Pre-Natal Care... |
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The Safety of Normal/Natural/Organic Birth (and some other random thoughts on the subject...) Midwifery Model of Care vs. Medical Model The Farm Midwives and the Benefits of Organic Birth What to Do?/What YOU Can do to Avoid Unnecessary Intervention
What is “normal” or “natural” birth? Normal birth refers to just that - a woman who is able to labour uninhibited, without medical, physical, and emotional interference, and in the absence of pathology, intervention, complication and/or augmentation. Some prefer to call this “natural” birth. However, I’ve decided to avoid this term because it implies something alternative or different as well as something that is difficult to achieve. Also, I think the phrase “natural birth” has been applied rather loosely by various people who have used a broad spectrum of criteria to define it – can you have an epidural and still have a natural birth? What about having your baby in the hospital? Is a natural birth simply a vaginal birth? It’s just too vague. Normal birth is about giving birth as you are, actively involved in your own care but with support from others. Normal birth, free of any intervention or complication, is possible for the overwhelming majority of women. However, that said I am also slightly wary of the word normal. First of all, what has become “normal” for women giving birth throughout the West is hospitalisation and usually involves some form of intervention (whether it is in the form of an IV, an EFM, amniotomy, episiotomy, forceps, etc.). With caesarean rates rapidly approaching one in four (!) in Ireland , surgical birth is itself practically becoming normal. Secondly, the word “normal” in and of itself is loaded and many people can reasonably perceive it as some sort of judgement. My discussion of normal, intervention-free birth is certainly not to imply that you are in some way abnormal if you give birth in another way. But it is important to understand that routine intervention definitely alters the normality of birth, as birth in and of itself is overwhelmingly a normal, safe, human function. Because of the confusion over the term “natural” birth, and my fear of encouraging some sort of exclusive power dynamic by using the phrase “normal” birth (although I will be using both natural and normal to describe specific aspects of pregnancy, birth, etc., for example, “birth is a natural, normal process”), I’ve attempted to come up with new terms that convey healthy, non-interventive, non-medicalised birth, that’s not too long-winded. I considered using birth with a capital B (as in Birth), with Spanish-style exclamation marks (¡birth!), written entirely in bold (birth), or perhaps a combination of all three (as in ¡BIRTH!). While certainly enthusiastic, no matter how dressed up the word birth on its own, unfortunately at this point in time it just doesn’t seem to convey enough. As a result, for the moment I’ve settled on the word “organic”. Organic is the word to describe food that is free from pesticides, antibiotics and other harmful chemicals, and that has been nurtured and protected to help it along to meet its highest potential. I realise it’s a little cheesy but for the time being it’s the best I can come up with. So please bear with me and if anyone can think of a more appropriate term or phrase – let me know! What is “organic” birth? Giving birth without the use of pharmaceutical or technological intervention is the backbone of an organic birth experience. In order to maintain normalcy and safety in birth - education, preparation, confidence, skilled assistance, and a supportive birthing environment - are essential. Organic birth can occur in a hospital setting, however, it will most likely be hard work to maintain normalcy in that environment. Fortunately, it’s not impossible and many, many women manage to give birth, free of any intervention, in the hospital everyday. On a final note, while discussing issues of childbirth, it is extremely important to interrogate commonly held beliefs concerning safety and personal responsibility, and be realistic and knowledgeable about the pros and cons of medical and technological intervention. Most people assume that the hospital is just about the safest place on earth to be, and sometimes it most certainly is – for acute illness, for severe injuries, and yes, for some women giving birth. There are absolutely some women, albeit a small proportion, who need to be in a hospital while giving birth and there are even some (an even smaller number) who require caesarean sections to safely have their babies. However, when you consider that childbirth is a healthy, natural and normal (there they are again!) experience, and that a hospital is for people who are ill or injured, it begins to become a little confusing as to why most healthy women are giving birth in that location, especially as the scientific data concerning the safety of homebirth, independent birth centres, and midwifery-led birthing units is available. Educate yourself on the safety of birth; consider the ways in which social beliefs affect the way we give birth and impact on our birth outcomes, and see if your perspective doesn’t change. While perhaps not the most uplifting topic to discuss while promoting organic birth, infant mortality is extremely relevant in the argument against the routine medical management of pregnancy and birth. The national infant mortality level is a good reflection of a state’s maternity services (as well as the quality of the general health care service and the social welfare system). Ireland is currently placed 21 st in international ranking of infant mortality. Interestingly, the United States – one of the richest, most technologically and medically advanced nations in the world – ranks 28 th! Although numbers might appear to be relatively small (5.84 in Ireland and 6.67 in the United States per thousand births), considering the number of births that occur every year within a country that number can become enormous as it multiplies the many times over per 1000 births. Another factor to consider is the vast under-reporting of infant mortalities, inaccuracy in reporting, and the inconsistency as to what actually constitutes as an infant mortality. In her research exploring childbirth in Ireland , Marie O’Connor found that “in Amsterdam , where the registration of infant deaths was studied, they found that 14% of infant or perinatal deaths had not been registered” (Birth Tides: 280). When one considers the relatively low infant mortality levels in Scandinavian countries, the picture becomes even more confusing. Why are Finnish, Swedish, and Norwegian [and Dutch as well] babies doing so much better than Irish babies and American babies? Both the U.S. and Ireland have high levels of oxytocin induction and augmentation, amniotomies (artificial rupture of membranes, or AROM), widespread use of anaesthesias in labour, routine electronic foetal monitoring, frequent use of forceps and Ventous, high caesarean section rates, and an overall high level of intervention (see Appropriate Technology for Birth published by the WHO and the Cuidiu/Irish Childbirth Trust report concerning Irish hospital practices, Birth and Beyond at www.cuidiu-ict.ie/ ). In the case of the United States , maternity care is largely the domain of obstetrician and midwifery care is still relatively uncommon. Is it possible that a link exists between the medicalisation of birth, increased intervention, and high infant mortality? Isn’t medical and technological intervention supposed to be used to decrease the incidence of injury and death in birth? Notably, Scandinavian countries have low levels of intervention among healthy women and use direct-entry midwives as the primary carers in maternity care. Planned out-of-hospital births are also relatively common in some of these countries. Comparatively, these countries have some of the lowest levels of both infant and maternity mortality in the world. Through his own professional experience as a neonatologist, paediatrician and perinatal epidemiologist, former Director of the Women’s and Children’s Health for the World Health Organization Dr. Marsden Wagner believes that increased use of birth technology and routine intervention are the primary causes of the increasing maternal mortality rates in the industrialized world. Dr. Wagner believes that “there is good research showing the maternal mortality rate for caesarean section is four times higher than for vaginal birth and is still twice as high when it is a routine repeat caesarean section without any emergency. With all the unnecessary caesarean sections done today in the U.S. , this could be part of the problem of rising maternal mortality”. Read more about this alarming trend in the United States (and consider what’s going on in this country as birth becomes more medicalised and caesarean births become more common) at the Safe Motherhood Quilt Project website – which aims to record the lives of women that have been lost in pregnancy and birth, at www.mana.org/quilt.html. Midwifery Model of Care vs. Medical Model Ultimately, it is a midwifery model of care ( www.midwivesmodelofcare.org/) that serves women, their babies, and their families the best. However, although midwives are unarguably the backbone of maternity care in Ireland , they have limited power under Health Boards, consultants and hospital protocols. Proof in the pudding comes in the fact that Irish midwives don’t even have their own representative body - they’re under the nursing board! Development and advocacy of midwifery-run maternity units and birthing centres, independent birthing centres, homebirth services for all low-risk women, direct-entry midwifery programmes, and a greater support of midwives to allow them to do what they do best will contribute positively to reducing Ireland’s higher standing in the infant mortality scale. As well, obstetricians should stick exclusively to what they have been trained to do – which is focus on the care of high-risk women and manage genuine emergencies. Also, following the 16 Recommendations from the World Health Organization as part of its report entitled Appropriate Technology for Birth, which endorses a midwifery model of care and supports the limitation on birth technology and routine intervention, will help to improve both maternal and infant morbidity and mortality levels, improve satisfaction levels among birthing ladies, and make most midwives very happy women indeed. Perhaps most importantly, the WHO states that “obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological, and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centres and to influence obstetrical views nationwide”. Unfortunately, this seemingly obvious concept appears to have met with some resistance among those who endorse a purely medical-model of care (as opposed to a holistic-model of care) and ignore empirical evidence regarding the safety of birth. Best possible obstetrical services advocate a system of evidence-based maternity care in which judgments and medical advice are based on scientific data as opposed to unscientific dogmas (an excellent example of this practice is the use of continuous electronic foetal monitoring in labour among healthy women who experience normal pregnancies and a normal labours). The Farm Midwives and the Benefits of Organic Birth Consider the statistical outcomes at the Farm Midwifery Center, ( www.farmcatelog.com/birth.htm ) located in rural Tennessee, U.S.A., where a group of lay-midwives (traditionally trained midwives, usually through an apprenticeship with a senior midwife) have delivered thousands of babies over a 30 year period with phenomenal outcomes (as compared to the larger American society). In 1994, the American Journal of Public Health analysed the centre’s statistics and noted their incredibly low morbidity and mortality rates, as well as their very low rates of medical intervention. Out of the planned 2,200 planned home births, 95.1% were completed at home, 3.6% resulted in non-emergency hospital transports and 1.3% transports were emergencies. Only 1.4% of their clients needed caesarean sections, while the remaining 98.6% had vaginal births (!!!). Compare this to the national U.S. c-section average of 24.4% and rising, and with the caesarean birth rate of Ireland which comes in around 22%. Alarmingly, recent studies have shown an 80% increase in the caesarean section rate in Ireland since the early 1990’s. Remember, based on extensive cross-cultural research analysis, the World Health Organisation concluded that “there is no justification in any specific geographical region to have more than 10 – 15% caesarean section birth”. The fact is it is the responsibility of health care providers, whether they are obstetricians, midwives, public nurses, general practitioners, or childbirth educators to emphasise the safety of birth and to inform their clients of the risks involved in all forms of intervention (that includes epidurals folks!) in particular the risks associated with caesarean sections, and to provide adequate informed consent (does she really understand what will happen when she gets that pit/oxytocin-drip and have you given her alternatives?). It is also the responsibility of the client to insist on this information and to form a partnership (as opposed to a patient/heath-care administrator dynamic). Finally, c-sections are not to be taken lightly. Statistically, evidence suggests that complications are much more likely to occur with c-sections and the risk of maternal mortality increases four fold every time this major abdominal surgery is performed. Again, there are some situations that absolutely warrant the risk of performing a caesarean, but this surgical procedure should be used only in the case of medical emergencies or in the rare situation when a vaginal birth is considered less safe. Caesarean sections are by far not the safest way to give birth for either you or your baby and there are a number of associated risks which include but are not limited to: the increased risk of maternal mortality (evidence suggest four times the risk of a vaginal birth); the increased risk of infection; the increased risk of respiratory difficulties in newborns; the increased risk of haemorrhage; the possibility of anaesthesia related complications; a prolonged and potentially problematic recovery period; a significant reduction in successful breastfeeding; and a long list of emotional/psychological issues that have yet to be thoroughly explored (but that hopefully every midwife knows something about). What YOU Can Do To Avoid Unnecessary Intervention Women have a great deal of (often unrecognised) power when it comes to the care of their bodies. To strive for the birth that you want, it is essential that you acknowledge, nurture, and utilise this power. As you make decisions concerning your pregnancy, your upcoming birth, your post-partum care, breastfeeding, childcare, parenting, etc., you must think of yourself as a consumer. This is true even in a semi-socialised health care system like in Ireland , because at the end of the day you are paying for the service through taxes and/or through private health insurance fees (this applies to about ½ of the Irish population). As recipients of health care services, you have rights and choices which may or may not be offered to you but you are entitled to nonetheless, and along with these rights and choices you have responsibilities. Claiming responsibility for yourself and your care is absolutely essential to working towards the type of experience that you desire (for example, it is your personal responsibility to take care of yourself nutritionally and otherwise if it is your wish is to have a healthy pregnancy – no one can make you do this or do this for you, therefore it is a choice). First and foremost, know what you want! You can’t expect to get the birth you want if you don’t know what that is. The people who work in hospitals are tired, and frankly, they are often over-worked. Unless you’re very lucky, they don’t have the time or the energy to tune into your own personal experience and determine your needs beyond a routine medical assessment. You can’t expect them to be clairvoyant, miracle workers, or your mother. In a sense, you have to be prepared, advocate for yourself, and ask for help when and where you need it. Obviously, in order to know what you want, it is essential that you educate yourself! If you are birthing in the hospital, find out their track record concerning birth (do they have a high induction/amniotomy/augmentation/episiotomy/caesarean rate? What are their policies/protocols/routines/etc?). Women living in rural areas will be limited in their choice of hospital or may have no choice at all (and it seems to be getting worse every day. If this is the case you might have to put in more effort into organising the type of birth you want to have). Be familiar with hospital procedures (ask questions!) and make a decision if you want those procedures to be used on you in a routine manner (keep in mind that an emergency is an entirely different situation). As part of your education, take childbirth classes that are consumer-oriented and positive about birthing. I realise that Irish hospitals require (!?) childbirth education classes for first-time moms, but I’ve received mixed reviews about these classes. A good class series should cover everything from nutrition, sexuality in pregnancy and post-partum, the pros and cons of intervention, alternative pain-relief, to caesarean prevention, etc. and should provide a comfortable and welcoming atmosphere for dads or other birth partners. Your birth partner should be well-prepared for the upcoming birth and should be aware of your wishes, your desires, your fears, and your needs concerning the birth. If you are birthing in a hospital, I would very much suggest that you hire a doula (a birth assistant). Studies have shown that with the help of a doula, the chance a caesarean section is reduced by 50%. Find out more about doulas at www.doulaireland.com. Write a birth plan and discuss it with your carer in detail well ahead of your due date. As you prepare for your birth, plan to minimize or avoid (even better) the use of pain medications and routine medical interventions, include your wishes in your birth plan, and discuss it in detail with your health care provider. There is a direct correlation between the use of medications used in labour and “the domino theory of intervention”. If you are going public, identify the midwives that are comfortable with organic birth, try and have a chat with them prior to your birth and request the one on duty when you go in to have your baby (this is not always possible due to shift work, but you would be amazed how women will hold out to go into labour when they know the midwife they want is on duty or when she is back from her holiday – find out their schedules in your last weeks of pregnancy and commit them to memory). If you are going private, realise that privately insured women are more likely to have procedures carried out on them (i.e. more intervention) – if you don’t like the sound of that then thoroughly discuss it with your consultant prior to your birth. When selecting a consultant to work with, pick an individual who shares your philosophy towards birth (or at least is as similar as possible), respects you and your wishes, is positive towards women and birth, and again has the track record to prove it (for example, if you do not want an episiotomy and he/she states that they often cut episiotomies, then you better have a long talk with that person and make sure that you want them at your birth, because probably you’ll end up with an episiotomy). As you share your birth plan with them, prepare a list of questions to discuss with them, note their reactions and see what they have to say. Remember, although a hospital is an institution, it is not a prison and the consultant is not the warden. As a client, you ultimately have a say in the care of your body and your baby, and you have a right to discuss this care in detail with your midwife or doctor. Take an active role in your pregnancy and birth. Consider a homebirth (remember, if you are a low-risk woman you are just as safe at home as you are in the hospital). Or, if you’re lucky enough to live near a midwifery-run birthing unit ( Dublin and Cork for the time being), go with that. Again, I have to emphasise the importance of taking responsibility for your experience. Have a reasonable expectation of your health-care providers but realise that it is your experience and you are the only one who can do it (and it is not anything that you are not capable of). Being responsible includes self-education, multi-sourcing information, and making informed choices. It also includes taking care of oneself, eating well, staying active, remaining stress-free, not smoking/ drinking/taking drugs/etc., and treating your body and your baby with respect. Finally, believe that you are capable of giving birth. Don’t let your mind interfere with what your body is capable of doing. Once more, I invite you to interrogate your beliefs on birth. Studies show that women who have negative and fearful belief systems concerning birth and their bodies are more likely to have intervention and perceive their birthing experiences negatively. Recognise the connection between your attitude and the way you experience life. Seek help from those who support you and your decisions, who have faith in your ability to give birth, and who respect and encourage you. Birth Is Not An Illness! 16 Recommendations from the WHO These 16 recommendations are based on the principle that each woman has a fundamental right to receive proper prenatal care; and that social, emotional and psychological factors are decisive in the understanding and implementation of proper prenatal care.
(These recommendations are taken from a report on Appropriate Technology for Birth published by the World Health Organization.) |