Thursday, 13 November 2008

Guest Post: The Womanly Art of giving birth

We approached Pauline to write a guest post on the medicalisation of birth after the (unexpected) furore that erupted when I posted the second part of my trilogy on the birth of my son. It's a difficult area to write about for an audience, especially on a blog where who knows who'll be reading, so big thanks to Pauline for the below.

Firstly I should probably declare my biases here. I am a mother of 3 small children, a midwife, although not currently practising, and a researcher in midwifery and birth.

My children all had very different births. My first was a caesarean section when I went into full-on labour 6 weeks early with a footling breech. The second was another early labour – 7 weeks this time – but a lovely normal birth in hospital. My third baby was only a couple of weeks early and born at home. I have had easy births and difficult pregnancies and a range of experiences, however these are my experiences only and if you work around birth you should recognise that every woman, baby, pregnancy and birth are unique.

I guess as a ‘recent’ birther, a midwife and a researcher I have been deeply steeped in the issues around birth, birth attendants, medicalisation and particularly the wide range of viewpoints and opinion on this highly emotive subject. A huge amount of research has been done around childbirth and even meta-analysis comparing studies can never come up with absolutes in this area. Some of these studies even have very flawed methodology but are still quoted when women are given “the facts” around birth options.

I am a fairly middle of the road person on the broad spectrum of views around birth, and feel that cautious and judicious use of medical interventions is the way to go. In my view the problem is routine interventions or intervening to save or do the best for the practitioner, not only for the woman/or baby. I also think we have an unhealthy focus on birth, when parenting is a much longer term prospect that most of us could be better prepared for.

The politics of child birth is a HUGE topic, and much of the current focus is on the escalating caesarean section rate. However before you end up there, you need to consider what has gone on before.

Consider pain relief. Not that long ago early feminists campaigned for the right of pain relief in labour. They didn’t think mostly male medical profession was putting enough effort into relieving the trial of labour for women because it wasn’t considered important and at that time labour pain was considered, by many, the curse of Eve and perhaps not meant to be alleviated. And nowadays, when you think about our “take a pill, no pain and suffering society” and when our lives have very little physical hardship, having a pain free labour can make complete sense. However is it actually good to alleviate symptoms (pain) without looking at the causes?

This all means that suggesting to a modern woman that a natural and unmedicated birth is the best option makes you sound a bit of a luddite. There is strong research that indicates medicated births (like very fearful ones) interfere with the delicate balance of our natural chemical responses to labour, and may have long term impacts on the baby. Also although “walking epidurals” are often touted, your movements are still restricted. And while fear might be your worst enemy in birth, your friend is gravity (simple when you think about it) so why would you want to be on your back where the birth canal is almost pointing uphill. But, hey I’ve had one “Give me drugs NOW” labour and two unmedicated ones and again I’d say its all about judicious use.

I firmly believe women’s bodies are made to birth. I don’t mean that it is our only biological destiny but there seems to be a prevalent thought amongst women that their body can’t do it. Unfortunately a paternalistic male obstetric ethos in the past (and still lingering around today) has used intervention to “rescue” women from their leaky, flawed bodies and in doing so has contributed to the undermining of women’s confidence in themselves to give birth. Again fear dominates and our natural abilities, responses and phenomenal power as women become hindered.

Research indicates that probably over 90% of well women can birth without any medical interventions. The thing is once you start intervening you set off a cascade. For example, walking into a hospital statistically doubles your chance of ending up with a caesarean section, with each intervention (e.g. continuous monitoring, lying down for long periods, medications, “coached” pushing, inductions and augmentations) you are carried further on down the medical path.

Is a section the end of the world and failure? – NO of course not. However once you have that scar on your uterus it is there for ever and impacts on any future births. VBACs (Vaginal birth after c/s) and having a ‘trial of labour’ are getting harder to obtain as fear of litigation as well as for the mother and baby. This is sad because in NZ we have sound VBAC guidelines that are very ‘middle of the road’.

You have to remember that everyone, from the most conservative obstetrician to the wackiest free-birther, wants a good outcome for mother and baby. No one is trying to endanger anyone. There are so many viewpoints and no one path is right for everyone. Research may indicate, and I personally may view, some options better than others, but I have seen beautiful joyous births at home, in birthing centres, in birth pools, in hospitals and operating theatres. I have also seen tragedies.

Our maternity system is woman centred and relies on midwifery-led care, unless there is a medical indication for specialist input, and meta-analysis just released has confirmed that this should be a normal option and recommended to all women. However a side effect is that unfortunately most doctors are hospital-based and only get to see the high risk, the problems and the disasters, so, with some cause, do feel like the ambulance at the bottom of the cliff.

I think some of our issues could be resolved if those medical oriented people could see (like myself and most other midwives) many, many, wonderful normal births in varied locations. Although always remaining vigilant for the ‘abnormal’, seeing normal births over and over tempers fear of the worst. And a fearful practitioner also is an enemy of normal birth.


Alison said...

Thank you! Seeing such a well-rounded post from a NZ midwife on this blog makes me super-excited to start my own midwifery training in February :)

I'm particularly interested in the suggestion that we put too much focus on birth as opposed to parenthood, as that's been one of my concerns as I researched pregnancy, birth and parenthood, trying to make a decision about my career change.

Perhaps the Hand Mirror crowd would let you write some posts on that at some point, because I think it is an important topic for women to discuss.

Jono said...

My wife and I had our first, at home two weeks ago. I had always been neutral on the how/when it happened but suffice to say afterwards I am fairly evangelical about homebirths if everything is looking hunky-dory at the outset.
My wife is small but strong and had a normal pregnancy, but the two days of latent labour really took it out of her. Once in the active phase she was so tired that she was seriously considering noving to hospital for some pain relief. The midwife was supportive but essentially implied that she was doing fine, nothing out of the ordinary, and was good to go at home. Which is how things ended up.
Within about ten minutes of the birth my wife was saying she was so happy not to have gone to hospital - no drugged up baby and being able to jump into her own bed were huge mental and physical plusses.
But I can understand how mileage may vary. We have good friends in the US, PhDs both, who had the full-on American US$30k delivery in the Standford University hospital and wouldn't dream of doing it any other way.
I also spent a couple of days last summer working with a mature uni student who is a GP. After a couple drinks one night she opened up with a vicious diatribe against Helen Clark and the maternity reforms...I dont think I have ever seen anyone so spitting angry in a social setting before.

The ex-expat said...

The thing that annoys me most about birthing debates is that the voices that should be heard the loudest, those giving birth, are often drowned out by the screeches of the midwives, doctors etc pushing their view of what birthing should be.

In the end, as you mention every birth is unique so foolishly clinging to this idea that there is a 'right' way to give birth only serves to silence the woman doing the labouring.

Thank you for your insight.

Alison said...

The thing that annoys me most about birthing debates is that the voices that should be heard the loudest, those giving birth, are often drowned out by the screeches of the midwives, doctors etc pushing their view of what birthing should be.

I question to what extent that is actually a reflection of the NZ maternity system as a whole - I haven't met any obstetricians while I've been researching midwifery, but I'm yet to hear a NZ midwife say categorically that epidural is bad, all natural at home is the only good birth and medical treatment be damned. Most of the midwives I've met or heard speak seem to take largely the same rational, middle-of-the-road approach as Pauline.

It seems to me that midwives are once again being forced into defending themselves loudly by media who are reporting the problem cases, always laying blame on midwives, before the cases have gone through the appropriate channels. It strikes me as rather like the "mommy wars" that the US have so kindly exported to us, in which media coverage whips up a furore that might not exist to the same extent otherwise, setting LMCs against each other who would otherwise work together for the same goals.

I don't actually fully understand the antipathy displayed by some GPs - as I understand it, they've dropped out of maternity care provision largely because they viewed the pay as insufficient for the work, and yet a vocal few are attacking midwives who've been willing to provide maternity care under those same pay structures. Are GPs paid less than midwives for maternity care? What is the argument for paying more? How long do GPs spend on obstetrics across their degrees, and how many births do GPs attend in a year if they provide that service? Would most want to go back to it anyway, given we're already short of GPs to provide the work they do currently? If morbidity and mortality rates seem to have dropped since the maternity reforms, according to most stats I can find, what's the GPs' argument against midwives, and is the antipathy as widespread as the media imply?

Pauline said...

Alison - thanks. I think we just need to start looking at pregnancy and birth as the beginning of the story rather than the end.

Pauline said...

About GPs involvement. I actually think there is a place for this as some (not many) women have a great existing relationship with their GP and in rural areas midwives and GPs working togther would help A LOT with women who have underlying medical problems. There are less than 17 GPs still offering maternity care in NZ. I have been on good terms with a few who have now dropped this side of their practice. One of the things they mentioned is that it is far more economic seeing lots of patients in a clinic than having to drop everything and rush off for a birth. Also one Dr mentioned that his "normal" patients were getting less and less tolerant of him cancelling to go to births. The money a GP gets paid for being 3 hours at a birth (as normally the hospital does a lot of the labour care for GPs) does not equal what you'd get for seeing clinic patients in that same amount of time. A GP usually would also have to pay a midwife to do the required 5 in-home post natal visits.

Alison said...

Thanks for explaining a bit more about the GP issue. I can see that many would be sad to lose that part of their work, but it still seems strange to me that a vocal few are "blaming" midwives for providing what they can't, or in some cases, won't. It also makes perfect sense to me that GPs might have a valuable role in some areas.

Azlemed said...

What a great post... i have had mixed experiences with LMc's, but over all have had good care for all three of my childrens birth... but the births are just that.. the start of being a parent...

midwifery in nz does get slammed yet those who slam it are often working as the ambulance to deal with problems... how many 'normal' births do ob/gyns actually see?

For interesting viewing watch the business of being born by rikki lake, its amazing and made me realise that having my babies in nz is much preferable to having them in the US.

Thanks Pauline for the awesome blog

Alison said...

midwifery in nz does get slammed yet those who slam it are often working as the ambulance to deal with problems... how many 'normal' births do ob/gyns actually see?

I agree. Do you think that there's any tendency amongst doctors to see midwives as the cause of the problem? It seems somewhat strange to take the view that birth is always able to go wrong, but then blame midwives on the occasions it does. In the US, that certainly exists, but I'm not sure about NZ.

I wonder if the problem is inseparably tied up with our current cultural avoidance and misunderstanding of risk. I hear the statistical concept of risk misused and misrepresented constantly in our media, and wonder how much that is contributing to women's decisions about birth and pregnancy. Fear is one of the most important factors in narrowing choice for women, so if risk is misrepresented, women are more likely to make a choice out of fear than out of genuine understanding. The increasing tendency in the US to pressure women into C-sections when they are expected to have "big" babies is one example of this - smaller and smaller (and often quite average sized) babies are being counted as potentially too big, with no real explanation of the risks, and no examination of the risk of inducing a baby before term, on the basis of a very fallible measurement.

We can't actually completely eradicate risk from birth, and one of the problems we face is the presentation of medical intervention as doing just that. In as complex a process of birth, there are SO many factors that can be measured in terms of risk, and only the woman can decide which risks matter to her, but she can only do that with balanced information, which many women don't have access to.

Alison said...

Please do go on about it! I find it fascinating.

Pauline said...

Alison. I see that "blaming the midwife" is completely understandable - but very sad. As most Doctors on work in the problem areas and get called in only when a problem beyond the scope of midwifery occurs. The problem most often has very little to do with the midwife but the Doctors has had no control or management up to that point and have to deal with whatever the outcome. I don't think blaming is right but you can kind of see why. Their answer of course is to have 'control' the whole way through and many Drs want all women birthing in central hospitals for this reason. Women at home or at birthing centres are way outside of their 'control'.

Part of my research (and a presentation I did at a conference) was about the differing perceptions of risk between the birthing woman, the midwife and the doctor. It is a very broad spectrum of thought and people do not stay in one spot on it. For example if you perceive a certain practice to be low-risk but then have a bad outcome, it obviously impacts on your perception even though it may have been an isolated incident. I could go on at length about this...

One thing I found is that the younger the person involved, the higher people tend to perceive the risk...and as birth involves babies...

Tania said...

"I think some of our issues could be resolved if those medical oriented people could see (like myself and most other midwives) many, many, wonderful normal births in varied locations. Although always remaining vigilant for the ‘abnormal’, seeing normal births over and over tempers fear of the worst. And a fearful practitioner also is an enemy of normal birth"

Thank you for bringing up this point, which I totally agree with. As a LMC in a primary birthing unit I sometimes get the sense that the Obstetrician sees the abnormal thereby having difficulty understanding why women choose a normal birth “rurally”. Likewise, if we transfer to the base Hospital for safety reasons and a normal birth occurs, or the woman chooses to birth at the base hospital, the opposite occurs and judgments are made about normal birth in a Base Hospital.

One way to help resolve this would be a short temporary placement in a primary birth unit as a condition of employment for Medical and Midwifery staff employed by the Base hospital. These practitioners can gain an understanding of normal birth, the choices women make and the implications for the rural midwife.

Pauline said...

Tania - when in practice I worked rurally with betwen 50-75% of births away from the base hospital and I totally agree with your comments.

When midives are doing their education they are required to attend a certain number of 'normal' and 'complex' births (although those definitions are up for debate), however there is no such requirements for Drs. It is possible for hospital staff to have never seen a completely normal, unfettered, maternally led birth.

Midwives who have not worked out in the community for some time may have also forgotten what this sort of birth is like

Julie said...

When I first read your guest post Pauline I was really struck by your observation about obstetricians getting a disproportionate number of abnormal births, and thus having a skewed expectation of normal.

Thanks for writing this Pauline, and for the discussion that is ensuing. As I've only had the one experience of birth (the one that produced my son) I really don't feel like I have much to add in the presence of so many knowledgable people!

Azlemed said...

I think there does need to be more consumer (mum) led discussions about birth, and the roles of midwives, ob/gyn etc.

When mw are reviewed each year there is a consumer(mum) involved in the process... does this happen with OB/GYN's? I doubt it....

having had three babies all with midwives for my lmc i have no desire to do any differently.. for 6 weeks of my last pregnancy i was under the clinic at the hospital and they said i didnt need to be.. i actually needed mental health services instead.

With my first child i was told that due to iron levels etc i needed to have a hospital birth, my mw managed the birth and the horror afterwards really well, and i am thankful for that. The next two havent had the same complications, one was born at a base hospital the other at the oamaru maternity clinic.

By sharing our stories and talking about the system we can make a difference for other women and ourselves, so thanks pauline and julie for facilitating this forum

Alison said...

Mothers definitely need to be involved with the decision making, and taking ownership of their experience, but there is, I think a limit to that; I went to a showing of "Orgasmic Birth" recently (not as hippy-dippy as it sounds!). There was a discussion panel afterwards, and I heard both a doula and a non-midwife (I think) homebirth advocate talking at length about "good birth" coming down to women taking ownership of their experience, educating themselves and advocating for themselves.

I was actually supremely uncomfortable with that; as someone who lives in Lower Hutt, and may well end up practicing there when I complete my midwifery studies, I wondered how that sort of approach would go down in low-income, underprivileged areas like Taita or Naenae. It's all very well to say that to the sort of educated middle-class women who attend that sort of event - entirely another thing to say it to a woman who has low literacy skills, or has lived in an oppressive situation for her whole life, and relies on her LMC to provide some guidance in the decision-making process. I understand that making educated decisions is important for women, but there are people who don't have the critical skills to assess the mass of conflicting information out there, and I think we need to recognise just how many women there are in that category. They also deserve a positive pregnancy/birth/postnatal experience, but I feel like they're just being left out of the discussion entirely at the moment, and missing out on some of the benefits of our maternity system. I don't have figures, but I suspect they're disproportionately represented in the morbidity and mortality figures.

Alison said...

Hmm, reading back, that sort of sounds like I'm advocating for underprivileged women to have less say in their care, and that's the absolute opposite of what I mean. What I'm trying to get at is the question "how do we provide women with true choice, when they don't necessarily have the ability to knowledgeably weigh up risks for themselves?"

Pauline said...

Alison - the issues you desribe are things I struggled with the entire time I was working in midwifery. For a start I think a lot of women sadly have little or no expereince of being in charge of themselves and making their own decisions. Also poor education/financial status doesn't bear that much relevance to empowerment. Some of the best times I had was seeing that 'lightbulb' go on for women that this was their experience and there were calling the shots - and these were women from all sorts of backgrounds.

Providing information in an accessable way for women and families with poor education (in some cases no literarcy skills) or poor english was a huge challenge and you had to find a medium that worked for them - video/DVD was great for many and I accumulated many titles and thought about doing my own video of "the basic information"

On the other hand you come across women who don't want to take control (for many and varied reasons) and to me this is more frustrating. Its like all they have to do is turn up and the midwife/Dr is meant to do the rest. This is a really bad space to be in (for everyone) and undermines the basis of the midwifery partnership