumn 2016. Midwife Karin Frostemo criticized a "culture of silence" among the clinic's leadership in a Facebook post explaining her decision to quit after 18 years.

Meanwhile, those entering the profession warn they won't put up with the current working conditions and salaries, which are lower than those given to other medical professionals with similar levels of training. One group of student nurses, graduating in January 2018, launched a petition saying they wouldn't work for less than 33,000 kronor and saying they "refuse to accept the unreasonable working conditions that exist".

Staff shortages means tougher conditions for those left working in Sweden's maternity wards. In July, Stockholm midwife Petra Vinberg Linder shared a photo of her scrubs stained with menstrual blood to illustrate the hectic pace of work that left her without any time even to go to the toilet or change her sanitary products.  

"I love my job, I chose it and I want to work in this field, but I wonder after a night like this how many years I'll manage," she told The Local at the time. Vinberg Linder said that midwives at her hospital assist an average of two childbirths at any given time, something which is the norm across the country.

"There are so many people in this country who want to work with childbirth, but don't because of the working conditions. It's just getting worse and there has to have a change," she said.


Midwives protesting their working conditions in 2014. Photo: Maja Suslin/TT

Marianne Weichselbraun from the Swedish Association of Midwives echoes these concerns. "If you do this job, you want to do it in the best way. And if you can't, you probably don't want to be part of a system that's not giving the best care," she tells The Local.

"We have clear ideas of what should be done; for example, having each midwife assisting just one birth at a time, rather than running between two or three as it is today. It's not just that, but we know this in particular would make our working environment a lot better."

Weichselbraun says that as well as hiring and retaining more midwives, it's essential for those in the profession to be given opportunities for further training and skills exchanges between hospitals and councils. "As it is today, you just do what you have to do each day; there's very little time for education," she says.

"Over the past few years, it's not that we work longer hours, but our salaries haven't gone up if you compare it with other jobs which need higher education; so many midwives don't feel valued for what we do."


A protest calling for better support for Sweden's midwives in 2013. Photo: Klara Westblom/Scanpix/TT

There have already been serious incidents possibly linked to midwives' heavy workload. In July 2016, a baby was stillborn after a clinic sent home a heavily pregnant woman. Though she was showing signs of pre-eclampsia, she was asked to leave due to a lack of space at the clinic, and the hospital said failure to admit her may have contributed to the stillbirth.

And in October last year, a Stockholm hospital investigation into the birth of a child with a severe brain injury ruled that the attending midwife's high workload was a contributing factor. The midwife was attending to three births simultaneously and was out of the room when the parents-to-be first noticed the fetus' heartrate looked weak.

These are extreme, rare cases, and sadly it's almost impossible to avoid all tragic accidents.

In January 2017, Sweden's National Board of Health and Welfare reported a "small but worrying" increase in both maternal injuries at childbirth. The most recent OECD data also shows that Sweden has a higher than average rate of obsetric trauma (injury to the mother during childbirth): 11.3 percent in instrument-assisted births and 2.4 percent for births without instruments. The differences between counties were significant: in Stockholm, seven percent of first-time mums suffered from serious ruptures, compared to four percent in Halland.

The health authority also reported a rise in mothers needing urgent care after having given birth and been dismissed from hospital. This comes as pressure on space has meant that the time women spend at the clinic after giving birth has fallen to 1.8 days on average, more than half of the average 30 years ago in Sweden and the lowest average across the EU.

So despite the generally high levels of safety and quality of care, it's easy to see why in 2014, the Swedish Association of Health Professionals in Stockholm gave a statement warning that mums in Sweden were increasingly scared to give birth.

And women who had suffered the kind of problems that might not show up in official statistics, but are still serious enough to impact their experience of childbirth and in some cases, their quality of life afterwards, such as lacerations, are raising their voices.

After the 2015 closure of yet another maternity clinic in Sweden, the non-profit organization Födelsevrålet was born. The group represents pregnant women who have experienced problems during childbirth and gained over 1000 Facebook followers within the first day, a number which has since swelled to 12,000. It has organized protests, including those in response to the closure last January of Sollefteå's clinic. At the site of the clinic, one group occupied the building and hundreds more marched in towns and cities across the country.


Women's rights campaigner and journalist Cissi Wallin leads a march through Stockholm. Photo: Jonas Ekströmer/TT

Jill Leckie runs the online parenting magazine Littlebearabroad about parenting in Sweden, after moving here in 2015 when she was seven months pregnant. Since her daughter Stella was born, she has attended the Barnvagnsmarsch (pushchair march) each year which calls for support of maternity and sexual healthcare in Sweden and around the world, and she says that readers of her blog regularly contact her with questions about Swedish pre- and post-natal care.

Leckie says that it's extremely worrying to hear of the maternity ward closures in rural Sweden, but adds that Swedish media may in some cases have overstated the crisis. "What Sweden deems a crisis may be par for the course in many other countries," she notes, adding: "Presenting stories of women having to travel to another hospital, 20 minutes away, as headline news is not helpful; it's scaremongering."

"But, it is important for parents-to-be in any foreign country, not just Sweden, to know your rights. Research the patients bill of rights and the rights of the labouring woman. And be mindful that births rarely go to plan," she says.

When The Local took to our Facebook page to ask parents about their experiences of giving birth in Sweden, the response was overwhelmingly positive, with many of our readers praising their midwives.

"From the pre-natal care to the birth and now my son's monthly check-ups it has been an absolutely amazing experience. Everything and everyone is so organized," said Francine Kinloch.

"Everyone we came in contact with was so knowledgeable and skilled in what they do. Plus the fact that everything was free made the whole experience amazing," said Linnea Hennings.

While some readers said that the Swedish system is less well-suited to pregnancies with complications or additional maternal health issues, Sofie Eskilsson said she had had a high-risk pregnancy and found Swedish maternity care "outstanding".

The government has focused increasingly on improving maternity care in recent years, and in 2015 the government and SKL signed an agreement to improve maternity care. Since then, an annual survey has been put together to examine rates and of obstetric trauma, with the stated aim of "indirectly improving" treatment of ruptures by looking into how they are diagnosed and treated.

Sweden's official Pregnancy Register shows that a majority of women are satisfied with their childbirth experiences, and in 2018 the health service has launched a new questionnaire for all pregnant women with the aim of taking on their concerns and suggestions.

"The results will lead to maternity care and maternity care being shaped according to women's needs, to a greater extent than is happening today," SKL bosses said in a statement announcing the survey.

More importantly than good intentions, authorities have also taken steps to ensure the funds are in place to make sure these changes can actually happen.

In response to the mass resignations in Huddinge, local authorities pledged to improve the situation by ensuring women receive full pay during training, and in October the Stockholm council raised pay of obstetricians for first time in eight years.

One of the biggest milestones came in the spring 2017 budget proposal, when Sweden's centre-left government allocated an extra 500 million kronor ($57 million) to improve maternity care.

This is a step in the right direction, however the money was earmarked primarily for measures aimed at skills development and improving efficiency, rather than to ensure proper staffing levels and retain employees, according to a report by the Swedish Women's Lobby.


Clara Berglund. Photo: Lena Hammar/Sveriges Kvinnolobby

Clara Berglund, General Secretary of the Swedish Women's Lobby, told The Local that the organization decided to carry out the investigation after years of hearing reports about pregnant womens' fears and midwives' stressful working environment.

"Maternity care is unequal across the country, and badly undervalued. It's a crucial question of [gender] equality, affecting women both in their working lives and as patients," Berglund explains.

"Despite the fact that it's been clearly expressed that these funds should first of all go to ensure more staff and better working conditions, the county councils often use the money for other things. Now, they're getting more money and it's irresponsible not to send the money where the need is," she continues.

"So that all women have an attendant midwife for support during childbirth, money needs to be earmarked for staffing. Only then can we ensure more maternity ward places and the best possible care for women giving birth."

The Lobby called for funds to be earmarked for hiring more staff and raising salaries to retain existing midwives, as well as requesting a nationwide review of maternity care – something which hasn't happened in over 70 years. They argued this was necessary to reveal the smaller problems which don't grab headlines in the way that car births do, but which affect women and their babies all the same.

Weichselbraun from the midwives' association says that while the extra funding is "very, very good news" for the sector, there are still plenty of challenges.

"Five years ago, I'd have said what maternity care needs is more money to be able to work to give better, more equal care. But today, there is money, but we need to have the time and the people to take care of the money in the best way," she says. "So the situation has changed; it's very good that we've got the money and the challenge is to use it in the best way now, which requires professionals to spend time on that in order to ensure we have enough midwives.

"I'm helplessly optimistic, otherwise you can't work on this sort of thing, but I do think we're going in the right direction," she adds.

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