September 1999 Vol. 26.3

Sheila Kitzinger's Letter from Europe

Midwives on Trial

There are signs that a midwife witch-hunt may have started in some European countries. Familiar in the USA, this is new to modern Europe where midwives are the foundation of all maternity care. In Britain some 80% of babies are delivered by midwives. Obstetricians rely on them completely, not only for normal births but to assist with difficult deliveries and Cesarean sections. It would be impossible for obstetricians to work without the support of midwives.

Now three prosecutions of midwives have hit the news in Britain, Ireland and France. They all concern midwives who do not tow the line and who assist at home birth and try to help women give birth physiologically. It looks as if independent midwives who challenge the medical establishment are at risk.

At face value the cases are very different. Madame Suzanne de Bearn in France has been prosecuted because she delivers babies in a birth centre with under 300 births a year, where there is no resident obstetrician and no pediatrician. The French National Health System has a policy of concentrating birth in large regional hospitals with complete cover for high risk birth. A warrior midwife, at the age of 83 Madame de Bean has stood her ground and resisted authority, supported by families in her local community. She has been accused of malpractice. She has broken the rules dictated by central government. But the Department of Health has sent someone to England to learn what birth centres are all about and the policy may change.

In Dublin Ann Kelly has been doing home births for 25 years. In Ireland there is a history of medical disapproval of home birth and it is considered a practice from the “bad old days”. The modern Irish way is to bring women into hospital where they are given Active Management, no labour is allowed to last longer than 12 hours and the odds are that just about every primipara will get uterine stimulation unless her cervix dilates at top speed. Irish obstetricians tend to be paternalist, authoritarian and charming. Midwives are called “nurses”. Ann was reported by a top obstetrician, the “Master” of one of the hospitals, for transferring a woman to hospital after a long labour at home. He considered that she should never have agreed to attend this woman at home. The Matron of another hospital looked through the files of other women who had been transferred and produced an extra batch of three cases. In one of these, in which the second of twins died, Ann was not the midwife responsible for the case and simply turned up to help a colleague. Ann was informed about the first accusation but was not told about the other three accusations until the matter came up before the Irish National Nursing Board. Between 1997 and 1999 the Board never once met to consider the evidence her lawyer had presented on her behalf. In May 1999 the High Court Judge lifted the injunction against Ann practising as a midwife because no single piece of evidence was produced showing that she was a menace to the public. It has already cost the tax-payer 150,000 Irish pounds, but the case continues in camera as is the Irish custom.

Caroline Flint is probably the best known midwife in England. She was the first elected President of the Royal College of Midwives and has written several books on birth, including `Sensitive Midwifery'. She has researched and developed a system of midwifery in which each woman gets to know her midwife in pregnancy, is assured of continuous care from not more than two or three midwives who have become her friends in the “Know Your Midwife” Scheme. She lectures world-wide and is always popping up on TV and radio. She loves doing home births and runs an independent Birth Centre with a birth pool in each room. She is a warm, outgoing person and, not surprisingly perhaps, because she has been midwife to pop-stars and media and theatre people, there are a handful of midwives who cannot help feeling jealous of all that she has achieved, though they would publicly find it difficult to acknowledge this.

She is well known for her standing breech births. It was one of these that had a disastrous outcome nearly four years ago. The baby died shortly after birth. The case was investigated by the hospital where the birth took place and then by the Local Supervising Authority and she was exonerated, but told that she must keep more detailed notes. Because this was a breech birth she had used a partogram instead of writing the copious notes she usually records so that the mother has a complete account of the birth: what they talked about, the atmosphere in the room and everything that happened. The mother was herself a midwife who later worked in Caroline's office. She and Caroline became very close and grieved together and Caroline attended her wedding a bit later. Then suddenly, in 1998, after this mother had given birth to another baby who was also breech, with obstetric rather than midwife care, Caroline was informed that there would be an judicial investigation by the UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting). This took place in May 1999 and Caroline was found guilty of professional misconduct on three counts: her notes were incomplete, she did not take the mother's blood pressure, pulse and temperature after the birth, and she failed to recognise maternal collapse. Caroline agrees that she did not keep her usual detailed notes but relied on a chart instead, and that she herself was in a state of shock after the birth, but called a doctor. The paediatrician was trying to resuscitate the baby and she had called another midwife who had not yet arrived. The verdict was that she was not responsible for the baby's death, which a post-mortem revealed was associated with hypoxia in the 24 hours before labour started.

Caroline was attacked by a largely hostile press. Banner headlines ranged through BIRTH PIONEER FOUND GUILTY OF ABANDONING TRAGIC MOTHER, NATURAL BORN BACKLASH, AT TIMES EVEN FEMINISTS NEED MEN and MIDWIFE ERRORS LED TO DEATH OF BABY. She was wrongly reported as having left the mother unconscious in a pool of blood, earning £100,000 per year and having killed the baby. She has complained to the Press Complaints Commission and is taking legal advice regarding libel. Thirty midwifery supervisors and obstetricians who have witnessed her skills have written supporting her and there is a huge wave of support from women whom she has helped.

A spate of emotion has also appeared, based on this case, against “Natural Born Fanatics” written by women journalists who favour treating birth like a trip to the dentist's, having all the painkillers you can get and saying, in effect, “Cut the kid out! My vagina was not made for this.” There is media back lash against “natural” births. One female journalist stated, typically, ” In their zeal to promote low-tech births, preferably at home, these fanatics persistently make light of the dangers and discomforts of childbirth, even to the point of denying that it's agony. `Most women get some pain in labour, but find it manageable' is Sheila Kitzinger's feeling about Eve's curse.”¹

The week after the publicity about Caroline a group of graduate psychology students, all feminists, in a tutorial run by my daughter Celia at an English university, discussed birth and all said, without exception, that they would opt for an elected Cesarean section, “like the Spice Girls”. They had heard about bladder and rectal injury after vaginal birth and women being “torn to shreds” and believed the assertive, feminist thing to do was to demand a Cesarean, which they thought would ensure no pain, no physical damage and a safe birth.

Caroline Flint's client gave birth in a major teaching hospital after she had driven her there after she had diagnosed the breech. Junior vice-president of the Royal College of Obstetricians and Gynaecologists, James Drife waded in with a letter to the Times that stating that home birth was three times more dangerous than hospital birth.² He made a glancing reference to American and Australian statistics and to the CESDI report (Confidential Enquiry into Stillbirths and Deaths in Infancy). Dr. Gavin Young, a member of the focus group that reported on the place of delivery, replied saying,³

What are the implications of these highly publicised three cases for midwifery and for women's experiences of birth? Midwives are at risk of losing self-confidence when they work independently or take professional initiative. At worst, they will only be safe when they function within an institutional bureaucratic system, keep their place in the hierarchy, and cover themselves legally every step of the way. They will be under pressure to do all investigations possible, intervene early, and let obstetricians make the major decisions. Then they cannot be found responsible. They will warn women that home birth is dangerous and refuse to attend those who do not come into the hospital. Then it is the woman's fault if things go wrong.

If midwives start to work in this way midwifery will be destroyed. In its place we shall have obstetric nurses. The painful conflict that has continued for so long in North America has now come to Europe. In spite of all the rhetoric of Changing Childbirth and talk about woman-centred care we are faced with a challenge to midwifery and also to women's right to give birth in their own way, in their own time, and in their own place.

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