September 2001 Vol 28.3
Sheila Kitzinger's Letter from Europe
Awake, Aware - and Action!
Lively debate is taking place around the subject of birth in Britain. There is a new awareness of its importance as a central experience for a woman's sense of self and for the family, and also of its major impact on public health. Discussion is no longer limited to those with specialist knowledge. It is right out in the open.
Instead of being confined to women's pages and parenting magazines, the topic of childbirth has moved center stage. It is presented on TV, radio and in the press as a subject about which we should all be concerned. Last summer a major theme was `Too posh to push?,' the hook being stories about pop stars and other celebrities who opted for elective Cesareans, and The Times published a special supplement on childbirth. Yet it is still easy to put cancer care in the head-lines, more difficult to demonstrate the vital importance of women having choice and control in childbirth.
Another positive sign is that birth has found a place in the political agenda, and is coming to be seen as integral to public health policy. Earlier this year, a Minister of Health stated: Our standard must be that women in all parts of the country, not just some, have choice, including the choice of a safe home birth. He also said: Just 70 percent of maternity units are able to offer women one-to-one continuous support during labour. This should be 100 percent. The gold standard should be that every woman will have access to a dedicated midwife when in established labour, one hundred percent of the time.1
Backing this is a one hundred million pound plan to attract more midwives into the NHS, with a pledge for two thousand extra midwives. The idea is to initiate projects all over the country. It will include birth centres, as well as family and waterbirth rooms in hospitals. The funding is available only if users are involved in deciding how this money is spent. Another Government initiative, Sure Start, focuses on the needs of disadvantaged women and their families, with a fresh injection of £60 million this year and a program on pregnancy, with prenatal groups for teenage mothers, and addressing the needs of early motherhood, nutrition during and after pregnancy, breastfeeding and postnatal mental health.
Since November 2000 an Inter-Party Parliamentary Group on Maternity meets regularly in the House of Commons. It was sparked off by a collaborative group that includes consumer organisations like the National Childbirth Trust, which is the largest birth charity in the U.K., and professional organisations such as the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. We need preventive action not only to reduce rates of postnatal depression, but post traumatic stress disorder following birth in which a woman feels she was treated like meat on a butcher's block. Urgent action is also needed about conditions in women's prisons, where pregnant women and new mothers are the most vulnerable in our society. (Some readers may know that these are two areas in which I have been working with special energy.) The All Party Parliamentary Group is also urging the Government to extend flexible midwife care to cover the first six weeks after childbirth, instead of 10 to 28 days as at present.
Major medical organisations are starting to explore how to provide woman - centered care and one-to-one midwifery. That is happening against a background of alarm about the increase in the rate of Cesarean sections. In some National Health Service hospitals one in five births are Cesareans now - and, as in countries around the globe, rates are higher still when women have private obstetric care. The Royal College of Obstetricians has conducted a Cesarean audit, with the reasons given for doing them. Every Cesarean must now be reasonably justified. It is clear that though, safer than ever before, Cesareans often introduce unacceptable risks. A study in South East England of births to close on 50,000 women reveals a four-fold rise in the rate of major life-threatening events or `near miss maternal mortality' associated with Cesareans.2 They include massive haemorrhage, severe sepsis, and uterine rupture. The researchers omitted to examine the incidence of thromboembolism, acknowledged as the leading cause of maternal death, because of difficulty in diagnosis. So the true incidence of risk is underestimated.
So many doula organisations have sprung into being in the U.K. over the last few years that some of us felt we must come to an agreement on standards, and reach consensus about the kind of people doulas are and the work they do. So we now have Independent Accreditation Panel (on which Michel Odent and I serve, along with activists in the various doula groups) which has devised a code of practice. Doula groups in this scheme include the Holloway prison doulas, who are now a registered charity called `Birth Companions'.
For a long time I did not believe that we needed doulas, because we had midwives. But it is clear that if women are to have one-to-one support they cannot rely on it coming from busy midwives in a high tech hospital, and that though agreed goals for midwifery include continuity of care and sensitive awareness of every woman's needs, at present this cannot be guaranteed.
We believe it is important that a doula gets to know her client before she goes into labor, and comes to help as soon as she is required, without the time lag that inevitably results if she is called only once a woman is already in hospital, when she has already been through the admission ritual, been put to bed, wired up, and had an epidural. The Kaiser Permanente and the Canadian research showed no reduction in Cesarean sections with doula care, and the authors suggest that since the doulas in these studies were not already on site, this is one possible explanation.3,4 Some British midwives are still uneasy about doulas and see their presence as implying criticism of the care midwives offer. Yet it is the hospital system that needs to be criticised, in which childbearing women and care providers alike become trapped, not the midwife.
Writing about the conflict between support and control by doulas and midwives Diane Walters, a doula, and Mavis Kirkham, Professor of Midwifery at Sheffield University, say that without a supportive culture for midwives `there is always the danger that we will act out of defensiveness or aggressive oppression rather than a true desire to give support. We therefore need to radically rethink the culture within which we work as midwives. ...The structures and responses of an era of hierarchical control are highly inappropriate to an era of choice and control for the women in our care. Doulas offer midwives an example of non-hierarchical ways of approaching issues of support for ourselves and for clients... We need particularly to examine our defences against the anxiety generated by the uncertainties of practice and by constant organisational change.5
The Birth Center movement is growing in strength. The first freestanding birth center within the National Health Service (women do not have to pay) is the Edgware Birth Centre in London. Midwives working there have a philosophy of no intervention. That includes no induction, no electronic fetal monitoring or other high tech equipment, no epidurals and no doctors. Of 396 women planning to give birth there (irrespective of where they actually delivered) only 1.5 per cent used pethidine (demerol), compared with a rate of 30per cent for those who had normal deliveries in hospitals in the area, and only six women received episiotomies, compared with a 26.5per cent rate in hospital.6 Each woman has freedom to do what she feels is right for her during childbirth, and half of all clients give birth in a pool, while partners can stay right through the 24 hours. If it is thought that a woman needs to be induced or she is having a very long labor,- the most frequent reasons for transfer her midwife goes with her to the hospital.
Other birth centres are starting up now, though some are outside the NHS. We are planning one in Oxford. Since the early seventies doctors in training have rarely had the chance of witnessing birth without intervention. There is growing concern on the part of many midwifery teachers that the same thing has happened in midwifery. Student midwives in large hospitals have little opportunity of ever seeing truly physiological birth. If we can attract investors the Oxford Birth Centre will also train midwives in the skills of supporting women who give birth at home - not only midwives in the U.K., but from other countries, too.
There are 55 freestanding midwifery-run birth units in England alone.7 They are a legacy from the past, and are highly valued by their communities. Whenever one is threatened (on the economic argument that all resources should be concentrated in a large regional centre) people come together to battle to save them. The caring, hands-on midwives who work in these small, cottage-hospital type units see themselves as guarding a precious heritage. This is true. But this image may have to change if they are to survive. For they have the potential to be transformed into birth centres and pioneer the process of giving childbirth back to women.
On a lighter note, a sign of the times may be that this year the Royal College of Obstetric Anaesthetists staged a debate in the prestigious Church House, Westminster (home of the Church of England Synod) about pain in childbirth, and asked me to represent women who declined medication for pain relief. It is significant that Cherie Blair, the wife of the Prime Minister, though the media assumed she was to have a Cesarean Section after her previous baby, a breech, was delivered that way, chose to have a vaginal birth, and instead opted for total midwife care, decided against an epidural, and returned home to 10 Downing Street within four hours of giving birth. Inviting me to speak against the motion `That natural childbirth is inappropriate in a modern world', and to present the Cherie Blair point of view, it seemed that the anesthetists were baffled by women who declined epidurals and who instead chose what my opponent, a consultant anesthetist at the hospital where Mrs. Blair had her baby, described as the curse of Eve. He cited Queen Victoria, who accepted anesthesia with her last birth, as the great advocate for women, and, defending interventions of all kinds, quoted maternal mortality statistics from Ethiopia, compared them with those in Britain, and attributed the difference entirely to obstetric advances. (Incidentally, I won the debate!).
|1||Alan Milburn speaking at the annual Conference of the Royal College of Midwives, 2001. The Independent, 3 May 2001|
|2||Waterstone M, Bewley S, Wolfe C. In: BMJ. Incidence and Predictors of severe obstetric morbidity: case-control study. Vol. 322, 2001:1089-1093|
|3||Hall J. Directory of Free-standing Midwifery-run Maternity Units in England. Leeds Health Authority, Yorkshire, 2001.|
|4||Gagnon AJ , Waghorn K and Covell C. DA Randomized Trial of One-to-One Nurse Support of Women in Labor. BIRTH 1997 24:2|
|5||Walters D and Kirkham MJ. Support and control in labour: doulas and midwives In: Kirkham MJ and Perkins ER Reflections on Midwifery, London Bailliere Tindall, 1997: 96-113.|
|6||Saunders D, et al. Evaluation of the Edgware Birth Centre, Barnet Health Authority, 2000.|
|7||Hall J. Directory of Free-standing Midwifery-run Maternity Units in England. Leeds Health Authority, Yorkshire, 2001.|