Birch Midwife & Lotus Doula

better late than never but here is part 5 – hope you enjoy it

Centralisation of Childbirth

The Peel report of the 1970’s has already been mentioned but another major factor in the implementation of the medical model of birth has been financial. The centralisation of services has huge cost saving. When resources are concentrated into one place then fewer resources are required. Whether this is equipment, infrastructure or staff, the less of these that are required the lower the cost, but this a very simplistic way of looking at costing and cost saving. In 2006 the Department of Health discussed the issue of the huge financial deficit in NHS budgets.  Many Trusts found themselves in dire financial circumstances. This led to NHS Trusts looking at rationalisation of services in an attempt to rectify the situation. In 2006 many birth centres were closed across the country. Statements issued from the various trusts involved all stated that staffing or under use were the major factors in the closures, but it seems ironic that all these issues all seemed to surface just as trusts were being told to redress their financial issues or face sanctions. The Comprehensive Spending Review of the Government in 2007 required a 3% efficiency requirement on all public sectors organisations meaning NHS Trusts had to make comprehensive strategies for increasing productivity as well as reducing costs. Rationalising and centralising services may be a logical way to reduce costs whilst still providing services but only in the short term. Long term this may create many more problems especially within the maternity setting where it has to be accepted that for the majority of women childbirth is a normal and natural event not a medical emergency.

Obstetrics and gynaecology speciality has the second highest claims rate for NHSLA and the highest monetary claims (NHSLA, 2009). Many claims made to NHSLA result from a perception of a ‘lack of assistance or care’ and ‘failure/delay in treatment or diagnosis’. With the centralisation of maternity services to large consultant units which are impersonal and not necessarily local to the individual, causing issues for transport, where each person is processed by number and condition not as an individual will lead to greater dissatisfaction and consequently more complaints and claims. A large amount of claims means a higher level of levy on the trust and the speciality by NHSLA. Still attempting to reduce costs each trust strives to reduce the levy not by increasing care provided but by trying to lower their premiums.

Each premium or Clinical Negligence Scheme for Trusts (CNST) level provided through the NHSLA commands a different payment amount for the Trust. For each level a different set of standards has to be met. Having ploughed through the standards set there is little with regard to providing a high quality caring environment, no provision for assessing the psychological and social support for women using the service. The standards are mostly concerned with the development and implementation of guidelines with reference to NICE guidelines and auditing to ensure compliance with these guidelines. There are standards set which stipulates set types of training for the specialty but no actual audit of what is actually being taught and by whom. It is all a paper exercise in an attempt to reduce litigation not by the provision of care but the ability to say we did all we could clinically and therefore it was not our fault.

In March of this year (2010) it was also announced by the Department of Health in response to the pre-election budget delivered on 24^th March 2010 that the NHS needs to make £4.25bn savings over 2 years. This is to be part of the efficiency drive to cut NHS spending by £20bn announced by the chief executive of the NHS in June 2009. Whilst having these spending cuts hanging over the NHS it has still managed to increase the number of managers within the NHS by 12% (BBC News [online] 2010). This is an example of how the NHS sees the bureaucracy of its own self to be of greater importance than the care being provided.

To my mind it seems logical to centralise services where large costly pieces of equipment are needed but in an area where the main provision by the NHS is a caring midwife for what is ostensibly a normal physiological event it seems that providing this service away from a central point eg small units, birth centres at home, is not going to vastly increase costs and in actual fact the reduction of the use of interventions which has been proven to happen when birth is treated as a normal physiological event in a calm and comforting setting would actually reduce NHS costs in the long term.

Medicalisation of Childbirth

Jowitt (1993) said

‘…with very few exceptions, technology has no place in childbirth’ p13.

For thousands of years women have been birthing babies without the necessity to have lots of technology or consultant hospitals. Not all babies survived and not all women did either but enough to perpetuate the human race to populate the entire world. In a recent bulletin from the WHO (2010) it was found that in China there was a direct correlation between increased institutionalised birth settings and an increase in caesarean birth to levels well above their recommended rates. WHO (2010) went on to say that institutionalised birth was not the only factor in the increase but that also the medicalisation of antenatal care contributed.

As a student midwife I learnt many things but two of the most important were the principles of non-maleficence and beneficence.

Non-maleficence means that our first priority must be to do no harm with our actions and balanced with this the principle of Beneficence which is that actions should be done to benefit the situation (UCSF School of Medicine, 2010).

Medicalisation just because an intervention has been invented is not an act of non-maleficence or beneficence unless full unbiased research proves the benefit of the intervention or treatment is outweighing the risk. The introduction of cardiotocography (CTG) in the 1970s is an example of how an intervention can medicalise childbirth with little benefit to the vast majority of those who received this intervention. Since its introduction many research findings have been produced which state that CTG confers little or no benefit for women and babies who are low risk, and actually increases operative interventions with their own inherent risks (MacDonald et al,1985, Thacker et al, 1995) and it is now commonly viewed that CTG use should be restricted to those women who are experiencing a complex pregnancy and birth.

Routine elective caesarean section for breech presenting babies as recommended by the Term Breech Trial (Hannah et al, 2000) is another example of how medicalisation of childbirth has had a major impact on women and babies. Since Hannah et al’s (2000) original recommendations opinion has been divided as to whether this is the best course of action in all instances but the effect of this and also the blanket introduction of CTG’s has had a much more profound and damaging effect on the provision of normal birth environments than just the actual intervention itself. These interventions are examples of how the medicalisation of childbirth has and can lead to the deskilling of midwives. Murphy-Black (1991) observed the reduction in midwives skills in auscultation of the fetal heart using a pinard and many midwives have not even been privileged to witness a breech birth let alone have the experience to feel fully competent in being the lead professional. This medicalisation of childbirth is having a profound effect on our profession and our ability to provide women with midwives who have a wide range of experience to facilitate normal physiological birth for women.

Moving childbirth into the medical field also disempowers women. Henley-Einion (2009) writes about the medicalisation of childbirth and explains how the patriarchal changes in moving from women supporting women in childbirth to a more medicalised and scientific approach moved childbirth into the realms of a male dominated hospital system with a greater reliance on experts in the scientific field with their complex words and scientific language creating a barrier to women being a part of the process encouraging them to be a passive recipient of treatment. The reduction in physiological birth has created a whole generation who have no experience of childbirth without medical and scientific input.

The prevailing attitude within the maternity wards is that of looking at each woman as not as an individual with a name and aspirations but as a condition. Many times, both as a student midwife and as a qualified midwife, I have listened to the handover of care and been have been complied in the treatment of women this way. The handover, not of Ann Other who is labouring and has a cervical dilatation of 6cm but, of room 3 who is 6cm. The handover of the ‘epidural and synto in room 6’ as apposed to Anita Person who has had an epidural and is currently receiving a syntocinon infusion. The clinical and medical information being the person, detracting from the individual who is experiencing childbirth, all reaffirming the importance of the medical and not the individual.

As a student midwife and a mentor to students I have also become frustrated with the way in which midwifery education has reinforced the medical model of care. A student midwife is required to conduct the ‘normal delivery’ of 40 babies in order to qualify but those 40 ‘normal births’ can be induced, augmented and with epidurals in situ. Midwives can qualify having never experienced a physiological third stage, a waterbirth or a homebirth. Students can’t count the long hours of supporting a woman who is labouring and birthing physiologically but requires a manual removal of placenta at the end of it but can count the woman whom she has never met and births 5 minutes after the midwife enters the room.

Universities appear to be trying to instil physiological birth into the programme but until the requirements of qualification, and the culture of the labour wards they are training in, are looked at, many midwives can, and do, qualify with out what I consider to be the prerequisites of a midwife who can support a fully physiological birth.

I am not having a go at the student midwives, their mentors or the lecturers but I am having a go at the system that perpetuates this hideous form of education for midwives!!!!

As a little interlude to my dissertation serialization I thought I might just air a few thoughts I have been having lately – a discussion came up on an internet group about how frustrating it is when people ‘won’t think for themselves’ people who hold the belief that ‘birth is a catastrophy waiting to happen’  The discussion became quite emotionally charged about supporting women in their choices and the question of whether they made informed choices. Women who ‘can’t see that the induction/epidural/forceps might have been a cause rather than a solution requiring another solution’, who ‘KNOW that birth is dangerous because had they not been rescued they and their babies would have died’ ‘ignorance of the cascade of intervention’ and I wondered ……perhaps they made the ‘choice not be become informed’ or perhaps we have in a way created this situation – I know I spend time explaining how women just need to detach themselves from that neo-cortex that makes us so human to become more mammalian and to enable us to really switch off the outside world and follow our bodies but have we really given women the tools to do this – the question I am asking is – have we told women to switch off their ‘thinking brain’ but not given them the tools to reach deep to the instinctive brain and therefore the only thing to do with the ‘thinking brain’ switched off it to allow others to take over!!!!

Fordism and Taylorism

Fordism was a method used mainly in the automotive industry, having been devised by Henry Ford in the 1940’s. It improved productivity, but it was also ‘a model of economic expansion and technological progress based on the mass production: the manufacture of standardized products in huge volumes using special purpose machinery and unskilled labour’ Tolliday & Zeitlin (1987). There were three main principles to Fordism, standardisation of the product, specially developed tools and equipment to speed up the assembly line, and the elimination of skilled labour.

Although the assembly line had a huge impact on the manufacturing industry it was the breaking down of complex tasks in to simpler tasks and the employment of equipment to assist with this that really created the revolution. The major advantage of such a change was that it cut down on the man power necessary for the factory to operate, reduced the skill required to actually produce the work and therefore reduced the costs (Burrows et al. 1992).

These principles could be shown to have been applied to the Maternity Service in the UK. Antenatally women are ‘processed’ on a conveyer belt system where each woman was ‘squeezed’ into the one size fits all system of care. Clinic appointments lasted between 10 and 15 minutes which allow little time to discuss anything outside of the standard clinical ‘testing’ which must be completed. No allowance was made for the individual you are caring for, the same amount of time was ‘allocated’ during antenatal clinic appointments for e.g. the woman who was needing and wanting little more than the standard ‘routine’ antenatal checks and the woman with serious physical or mental health issues, or with social and domestic issues. The constraints on the time spent with women prevent the health care professionals from getting to know the woman and their individual needs.

The remit of the midwife is to provide postnatal care until 28 days, but women and babies are routinely discharged from midwifery care at or around day 10 and the ever increasing role of the Maternity Care Assistant especially with regard to postnatal care are examples of how Fordism is being enacted within the Maternity Service. The breaking down of tasks into simple individual parts and then having these tasks performed by less skilled people.

Head (2005) describes the general principles of Taylorism. Demarcated roles with the shift in decision making from employees to managers. The ‘supporting’ of workers by planning their work and eliminating interruptions, tightly regulating and controlling the workers and the low level of autonomy is all part of Taylorism, creating a management/worker split and reducing teamwork. This creates a system of tick boxes and standardisation to the detriment and exclusion of individualised care.

Assembly Line Birth

The need, when working in a medical model, to control the time of women going into labour and not just trusting the individuality of the woman’s body and its own gestational body clock, when looking back at previous (blog) comments on the use of the word ‘term’, may be the first indicator of the assembly line attitude to birth.

This can then continue into our attitudes to the progress of labour itself. The assembly line concept has been perpetuated with the rigid application of the partogram. Friedman introduced the concept of a partogram in 1954 by graphically depicting the dilation of the cervix during labour and then this concept was further developed by Philpott and Castle in 1972. More currently the partogram has been designed to monitor not only the progress of labour, but also fetal and maternal condition during labour. A recent Cochrane Review concluded that ‘we cannot recommend routine use of the partogram as part of standard labour management and care’, and a summary produced by Reproductive Health Library (Soni, 2009 [online]) stated that ‘partograms may be useful in settings with poorer access to healthcare resources’. With these recommendations it appears that the continued use of partograms, rather than to increase maternal and fetal wellbeing, are actually being used to framework women and the maternity service into a regimented system designed to produce efficiency rather than care. Enkin et al (1995) stated the partogram can become ‘an agent for regimenting labour’.

Enkin et al (1995) illustrated this by saying ‘A dilatation rate of 1cm/hr in a woman who is having strong contractions and is in severe distress is far more worrying than a dilatation rate of 0.3cm/hr in a woman who is comfortable, walking around, drinking cups of tea and chatting’

Perkins (2004) talked about this assembly line within childbirth and discussed how models of care within the health care setting were emulating how models of working practices were being constructed within the manufacturing industry.

This system reduces the continuity of care so the women can no longer engage fully with a midwife she knows, does not allow women to discuss personal issues with regard to their pregnancy, their hopes and fears, their wishes for the birth and postnatal period or disclose sensitive information which may impact on the care required.

Pregnancy is no longer perceived to be a wonderful journey in the transition to parenthood but an obstacle course to be traversed. Birth, the most intimate of life experiences now commonly takes place in sterility and in the presence of strangers with timescales being imposed on the birth process for the benefit of the system not for the benefit of women and babies.

Women are routinely defaulted to the medical model of care, this model extols many of the ‘virtues’ of the Fordism and Taylorism. From booking when women will be routinely booked to birth at a consultant unit unless they specifically request a preference for another birth setting, where interventions will be ‘offered’ routinely unless specifically declined for example active management of third stage, where the individual autonomy of the woman to assess her own values of ‘risk’ for her and her baby with regard to decision making during pregnancy or birth show that the assembly line maternity unit is alive and well, and the concept of do not intervene in physiology unless intervention is known to be more effective than nature has been lost.

In order to ensure intervention has no side effects that outweigh benefit each woman, family and maternity episode must be considered on its individual merits and not on a standardized system that only benefits the strategic objectives of the Trust.

Biopsychosocial Care is Central to Normality

Biopsychosocial well-being incorporates three elements that are intertwined and interdependent. These three elements are the biological aspect of care, the psychological aspect of care and the social aspect of care. The biological aspect covers clinical needs, physiology and physical health promoting a healthy pregnancy, mum and baby. This is the element of care that is primarily focused on during routine antenatal care (McCourt & Percival, 2000).

In order to provide good biopsychosocial care there needs to be an understanding in all three areas – physical, emotional and psychological and all aspects need to be accounted for when providing care to women. We need to take into account the hormonal and emotional side of childbirth as well as the ‘mechanical’.

Psychological well-being incorporates the psychological and emotional well-being and social includes the support for and from partners, the wider family unit, the environment and education. The World Health Organization (WHO, 1948) in its definition of health brought together the three elements of ‘physical, mental and social well-being’ as combining to bring about health in an individual or group. This places equal weighting on each of the three elements.

Each of the three elements of biopsychosocial care can impact on the other two. In basic terms a physiological condition can cause anxiety, which can impact on the social environment by causing stress on the family unit. Conversely, and perhaps more significantly for this case study, anxiety can cause the release of stress hormones such as catecholamines and glucocorticoids (Stables, 1999). Catecholamines include adrenaline and noradrenaline have short term effects on the body (Stables, 1999). Glucocorticoids, for example cortisol, have an effect on cell metabolism, and secretion can rise dramatically in response to severe stress including emotional distress, which can effect changes in ‘cardiovascular, neural and gastrointestinal function’ (Stables, 1999). This shows that the psychological element can impact on the biological. These psychological influences are increased within the maternity service pertained by the medical model of care in the hospital setting. Routine admission to hospital with its bright lights and uncomfortable environment for women can increase adrenaline levels as previously mentioned; routine use of beds restricts mobility and reduces gravity (The second stage lasts substantially less for both primips and multips who adopt upright positions such as squatting, Golay et al, 1993). Floyd-Davis (2002) likens the biopsychosocial model to humanism taking about the association between the various aspects of the client, the family, the culture and the practitioner and how humanism acknowledges the influence the mind has over the body. The humanistic model of care can add to the social model of care previously described.

The Humanistic (biopsychosocial) Model of Medicine

1. Mind body connection
2. The body is an organism
3. The patient as relational subject
4. Connection and caring between practitioner and patient
5. Diagnosis and healing from the outside in and from the inside out
6. Balance between the needs of the institution and the individual
7. Information, decision making and responsibility shared between patient and practitioner
   1. Science and technology counterbalanced with humanism
   2. Focus on disease prevention
   3. Death as an acceptable outcome
   4. Compassion driven care
   5. Open mindedness toward other modalities.  (Floyd-Davis, 2002)

Pain and midwifery

For the majority of women one of the most significant factors related to giving birth is the prospect of pain in labour (Moore 1997).

Understanding both the neurophysiology and psychology of pain enables midwives to give individualized care, and the ability to utilize methods to alleviate the perceptions of pain.

There are two approaches to dealing with pain in labour. Working with pain where it is believed that pain has a purpose and is physiological, using a variety of supportive strategies such as movement, positioning, massage and touch therapy following the woman’s lead as to what she is finding is effective. Birth partners and the environment are critical when utilizing this strategy. (Lundgren and Dahlberg 1998)

The second approach is the one lent to within the medical model is the pain relief approach. This approach is that pain is negative and needs treating. This approach is the one that leads to the trend of elective epidurals.

The Gate Control Theory is a pain theory first proposed by Melzack & Wall (1965).

Pain messages originate in the nerve affected by pain and flows along the peripheral nerves to the spinal cord and up to the brain. Before they reach the brain, they encounter ‘nerve gates’ in the spinal cord. When open the pain ‘messages’ get through. When the gate is closed the messages are stopped.

There are three main groups of events and conditions that may ‘open’ or ‘close’ the gates. Sensory events such as injury, inactivity, long term narcotic use, cognitive events such as focusing on the pain, having no outside distractions, worrying about the pain and negative thoughts, and emotional events such as depression, anger, anxiety, stress, feelings of hopelessness and helplessness all ‘open’ the gates to intensify the pain sensations.

Influences that may ‘close’ the gates

Sensory events such as increasing activities, shot term use of medication, support and meditation, cognitive events such as outside interests, thoughts that help the client cope with the pain and distracting oneself from pain, and emotional events positive attitude, overcoming depression, feeling reassured that the pain is not harmful and taking control of ones pain and ‘close’ the gates.

It is eessential for the health care professional to recognize that pain perception varies among women. By understanding the physiology of pain will enable a variety of techniques to encourage the ‘gates’ to close to pain. This approach lends itself to the social model of care

Psychosocial Support

When reading McCourt & Percival (2000) it is apparent that social support makes a positive impact on how women feel about their pregnancy, pronouncing that social support should be integral to maternity care but that ‘fragmented’ care made social support difficult to achieve. Walsh & Newburn (2002) make it clear that continuity of care should not be an ‘optional extra’ as implied by the medical model but ‘fundamental to effective care’.

Medical Model of Birth

Since the Peel Report in the 1970’s and his recommendation that all births should take place in hospital, technology has played an increasingly important role in childbirth, increasing the medicalisation of childbirth and pushing the experience towards the medical model of birth.

Bradshaw (1994, cited by Walsh & Newburn, 2002) drew up a comparison of the social model of health and the medical model of health and used the World Health Organisation definition of health to underpin the social model.

The Medical Model of Health

• Absence of disease
• Cure rather than prevention
• Disease rather than promotion of health and welfare
• Priority to acute specialist medicine
• Hegemony of medical profession
• Emphasis on throughput numbers
• Paternalistic/patriarchal

The medical model has its place – but not necessarily in the first instance of care in midwifery

The Social Model of Health

• Holistic, life-enhancing
• Emphasis on prevention
• Links Health and Social structures
• Quality of Life
• Primary care focus
• Interprofessional cooperation
• Personal experience of health valued

Individualised Care allows woman’s individual perceptions of ‘normal’ to be incorporated in the care provided. The medical model suggests that childbirth is normal in retrospect; the social model suggests birth is normal until proven otherwise.

If we are practising normal until proven otherwise the medical model of care should only be applied when it is ‘proven otherwise’

The social model of care not only benefits the women we are providing care for but also promotes the midwifery profession as being autonomous.

It allows us to provide care on an individual basis using the values of the individual concerned.

When employing the medical model of care we move towards thinking in terms of productivity, yield, output and efficiency; these are terms used by the manufacturing industry.

Influences on a Woman’s Perception of Normal Birth?

Media

The media can have a huge influence on the women’s perceptions of childbirth. British Journal of Midwifery in 1997 published an article by Sarah Clements which analysed birth screened on TV in 1993 (Clement, 1997). 92 births were shown in that year.  In 1993 there were only four television channels available on terrestrial television and it was only 4 years since the first installation of domestic satellite television so there was not the proliferation of channels there is today.

Approximately 65% of the births portrayed were in hospital and 25% of the births shown were homebirths. Two thirds of the homebirths were planned homebirths but half of these were in an historical context where homebirth was the norm and also showed little relevance to modern maternity issues. Within the 92 births only 6% were planned homebirths set in the modern era. These figures are good when compared to national statistics from the National Health Service Information Centre (NHSIC) that say only 2.6% of births in 2006 were at home (NHSIC, 2007), but this lovely view is then distorted by the fact that these births on TV show a higher than normal figure of death of baby or severe illness in baby and mother or took place in a historical context. Many of these births show other stressful circumstances such as no midwife, birthing alone or without their birth support of choice.

The article summarises that the labours and births shown on television have a tendency towards drama, crisis and unpredictability. For many women in the UK today, labour and childbirth is a ‘behind closed doors’ event and therefore what is portrayed on television may have a great influence on women’s perceptions of birth as being the only reference point they have.

In addition to the drama series portrayal of childbirth there is also the documentary series where, again, with editing, the dramatic and heart wrenching births command more ‘airtime’. A good illustration of this is in the recent series ‘One Born Every Minute’ shown on Channel 4 during 2010 where very limited time was given to physiological birth. It was noted that in one episode where a waterbirth was shown, out of the total of 47 minutes of that episode only 7 minutes was dedicated to the only ‘normal’ birth.

Language

The language used commonly amongst health care professionals and also when talking to women can have a huge influence on how women view childbirth.

In March 2007 I was lucky enough to have a conversation with the well known Midwife Mary Cronk discussing the use of language within the birth setting. The negativity of words used was highlighted. Common terms such as ‘incompetent cervix’ ‘inadequate pelvis’ ‘failure to progress’ and ‘trial of scar/labour’ all serve to place a negative attitude towards childbirth. (Cronk 2007). The most commonly used term that implies that childbirth is not considered to be a normal, natural and healthy process is the term ‘delivery’. To deliver or be delivered suggests that this is a process where the woman is not in control, she has not/ is not given/giving birth but someone else has delivered or is delivering her. The word deliver is defined as ‘to give into another’s possession or keeping’; ‘to assist (a female) in bringing forth young’ (Dictionary.com2010).

All of these negative influences on the woman and her family distort the physiology of the birth by distorting the hormonal actions required to birth, interventions are then required to assist the woman thus perpetuating the concept that woman require help to birth their babies. When a woman is stressed and the rational brain is stimulated by the answering of rational questions her body will produce catecholamines and cortisol which will inhibit the oxytocin required to produce contractions within the uterus and endorphins needed to help cope with the intensity of the contractions (Anderson, 2002).

Fear is a major factor in a woman’s ability to ‘cope’ with labour and birth. It affects the hormonal systems which control the labour process and also creates an environment which decreases the woman’s ability to deal with the pain of labour as described by Grantly Dick-Read in his book ‘Childbirth Without Fear’ (2006). Reducing the fear can therefore reduce the need for pharmacological pain relief and other interventions as can having a trusting relationship with the caregiver (Niven, 1994)

Professional Attitudes

Fear of litigation and complaints against Health Care Professionals and Establishments affects the attitudes of the professionals with in the maternity Service.

The concept of litigation itself is discussed elsewhere in this piece but it is worth mentioning that this can also influence the women’s perception and experience of birth. Anderson says

‘midwives who were trained and have worked in the setting of a busy maternity ward, who have spent years surrounded by fetal distress, emergency deliveries and haemorrhages may have developed a fundamental disbelief in the normality and safety of birth.’

(Anderson, 2002 p68)

This may also be said of doctors.

In the urgency to prevent a problem from occurring hospital personnel may feel compelled to push procedures that may actually cause problems in themselves (Falcao, 2010 [online]). Health Care Professionals may deem this to be a prophylactic attitude to care; prevention being better than cure; and ‘sell it’ it as such. In my opinion, for a treatment to be prophylactic it must not only be used to prevent a ‘problem’. A woman or baby should be at high risk of suffering that ‘problem’ and that risk must be actual risk not just perceived risk taking us back to the concepts of ‘what is risk?’, ‘who defines this risk?’ and ‘whose risk is it?’.

Anderson explains this atypical concept of prophylaxis

‘we stress women by bringing them into modern ‘laboratories’ to have their children and then use syntocinon to ‘fix’ the slowing contractions and instrumental deliveries to reduce the distressed babies that are a result of what we have done’

(Anderson, 2002 p66)

Physiological V’s Normal

Association for Improvements in Maternity Services (AIMS) defines physiological birth as a birth without any technological intervention (Beech, 2003). Physiology is defined as

‘a branch of biology that deals with the functions and activities of life or of living matter (as organs, tissues, or cells) and of the physical and chemical phenomena involved’

(Dictionary.com [online] 2010).

Anderson (2002) describes this in her article ‘out of the laboratory: back to the darkened room’ where she explores how the whole environment of the labour ward can actually cause more intervention to be required. It could also be said that any intervention will affect the physiology of birth even the presence of a midwife. This appears to make the achievement of physiological birth a step too far for all but does not prevent us from striving to achieve something as close as possible to a physiological birth.

In addition to media and the written and spoken word statistics can also portray a distorted view of normal birth. Many women and midwives will consider any unassisted vaginal birth to be normal and many maternity service statistics will also uphold this view (Downe et al 2001). Maternity statistics published use the much more inclusive definition to show high ‘normal birth’ figures. In Recorded Delivery – A national survey of women’s experiences in 2006, the definition of normal birth is one that

‘excludes induction, the use of instruments, caesarean section, and general, spinal or epidural anaesthesia during delivery, the proportion of women giving birth in this category is 38%. A more limited definition which also excludes augmentation, the use of pethidine for pain relief and episiotomy, results in 13% of the study births being categorised in this way.

(National Perinatal Epidemiology Unit, 2006 p26)

If only 13% of women are experiencing this kind of birth it may be difficult to define this as normal birth as ‘normal’ is commonly defined as being usual. A dictionary definition of normal is ‘conforming to the standard or the common type; usual’ (Dictionary.com 2010). With this definition in mind it may be perceived that birth with intervention and clinical assistance is ‘normal’ – are we all changing the concept of normal and making the abnormal normal – if so then we are all to blame for women’s misconceptions around birth.

Marsden Wagner used the analogy ‘Fish can’t see water’ (Wagner, 2001) to illustrate how Health Care Professionals whose only experience is of high levels of intervention in childbirth can’t see that their concept of prophylaxis may actually be causing more problems than solving them.

I have decided to serialize my dissertation in my blog for a couple of months in the hope it might generate some discussion!!!

Normal Birth?

Association for Improvements in Maternity Services (AIMS) defines physiological birth as a birth without any technological intervention (Beech, 2003). Physiology is defined as

‘a branch of biology that deals with the functions and activities of life or of living matter (as organs, tissues, or cells) and of the physical and chemical phenomena involved’

(Dictionary.com [online] 2010).

Anderson (2002) describes this in her article ‘out of the laboratory: back to the darkened room’ where she explores how the whole environment of the labour ward can actually cause more intervention to be required. It could also be said that any intervention will affect the physiology of birth even the presence of a midwife. This appears to make the achievement of physiological birth a step too far for all but does not prevent us from striving to achieve something as close as possible to a physiological birth.

Many women and midwives will consider any unassisted vaginal birth to be normal and many maternity service statistics will also uphold this view (Downe et al 2001), but published maternity statistics can use the much more inclusive definition to show high ‘normal birth’ figures. In Recorded Delivery – A national survey of women’s experiences in 2006, the definition of normal birth is one that

‘excludes induction, the use of instruments, caesarean section, and general, spinal or epidural anaesthesia during delivery, the proportion of women giving birth in this category is 38%. A more limited definition which also excludes augmentation, the use of pethidine for pain relief and episiotomy, results in 13% of the study births being categorised in this way.

(National Perinatal Epidemiology Unit, 2006 p26)

If only 13% of women are experiencing this kind of birth it may be difficult to define this as normal birth as ‘normal’ is commonly defined as being usual. A dictionary definition of normal is ‘conforming to the standard or the common type; usual’. With this definition in mind it may be perceived that birth with intervention and clinical assistance is ‘normal’

In order to support women to achieve ‘normal birth’ we need first to define normal birth. The World Health Organisation (WHO) in 1997 stated that Normal birth is defined as being

‘Spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 weeks of pregnancy. After birth mother and infant are in good condition’.

(WHO, 1997, online)

There are many elements of this definition that need to be explored and also defined themselves. Within the United Kingdom (UK) there are many different working definitions being employed. It is generally deemed to be somewhere between any birth which is vaginal, vertex and without instrumental intervention to a completely physiological birth where no interventions, no matter how small or seemingly innocuous, which may effect how the body should function, are used.

When the WHO definition is broken down it is easier to see how the medical model of care has created its own definition of normal birth to normalise commonplace interventions.

The first part of the WHO definition states ‘spontaneous in onset’ – induction is very common within standard maternity care provision from a ‘stretch and sweep’ to full clinical induction. A ‘stretch and sweep’, where the midwife or doctor will attempt to stimulate labour contractions by manually stretching the cervix and sweeping the membranes using gloved fingers, although commonly used as a ‘gentle stimulant’ to labour is an intervention that would not normally occur without the midwife or doctor instigating it.  These are interventions that are increasingly becoming ‘normalised’ by the fact that they are commonplace and the frequency in which they occur. The National Health Service Information Centre (NHSIC) (2009) showed a national rate of induction to be 20.4%, the equivalent of 1 in 5 women. The National Institute of Clinical Excellence (NICE) (2007) has recommended routinely offering induction of labour to all women, regardless of risk status, thus normalising the induction process. National Institute of Health and Clinical Excellence (NICE) (2007) suggests the routine offering of a stretch and sweep to all women at 41 weeks gestation and then a clinical induction using a combination of prostaglandin pessaries or gel, artificial rupture of membranes and intravenous infusion of syntocinon.

The second part of the WHO definition states ‘low risk at the start of labour and remaining so throughout the labour and delivery’. Dobos (1992) defined risk as ‘any situation in which the outcome is uncertain and in which something of value could be lost’. Using this definition all pregnancies and labours have an element of risk. The difficulty is in defining that risk and the assumption therefore that ‘high risk pregnancies’ can be identified. The concept of risk is subjective, individual and contextual. Within the medical model of care for maternity the assigning of risk is done by parameters set by health care professionals and, predominately in the hierarchical set up of the National Health Service (NHS), by doctors, risk managers and the Trust, under guidance from the National Health Service Litigation Authority (NHSLA), making the risk assessment subjective, individual and contextual to the criteria of others not individual to the woman concerned. I believe the use of different values when assessing risk, by viewing the risk across a wider group rather than the individual and looking at global issues of Health promotion, Ill health prevention, Cost-benefit balance and Litigation as markers for this assessment, prevents risks being assessed in a way that is beneficial to the individual. It is also not a clear cut issue of determining if there is a risk but the establishing and categorising the level of risk. Risk, being subjective and individual, is not black and white but a multitude of shades of grey. The medical model of care needs to simplify this and polarises these risks into two categories, low risk and high risk. Any risk, therefore, will place someone in the high risk category.

It is ultimately the women and their families who have to live with the outcomes and consequences of risk assessments made by others who are paid to do this.

I believe that this seeming obsession with risk and the possibility that something could go awry may cause us to lose sight of normality. It may be that too much emphasis is being placed on the outcome being the be all and end all, and that we are forgetting about the process, we as midwives and other health care professionals, are supposed to be the guardians of.

The third part of the WHO definition states ‘born spontaneously’. Many women are encouraged to use valsalva pushing and are ‘cheer lead’ into birthing their babies (Roodt & Nikodem, 2002). This may be due to women being confined to birthing positions not conducive to birth, due to epidural or continuous fetal monitoring. It may be due to the ‘normal’ practice of the health care professional who is ‘conducting’ the birth, or it may be due to time constraints imposed by guidelines such as the NICE Intrapartum Care guidelines (2007). Cooke (2010) summarises that guidelines on Labour Wards should be altered to reflect current evidence with regard to the timing of labour to prevent health care professionals feeling under pressure to direct pushing to fit current timescales.

The fourth part of the WHO definition states ‘in the vertex position’. This excludes any woman who achieves a spontaneous vaginal breech birth from being considered to have had a normal birth. Cronk (2004) states that ‘breech birth is not a malpresentation but an unusual presentation’. Women with a breech presenting baby within the medical model of birth are high risk and are usually ‘managed’ by being presented with the choice of elective caesarean section or a breech ‘delivery’ both of which are high risk interventions .

The fifth part of the WHO definition states ‘between 37 and 42 weeks of pregnancy’. Term is 37-42 weeks – so why do we perpetuate the view that women are overdue if they go past their ‘due date’ which we set at the 40 week mark.

The use of the phrase term + when in actual fact they are not term + but 41 or 41+4 weeks – term means 37-42 weeks. This is an example of where the medical model is abnormalising the normal. Women are set to believe that once the magic 40 weeks gestation has been reached that their bodies are now not functioning properly and they are now overdue. NICE states

‘Women with uncomplicated pregnancies should usually be offered induction of labour between 41⁺⁰ and 42⁺⁰ weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman’s preferences and local circumstances’ (NICE, 2008, p8).

Women are encouraged to accept induction of labour prior to the end of normal human gestation period, 42 weeks, engendering the ethos that it is not normal to gestate to 42 weeks. Are we considering women’s preference or are we just pushing women to ‘choose’ our preference by convincing them we know all and they should trust all we say or suggest – the power of suggestion is huge!!

I am not a hugely profound writer and tend to pose more questions than I could ever attempt to answer so anyone reading my blog looking for a huge amount of insightful comments or answers to questions about birth are in the wrong place – but remember asking the questions is always the first step to finding answers.

In the past week or two I have as usual had a mixed bag of experiences. I have said goodbye to clients who have ‘outgrown’ the need for my care – always tinged with sadness but also a satisfaction that these families have developed to be self sufficient from me! I have also had the pleasure of meeting new and potential new clients.

my client base is very varied. I have women who are booking me purely due to the perceived failings of the NHS to commit to providing the care they want and need. I have also met a woman who was considering booking on a personality basis alone- which is lovely that they may want to share what is going to be a momentus event in their life with me.

This has made me consider the concept of control – many of us in the birth sphere spend time discussing women taking control of their birth and that is what is needed for many – but others need to let go of control and in differing ways.
There are those who feel the need to give up control to others such as midwives and doctors as that is their need and desire and who are we to prevent that although there is a lot of research that has and could be done to explore the reasons for this but there are others who give up control in other ways.
Giving up control to the birthing process itself is a very different giving up of control. Not fighting the body and the process; allowing the body and the process to move in its own time pace and manner is a very positive giving up of control for many women – it allows them to ‘let go’! Labour usually progresses better with this type of letting go by allowing the hormonal systems to ‘do their thing’ unhindered.
So although women in the generic sense need to take control of birth in the personal sense control needs to be given up to the primal and primitive sides of ourselves – birth preparation is imperative to this aim – in order for a woman to shut down the neo-cortex (new brain) then ensuring that this higher brain centres don’t need to be employed making decisions and processing questions during the birth – choosing who will be at your birth supporting you and taking the time to build close relationships with these people before the birth will assist in keeping this stimulation to its minimum. This is one of the many benefits of independent midwifery care – a known birth supporter who can support the kind of birth you are planning.

I hope the women I met this week achieves all she desires with this birth and if this includes me then fabulous but if it doesn’t then again that is no problem – I will support all the decisions women make.

Well the past few weeks have been very busy. It is amazing the variation in pregnancy and birth. a couple of clients and their babies decided to wait well into the 42nd week of pregnancy before birthing and another decided to start before 40 weeks making a very eventful week of 3 births one after the other. Wonderfully they all birthed on different days allowing me to recover myself between births. Then one week later another 2 babies also arrived that makes 5 fabulous births in 13 days – exhausting but exhilerating! 5 fabulous mothers, birthing 5 gorgeous babies supported by 5 wonderful partners – this is not a job its a privilege!
It was great to also have 3 of these babies very local to me, Witham, Braintree and Dunmow. Made my postnatal visiting easier on the environment anyway!
So in summary – 2 hospital births (planned) – 1 first time mum and 1 second time mum; 1 homebirth – first time mum; and 2 home waterbirths – 1 second time mum and 1 third time mum. 4 girls and 1 boy, weighing from 6lb 8oz to 9lb 12oz. All the babies birthed under their own steam, no inductions or augmentations, no interventions or problems.
Having a 2 weeks break from on calls – although obviously still working doing antenatals and postnatals.
Drop me a line if you are interested in finding out more about independent/private midwifery care and whether its right for you – always happy to answer any queries.
Sad news with regard to WJC Birth Centre in Braintree – the local people have lost the fight to keep postnatal inpatient care in Braintree. The Birth Centre is to move from the WJC site and when it does the double rooms and the postnatal ward will be lost - this is a blow to the people of Braintree and surrounding areas as well as the staff who were fighting to keep these facilities open. This will mean that those giving birth at the Birth Centre will have short stays/quick discharge home – for those worried about breastfeeding/postnatal support at this time I am sure the community staff will be doing their best for you but don’t forget I do offer postnatal only packages if you want more help/support at this time.
I have special links with Mid Essex Hospital (Broomfield, St Peters and WJC) and particularly welcome enquiries from people in these areas, and also have good links with Colchester and Rosie Maternity (Addenbrookes in Cambridge). Don’t hesitate to contact me in confidence if you have any questions.

Its been a while since I posted and we have been very busy – 1 birch baby, 1 shared birch and essex midwifery baby and I have been back up for a couple more essex midwifery babies – had a lovely christmas with lots of nice postnatal visits and now looking forward to a busy January – am going to try harder to blog what Birch Midwifery Practice is up to more often in this coming year

Since my last blog I am happy to announce the birth of a gorgeous baby boy!! A fabulous home waterbirth. Both Mum and Dad were wonderful and calm even making me wonder if this really was labour at one point!
Baby is now over a week old and everyone is doing really well and both big brothers are doing reallly well too!
Congratulations to the whole family – it has been an honour and a privelege to have shared this birth with you all
xxx