September 2003, Vol 30:3

Sheila Kitzinger's Letter from Europe

The Politics of Birth

The National Childbirth Trust in the U.K. sprang from the philosophy of Grantly Dick-Read. In Natural Childbirth ¹, the book which later became Childbirth Without Fear,² he wrote that preparation for birth enabled a woman to sit and wait patiently for her baby and would beautify the maternal consciousness. Natural birth would develop the innate “feminine” qualities of patience, sensitivity and understanding, and enhance a marriage. He told the reader how to behave following birth, too. She should show more tenderness to her husband in order to strengthen the bond of affection between them.

This was the dominant ethos until psychoprophylaxis, from Russia via France, suddenly changed the purpose and his was the dominant ethos until psychoprophylaxis, from Russia via France, style of birth education. The pregnant woman became a “parturient” conditioned to jump through the flaming hoop of labor, so highly trained that every muscle was toned, and her mind a white blaze of determination. She was instructed to make an unwavering commitment to succeed at what was claimed to be “painless” childbirth, achieved through breathing drills and distraction techniques. Women with “intellectual conceit” –professional women who asked too many questions and did not have complete faith in the techniques – were certain to fail. He claimed that working class women who believed and obeyed what they were taught were much more successful.² Fernand Lamaze listed his results over three and a half years at the Clinique des Metallurgistes: 18.43 percent “excellent”, 4.76 percent “complete failure,” the evidence for which was restlessness and screams. Women who suffered were themselves responsible because they harbored doubts or had not practised sufficiently.³

When this method was first promoted in Britain by Erna Wright at the end of the sixties. She introduced military metaphors. Labor became “B-day” – a direct analogy with “D-day”, the decisive battle of the second World War. Birth became an athletic performance and women were treated as like Pavlovian dos conditioned to salivate at the sound of a bell.

In both Dick-Read and Lamaze the issue was “a woman's control over her own body rather her control over what other people are doing to it....."Far from explicitly challenging medical power... the NCT appealed to doctors' paternalism, asking them to be more indulgent of women at a time of particular vulnerability....It was a logical consequence of the Trust's `non-threatening' stance that it should present the inhumanity of the obstetric services as the unfortunate side-product of misunerstandings rather than the consequence of any conflict of interest or power-imbalance.”⁴ Individual women could only hope to change things by being charming and tactful.

Today the NCT is politically active, working to correct the imbalance of power between professional care-providers and women giving birth, educate those in the professions, and ensure that positive government policies are translated into practice.

Already, in the last decade of the twentieth century, the NCT was becoming increasingly politically aware. In 1992 it lobbied and gave evidence to the Health Select Committee Enquiry into the Maternity Services, which produced a radical report led by the unlikely partnership of the Conservative M.P. Nicholas Winterton and the Labour M.P. Audrey Wise, an outspoken a warrior for women's rights and birth issues. The Conservative Government had to reply to this report, and Eileen Hutton, NCT President, served on the Department of Health Committee that developed Changing Childbirth.⁵ This became Government policy in 1993, advocating woman-centered care, with choice, control and continuity of care for all women.

In 2000 The N.C.T. set up a Maternity care Working Party and an All Party Parliamentary Group to bring health professionals, parliamentarians, academics and consumer groups together, and explore with MPs how the recommendations in the document Changing Childbirth should be put into action. Catherine Eden was appointed to head the secretariat for this. At a recent count the APPG had 130 parliamentary members. Midwives,.

The N.C.T.pushed for a further enquiry by the Health Services Select Committee. The government is obliged to respond to Select Committee reports, and each relevant government department must give evidence if called. The Department of Health was subjected to gruelling cross-examination and challenged it as to why it gave such weight to the opinions of doctors, and failed to look at research evidence.

The NCT also began to do research into women's experiences of birth. This was new. When I undertook research into experiences of prenatal care, induction of labor, episiotomy and epidurals and home birth in the 70s and 80s, the NCT published the results as reports or booklets, but I did the work independently, and without funding. It is very different now.

Another step forward in campaigning was establishing an effective press office to collaborate with the media and keep birth issues center stage through questionnaires and surveys published in parenting magazines, and widely publicised.. Multidisciplinary conferences and reports were organised, together with surveys that were often collaboratively carried out with magazines used to fuel the debates by injecting new evidence.

When the Labour Government came to power improving public health was a major part of its policies. The NCT took advantage of this and at an open meeting in the House of Commons the NCT and the Maternity Alliance stressed that the quality of birth is a vital element in public health. The message is that maternity care is not exclusively a women's issue, but has life-long effects, for each individual and family, and for society as a whole. With this, the NCT underwent a metamorphosis from an organisation of childbirth educators and mainly middle class mothers to one that speaks for all women and families. The NCT now studies the government agenda and works out specific campaigns both to shape and develop that agenda, and to co-ordinate action with consumer and professional organisations to improve care. It has researched women's access to information and support, for example, and revealed that young and ethnic minority parents have urgent need for more open information and support.

Mary Newburn, Head of Policy Research for the NCT, observed a “sea change” three years ago with the appointment of Belinda Phipps, formerly a manager in the National Health Service, who understands how it works and has introduced sharply focussed strategic thinking. With a professional manager at its helm, the NCT now became street wise.

The NCT focusses on the importance of working with professional organisations and identifying key figures who have influence with their peers. One result is that in 2001 the RCOG, RCM and NCT jointly published Modernising Maternity Care.⁵ It established benchmarks for a quality service, asked Primary Care Trusts “How do you stand?”, and guided them as to how to evaluate their own services.

The Maternity Care Working Party organised meetings on domestic violence, mental health, and breastfeeding, and three successful conferences on what can be done to reduce the rising Cesarean section rates. Half of all senior obstetricians consider these rates are too high in their own hospitals.⁶ This implies that the other half think that they are just right, or not high enough. One of these obstetricians, (now retired) wrote to a national newspaper earlier this year, saying:" I would advise them (women) that, soon after conception, they should book their Caesarean section with epidural or spinal analgesia."⁷

But the tide is flowing in the opposite direction. Lesley Page, Head of Midwifery and Professor at Guy's and St. Thomas's, and Specialist Advisor to the House of Commons Committee on Maternity Care, points out that in the USA midwifery has come from the counter culture, whereas in the U.K. it is main-stream. The N.H.S. would collapse without midwives. When midwives and consumers work together they speak with a powerful voice, and parliament cannot ignore it.

Earlier this year the APPG sent a letter to every maternity unit in England inviting it to compete for two awards, to be presented at the House of Commons by the Health Minister. One is the Increasing Normal Births Award; the other, the Most Improved Home Birth Rate Award. The letter went on to say: “We would like you to look at your figures from April 2002 until now, and compare them with statistics in the previous two financial years. We want to hear from you if you feel efforts you are making to increase the numbers of normal births or improve homebirth rates have been successful this year.” There is an additional note: “Although the definition of a `normal' birth is one of much debate, for the purposes of these awards, we are defining `normal' as birth that starts, progresses and concludes spontaneously and one where the woman does not have anaesthesia or an episiotomy.”

It is the goal of normal birth for most women that the NCT, together with the two major Royal Colleges, is strenuously pursuing now... Education for childbirth, without radical change in the medical system, imposes a burden on women to put on a performance, and to demonstrate that they can succeed. In critically examining the way childbirth is now, and creating a better system, reducing the Caesarean rate is a good start. But it is not enough. The challenge for all obstetricians and midwives is to have respect for the physiology of labor, and to acquire the human understanding and skills to enable the vast majority of women to give birth normally.⁶

References