British Journal of Obstetrics and Gynaecology, September 1992, Vol. 99, pp. 709 - 710

WHO appropriate technology for birth revisited

In August 1985 The Lancet published the WHO recommendations for birth in an article entitled 'Appropriate technology for birth'. This publication followed the appearance, in the same year, of the WHO book, Having a baby in Europe, which described the current status of childbirth care in Europe. both these publications resulted in controversy as to their validity. In many, if not most, parts of Europe as well as in other regions this controvery continues.

Questions such as: How were the publications arrived at? How representative are their contents? Are these biased, 'liberal' views? And, most importantsly, how well do these recommendatoins match up to research findings?

Development of the WHO recommendations for birth

The United Nations declared 1979 as the International Year of the Child. At the Regional Committe for Europe in that year, concern was expressed over a number of issues including: the rapidly expanding technology being applied to birth with its associated rising costs; the doubling or even tripling of the caesarean section rate which took place in the 1970s, the question of whether this was associated with the increasing use of electronic fetal heart rate monitoring; the increasing demands from women's groups to resume control over their birth experiences and the poorly understood inequities relating to perinatal mortality (Wagner, 1991).

The outcome of this debate was a decision by the WHO to undertake research into perinatal services and to develop recommendations for appropriate technology for birth.

A series of events followed. The first was the establishment of a multidisciplinary, 15-member, perinatal study group. This consisted of representatives from obstetrics, paediatrics, nursing, midwifery, epidemiology and statistics, health administration, sociology, psychology, anthropology, economics and consumer groups. Meeting at least once a year as a full group, and more frequently in subgroups, the team investigated the available literature, the perinatal services in 23 of the then 32 WHO-Europe member states, mother-infant contact practices in a detailed study of ten representative member states and alternate (meaning outside of the formal health care system) perinatal services in Europe, as well as in the USA and Canada (Wagner, 1991).

Debate and eventual consensus between the members of the team resulted in Having a baby in Europe (WHO, 1985). This was directed towards lay readers; Perinatal Health Services in Europe: Searching for Better Childbirth (WHO, 1985) was aimed at the academic reader. The second major step in the process followed: the organisation of Birth Conferences. These were national conferences designed to debate the applicability of the recommendations of the WHO books to a country. These conferences have almost always involved professionals and consumer groups as well as non-governmental organizations and the media. To date 43 conferences have been held in 23 European member states, as well as in the USA, Canada, Australia and China (Wagner, 1991).

The birth conference movement led to three major interregional meetings. These, combining in particular the WHO areas of Europe and America, covered appropriate technology for pregnancy, for birth and for after the birth. These conferences always involved multidisciplinary representation and required participants to submit their papers well in advance to enable translation and circulation before the meeting. At the conference issues were debated until consensus was reached. The outcome of these deliberations was published in the Lancet (WHO, 1985).

How valid are these recommendations?

There is no doubt that much deliberation, research and discussion went into the development of the WHO redommendations for appropriate technology at birth. Nevertheless, some questions persist. How valid are these recommendations? How representative were the participants in the various conferences and research teams? Is it not possible, if not probable, that individuals willing to participate in such meetings and activities would have an interest in 'changing the system' and would be biased? Most important, how well do the recommendations match up to research findings?

The recent publication by Chalmers, et. al. (1989) encompassing a careful scrutiny of randomized control trials of perinatal technology allows these questions to be answered. This two volume tome contains many reviews of great value but of particular relevance here are four appendices. These list the forms of perinatal technology that

  1. reduce the negative outcomes of pregnancy and childbirth;
  2. are promising but require further evaluation;
  3. have unknown effects and require further evaluation; and
  4. should be abandoned in the light of the available evidence.
The WHO recommendations for appropriate technology for birth are examined in Table 1 in terms of their classification by Chalmers et. al. (1989). This appendix deals only with the specific birth technology recommendations and does not assess the general recommendations regarding perinatal health care policy and the setting of policy.

The recommendations of the WHO for appropriate technology at birth, developed through survey research, discussion and debate, are strongly endorsed by the findings of carefully controlled and critically evaluated randomized control trials. The recommendations provide sound guidance for those providing perinatal care.

Table 1. WHO recommendations for birth classified according Chalmers et. al. (1989)

Beverley Chalmers

World Health Organization
Regional Office for Europe
Maternal and Child Health

8 Scherfigsvej
DK-1200 Copenhagen


Chalmers I., Enkin M. & Kierse M.J.N.L. (eds) (1989) Effective Care during Pregnancy and Birth, Vol I & II, Oxford University Press, Oxford.
Wagner M. (1991) Appropriate perinatal technology of having a baby in Europe. In: From Research to Decision Making, WHO, Geneva, 1991.
WHO (1985) Appropriate technology for birth. Lancet ii, August 24, 436 - 437.

The World Health Organization
WHO Regional Office for Europe (EURO)
Centre of Information on Public Health in the European Region (CIPHER)

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