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.