Friday, June 17, 2011

Do women have a right to choose natural birth?

It's a simple question. Do we?

We know that most women are able to give birth under natural, physiological conditions, and we know that for most women and babies there is no safer way than via that natural physiological process.

But, being able is different from having the right to choose.

Here are a few ridiculous questions:
"Do people have the right to choose to breathe?"
"Do babies have the right to choose to learn to walk?"
"Do we have the right to choose to eat?"

The answer, of course, is that it's not about a 'right' - breathing, walking, eating, ... are basic physiological processes for the normal function of our bodies, as is the process of giving birth.

Not every person is 'able' to function at the normal level in breathing, walking, eating, or in birth, all the time. But, in the cases of breathing, walking, and eating, and a host of other physiological activities, there is an unspoken expectation that 'it' will happen, under the direction of natural processes. The drugs and machines and complex medical interventions that have been developed in the medical world are used only when the natural function is deficient in some way.

It's at this point that giving birth 'naturally' is different from, for example, breathing 'naturally'. The knowledge of birth as a natural process that is not only safe but brings clear advantages over any other possible processes has been virtually lost from the world of maternity care and from the public. This 'medicalisation' of birth is escalating over time, with continuing increases in reliance on technology rather than skill at working in harmony with the natural physiological processes, to protect, promote and support health in the mother and child.

"In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

This statement should be the guiding principle for all materntiy services. Clearly, it's not. Most fail miserably, but are not even aware of their deficit.

The ever-rising Caesarean birth rate is evidence of the maternity system's failure to understand and to work in harmony with normal birth. It's around 30% of all births in Australia, and the USA, and other developed countries. It's much higher in some hospitals and locations.

AB wrote:
I live in a developing country, Guatemala, where women are not educated about birth choices and many times they only have one option. Due to lack of money they go to the public hospitals where there is more than 70% C-section rate. Then, confronted with birth trauma, they search for any other option possible. Many of them find my midwife with Manos Abiertas, a clinic dedicated to helping these women have a natural birth.

In a developed country, people have the luxury of forming a self-educated opinion on their preferred manner of giving birth, thankfully, and we are working towards making that an option in Guatemala.

The clinic that helps mostly indigenous and low income Guatemalan women works on a sliding pay scale. This often means patients visit free of charge or pay much less than their visit costs, because most can't afford the $5 for a checkup. However, as anyone involved in midwifery knows, there are always numerous costs involved.

I am asking you to help by spreading the word via an interview with one of the only licensed midwives in Guatemala who has her own birth clinic: Hannah Freiwald. The situation is also explained in this blog story

If you can link to us on your blog or forum, more people will see and hopefully help. I am not a midwife. I am only a citizen who supports my midwife and who sees a very great need with the women of Guatemala. If nothing else, they need the power to choose their birth. They need the right and education to know and choose what happens with their own bodies. Together, we can make this an option.

Thank you,

Manos Abiertas
"All women have the right to dignified health care."

Thankyou AS for bringing this matter to our attention.

Returing to the question posed: "Do women have a right to choose natural birth?", I hope the reader agrees with me that this is a ridiculous question.

It's not a matter of right to choose.  Women will usually give birth naturally and safely if given the opportunity.

It's more a matter of the skill and intention of the care-provider. Many women in Australia face the same lack of skill, and lack of understanding in their maternity care that is faced by indigenous and low income women in Guatemala. These women face systematic interference/intervention into the finely tuned natural physiological processes of birth, as well as crippling anxiety that impedes progress. Although attended by people with the title of 'midwife', these women feel isolated and fearful. Even those who, prior to labour, thought they would like 'natural birth' are quickly convinced that they need all the 'help' that the hospital has to offer.

The cascade of interventions is then unstoppable. Medical management of birth, whether vaginal or caesarean, is the only option.

Midwives in Australia, and in much of the developed world, must accept responsibility for the unacceptably high (and rising) rate of Caesarean births in our countries.  Midwifery is the only profession that has access to the knowledge and skill of working in harmony with the natural processes in birth.

PS: A recent Cochrane review "Non-clinical interventions for reducing unnecessary caesarean section" has been highlighted in US-based Medscape article "Cesarean Delivery Prevention Efforts Should Target Clinicians" (Author: Norra MacReady)

To reduce the number of unnecessary Cesarean deliveries, the focus should be on clinicians, a new meta-analysis suggests. Mandatory second opinions, peer review feedback, postcesarean surveillance to prevent repeat cesarean deliveries, and guidelines endorsed and supported by local opinion leaders ...

While noting that the midwife is absent in these reports, the recommendation that 'clinicians' (ie the obstetric doctors who perform caesarean surgery) be required to justify the decision to operate is worth consideration. Applying this research to the Australian maternity context, it would appear worth requiring midwives who are in attendance when the decision is made to engage in collaborative critical peer review and professional reporting, alongside the obstetrician. 

Thankyou, reader, for visiting this blog. Your comments are always welcome.


Adina said...

"But, being able is different from having the right to choose."

Yes, that is the crux of the matter.

Well said. Thank you!

Joy Johnston said...

Response from midwife Sue Cookson:
Hi Joy,
I really liked your commentary and agree with every bit of it except the last :
"Midwifery is the only profession that has access to the knowledge and skill of working in harmony with the natural processes in birth".

I fully believe that midwifery education today in the most part is bereft of ANY handing on of skill or knowledge of working in harmony with natural processes. I say that coming from the place of 25 years of being taught by practitioners who only attended birth in normal settings and the women who chose to birth normally at home, and then comparing the skills and knowledge I gained through that process with recently doing a Bachelor of Midwifery degree.

There was not one aspect of the degree I was taught in 2005 and 2006 that remotely resembled skills and knowledge to facilitate normal birth processes. All the clinicals I underwent were in tertiary hospitals where the medicalisation of birthing is complete. I was laughed at when women birthed on the floor or standing or in the shower. I rarely even unveiled the trolley full of equipment as it was not necessary to the birth at hand. I was bulled and ridiculed for my belief in the normal process and this was by my supposed mentors - the other midwives working in the system. We were not able to attend births with homebirth midwives due to the insurance issue.

As homebirth midwives we probably operate in a vacuum, surrounded by like-minded others who think and breathe and believe in the normal birth process. But it certainly is not how midwives in Australia, on the whole, are taught.

In this region we have 3 newish caseload programs running out of 3 hospitals and this is where the difference between understanding the normal process and not understanding the normal process and not valuing the normal process, becomes obvious. For the first time, these midwives are faced with the complexity of every woman's total pregnancy and birth, not just one small aspect of that. Each midwife now has to take those calls from the women on their caseload - the pregnancies worries, relate pathology to a person not just a clinical value, hold that woman through the baby being breech or going post-term or the 4 day prelabour exhaustion. They begin for the first time to actually have to think about what the woman needs and how they can assist the woman to achieve their goal.

And I will also say that a lot of new midwives think that having a toolbox full of 'things to do' to women and for women in birth, is being a midwife. For me, a true midwife uses every bit of intuitive sense to assist a woman she knows pretty well to move into that strong, solid place the woman needs to reach in order to birth normally. Most of the modern midwifery tools today including most of the theoretical knowledge, I see as gimmicks and nothing more.

Midwives become midwives through quiet observation, through listening well and through positive guidance by their elders. Modern maternity care and midwifery education offers none of that.

Sue Cookson