Why 'Knowing Your Options' Matters in Birth.
If I don’t know my options, I don’t have any. -Diana Korte
Options matter when it comes to childbirth. I once heard from a woman who was in the late stages of her pregnancy. "I'm just going to go to the hospital & have my baby.. women have been doing this for millions of years, I'm not going to be doing anything new.." Responding to being asked if she prepared for birth, the answer was no and this was the given reason. She only saw one option for her situation.
While her statement is mostly true, there is a significant & crucial part missing in it. Women, for millions of years, have been having their babies undisturbed. This, coupled with trending societal beliefs & mind-sets makes for a very dangerous & misinformed view of birth. On top of this are the various risks of giving birth, many of which cannot be minimised without the mother & father/other parent knowing more about birth & the impact it will have on their lives.
Birth is one of the most significant experiences a woman will go through in her lifetime. Bigger than any other major personal event, this one will hit her on all levels. Her core-values will be challenged, her pain threshold will be pushed to its outer limits and beyond - creating new boundaries of inner strength. Her ideas of what support means will expand & her emotional, spiritual & mental self will grow beyond belief. Beyond what she could have ever imagined before the event.
Birth has an incredible impact on a woman's life. Many Midwives set their eyes upon midwifery only after the birth of their first child. Most of the most passionate birth-keepers started their journey after the birth of a child. Some due to a bad experience and many due to a good one. Women in their 80's & 90's vividly remember their births. Tears flowing from their eyes or big hearted laughter, they will tell you the story, if you only ask.
Why do I want to know about my options in Birth?
Feeling Private, Safe & Unobserved - the term coined by Dr Sarah J Buckley an expert in Maternal health and Childbirth - tremendously impacts birth. Her tireless work has shed light on the inner working of childbirth. Her main findings suggest that for normal physiological birth to go as smoothly as it possibly can in many birth circumstances (i.e. not only in low-risk pregnancies), the woman giving birth needs to actually feel herself (not someone else's idea of it) - Private, Safe & Unobserved. All of which will present a challenge in a hospital environment.
In Australia, 98% of women give birth in hospital, out of these about 40% experience some form of intervention and 1 in every 3 women, will have their baby via major abdominal surgery, a C-section. That's one in every three women. This is an astounding figure given that the World Health Organisation suggests the rate of C-section should be somewhere between 10% - 15%.
The system of maternity care was identified as being dominated by medicine,
"The system of maternity care was identified as being dominated by medicine, not evidence based and restricting of women's choices, with midwifery autonomy not recognised or supported. The invisibility of midwifery within the community was identified as a significant barrier which, in conjunction with the occupational imperialism of obstetrics, ensures ongoing strategic control of maternity services and a denial of the rights of consumers to access midwifery care."
This quote above was taken from a research paper conducted by Pat Brodie, Addressing the barriers to midwifery. Named 'Australian Midwives Speaking Out, the paper was published in The Australian Journal of Midwifery, in September 2002. Not much has changed since, and perhaps some would argue, matters have become more difficult.
The reason why I bring up this paper is because of one very important fact. This fact being researched time & again with the same conclusions achieved, most recently & notably by the distinguished Cochran Review on Midwifery Led Continuity of Care (a plain language summery of the review can be read at the bottom of this article).
Maternal & Baby outcomes are much better when Women have Woman Centred, Primary Midwifery-Led, Continuity of Care
Maternal & Baby outcomes are much better when women have Woman or Patient-Centred, Primary Midwifery-Led, Continuity of Care. Now that's a mouthful. I sometimes struggle to get the whole sentence out in one attempt :-). Laughs aside, this is a serious matter. So serious, that as a mother who has spent the last 7 years concentrating my working efforts on birth, this to me, is the most pressing and most overlooked issue facing pregnant women today.
Your iron levels are very important - without sufficient iron, transporting oxygen throughout the body in the needed amounts to sustain a healthy pregnancy is impossible. Folate levels are so important, that eating your greens & vegetables on a daily basis has never been more pressing. Knowing the size of your baby, how many fingers they have and the sex of your baby may not carry as much relevance from a medical point of view, yet we emphasise these as relevant enough that all should have access to these services. But having acceptable outcomes for mother and baby are a must, in my book. And the definition of acceptable in today's obstetric world is simply not cutting it.
A lot of it comes down to Philosophy of Care, as explained in this research paper by Richard Johanson Professor of Obstetrics at the Academic Department of Obstetrics and Gynecology, North Staffordshire Maternity Hospital, Stoke on Trent, et al: Has the medicalisation of childbirth gone too far? Their summery points being:
Note that in the first point they stress that obstetric care is relevant when there are complication during pregnancy & labour. What you read between the lines is that OB's are primarily trained to seek & correct problems during pregnancy & childbirth. While it is within their scope, normal physiological childbirth is not a main focus of their training.
One of the main reasons you need to know your options when it comes to birth is because not everyone believes birth is a natural physiological process. Including you! What do you know and believe about birth? I would love to hear from you.
Perceiving birth above all as a Normal Physiological Process.
Another important insight from this study; "Philosophy of care: The Scandinavian countries and the Netherlands, which did not follow the trend towards steep increases in caesarean sections during the 1990s, have a tradition of perceiving birth above all as a normal physiological process and of valuing low intervention rates."
Perceiving birth above all as a normal physiological process.. repeat.. perceiving birth above all as a normal physiological process. Let that echo in your mind while I quickly go and grab another quote.
My father-in-law, bless him, who was a prominent doctor in a major hospital in Sydney for over 35 years and is now retired recently said in passing during a dinner party that the only thing that can truly cure everything, is surgery, the rest if b****it. He is a lovely man and we love him dearly! and he has helped save many lives, I am certain of it, but his statement speaks to his perception of extreme medical intervention and the perceptions of the medical world he was a part of for most of his adult life.
Recently, following the death of a baby who was lying on his mother who fell asleep in hospital, a prominent Obstetrician in Perth angered many health professionals & community around Australia by stating that "An “obsession” with skin-to-skin contact between mothers and babies after birth is putting newborns at risk of death and serious injury".
He went on to say “I think that gets over-interpreted. Babies, instead of being in a safe environment like a warming crib, are being left on their mother’s chest”. His beliefs that the reason for the death of certain babies was because there was a 'skin-to-skin fad' and that babies are safer in a crib than with their mothers is telling to how little obstetricians understand natural physiological processes of the human body and, of women's bodies and their bodies' innate relationship with their offspring. They are obviously simply not taught the essentials or the gravity of the natural physiological processes at medical school. It is more likely that the mother was extremely tired, possibly had lingering drugs in her system from the birth and was left alone by the hospital staff due to lack of resources. None of which was mentioned by him.
Maternal mortality & Maternal morbidity rates are often cited by obstetricians as the reason for higher intervention and C-section delivery occurrences. I.e. Having an alive mother and baby is the best possible outcome. And while no one can argue with that, again, half the message is missing. What obstetricians hardly ever take into account is overall maternal and baby outcomes. Overall including the short and long-term effects of any intervention on all the physiological, emotional & mental states of both mother & child and the consequent ripple effect in their family life.
We also know from research that intervention leads to more intervention. This is called the Cascade of Intervention. When a woman is supported from early on in pregnancy by a trained professional that understands and perceives birth above all as a normal physiological process, it is more likely that mother and baby will have better outcomes and more likely that there will be less intervention during labour & birth and more likely that the birth will resemble a normal physiological process.
Professor Michael Permezel head of RANZCOG (at the time) -The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, named one of his recent presentations: Bad outcomes in Maternity Care: Do Obstetricians intervene enough? I think that title pretty much says it all. Although obstetricians' rates of intervention are profoundly higher than acceptable, they are still wondering weather they are intervening enough. I would laugh at the irony, but as mentioned previously, there are real lives at stake here with short & long term outcomes imperative and the matter is far from funny, since parents/caretakers are left to live with the consequences of intervention and those performing intervention go home with a pay-check and insurance to boot (it is virtually impossible to sue a doctor for intervention as they are heavily protected by hospital policy & insurance). From many conversations over the years, i have found that in many cases those performing intervention are completely unaware of their privilege and the consequences of their actions.
Another example of the various aspects that dominate decision making in the labour room is this one, note taken from an overview of a conference on litigation in obstetrics (of course this is taken out of context - it is one discussion point among many over the course of the conference, but it does say a lot regardless) : - Balancing the interest of your clients and mitigating litigation opportunities. Doctors are asked by the hospitals & the doctors unions to weigh in any factors that might get them sued, against the best medical practice for this specific patient.
Other factors which persuade decision making for medical staff in the very heavily regulated hospital environments in Australia are; the many boxes that require ticking i.e. protocol; insurance & public liability that covers the hospital is a huge factor that prevents treating birth as a normal physiological process; a strong underlying culture which sees Midwifery based care and continuity of care models as irrelevant in the fast paced hospital system; powerful obstetricians unions preventing hospitals and government handing over the rains to midwives; the constant change of staff; profitability of interventional procedures both for the hospital & the obstetrician and most notable - lack of feedback from women post birth as to their experience - with this last one being a massive missing piece in the puzzle.
Almost all women are plain & simple too busy, overwhelmed, sometimes in a state of shock, to take even the smallest action in relation to a bad experience they had during birth.
Almost all women, and I say this from my experience as a consumer representative as well as a mother, are plain & simple too busy, overwhelmed & even in shock, to take even the smallest action in relation to a bad experience they had from their carers during pregnancy & especially, during birth.
This fact will come as a huge shock, i imagine, to obstetricians, as of course they haven't heard from hardly anyone about their bad experiences. And when they do, these "experiences" are put down to either the woman being over-reactive or simply not understanding the gravity of the situation. If fact, most obstetricians believe whole-heartedly, that they are the hero in the story. Many women and families believe this too. And sometimes, they are right. But often, its the very interventions that are supposed to "save the day" that promote more stress & deviation from the natural physiological process.
Midwives are not exempt from making mistakes and even completely mis-understanding birth. I've heard from many women with different stories about the harshness of midwives in a hospital settign. A midwife might pull on a placenta to get it out faster, causing a dangerous haemorrhage & requiring extra intervention, or Midwives being impatient & wanting 'to take control' of the birth, there are amny examples. Midwives can be hard on women, sometimes harder on them than the doctors themselves.
They too are under a lot of pressure and they also come in many different 'types'. There are the new, informed and fresh out of school midwives that might have never had a baby themselves. Then there are the well seasoned, ones, that have been quiet for years, those many midwives who hold the same view of the obstetrician, either because they trained many years ago and their information and understandings are out of date (remember - this is a mind-set/perception as well as medical data matter) or because they are persuaded by peer pressure. There are so many different people with different views working within the very large & impersonal medical system, that it becomes vital that you know your care team well in advance and area ware of their perspectives, perceptions & policies when it comes to birth.
Then there are the strong, knowledgeable, informed, sensitive & awake Midwives
Then there are the strong, knowledgeable, informed, sensitive & awake midwives, these are few and far between and not as easy to come by as you would hope. But they do exist and you can find them! One of whom, a good friend, has recently retired because she simply could not keep being a midwife in the highly medicalised world. You can read Angela Fitzgerald's insightful story Shedding My Skin here.
I remind you of the findings from Brodie's report - "The invisibility of midwifery within the community was identified as a significant barrier which, in conjunction with the occupational imperialism of obstetrics, ensures ongoing strategic control of maternity services and a denial of the rights of consumers to access midwifery care."
While there is no doubt that medical intervention can save lives, there is also no doubt that medical intervention interferes with natural physiological processes and when it comes to birth, holding a normal physiological attitude about it is the key to better outcomes.
Doctors and midwives are often overworked, tired, and put in a tough position with all the facets of what it means to be a doctor or midwife within the medical system of today. That is not to say they are not responsible. When you understand that your wellbeing and that of your child is your primary responsibility, then knowing all the options is paramount. Understanding birth and the context in which birth exists is of the highest order.
"If I don’t know my options, I don’t have any". While birth is certainly a normal physiological process and women have been giving birth since the time women existed, birth today, exists within a framework that inhibits its natural physiological process, for better or for worse. Knowing your options, such as having a midwife as your primary carer & for the duration of your care during pregnancy, birth & postnatally, or understanding that you can say no to an episiotomy or ask for delayed cord clamping or bacterial swabbing of your baby if you have to have a cesarean will make all the difference in yours and your baby's outcomes.
Below a video by Dr Sarah J Buckley explaining 'Private, Safe & Unobserved'. I leave you with this.
PS - I would LOVE to hear from you. Whether you are a doctor, midwife or consumer of healthcare services and have something of value to share, I would love to hear your story! Fill out the form below to send me your story.
PPS - Please find afternotes including the plain language summery from the Chochran report, below the video.
Sarah Buckley video here: https://youtu.be/7446t4WE_Lw
Definition of Obstetrics
Obstetrics and gynecology is a diversified specialty concerned with the delivery of medical and surgical care to women. This field combines two specialties: obstetrics, which focuses on the care of women before, during, and after childbirth; and gynecology, which involves the diagnosis and treatment of disorders of the female reproductive system, breasts, and associated disorders.
Definition of Midwifery by the International Confederate of Midwifery
Scope of Practice: The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practise in any setting including the home, community, hospitals, clinics or health units.
PLAIN LANGUAGE SUMMARY Midwife-led continuity models versus other models of care for childbearing women BY Sandall J, Soltani H, Gates S, Shennan A, Devane D, a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 8: In this review we included models of care where midwives provided care throughout the pregnancy, and during labour and after birth. We identified 13 studies involving 16,242 women both at low and increased risk of complications. Midwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care. The main benefits were a reduction in the use of epidurals, with fewer episiotomies or instrumental births. Women’s chances of being cared for in labour by a midwife she had got to know, and having a spontaneous vaginal birth were also increased. There was no difference in the number of caesarean births. Women who received midwife-led continuity of care were less likely to experience preterm birth, or lose their baby before 24 weeks’ gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. All trials included licensed midwives, and none included lay or traditional midwives. No trial included models of care that offered out of hospital birth.
The review concludes that most women should be offered midwife-led continuity models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.
Copyright Annalee Atia, April, 2016.