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Why women don’t often get the birth they want: my thoughts on the topic

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At the beginning of last week, Kirstie Allsop guest presented a BBC Radio 4 Woman’s Hour special. During the programme, Kirstie ‘embarked on a personal journey to investigate why women often don’t get the birth they want’. I was initially asked to participate in the programme, and I gave it a lot of thought. I have commented on Kirstie’s views about childbirth before. Once following her public criticism of NCT antenatal classes, and another post in response to a letter she wrote to the Telegraph newspaper, concerned that women were being made to feel like a failure if they didn’t nave a ‘normal’ birth, or chose not to breastfeed.

I was pleasantly surprised when I listened to the radio show. The guests gave some fairly balanced viewpoints, around topics such as women’s expectations and preparation for childbirth classes. I was delighted that Kirstie chose this topic for her guest session, as it gave the issues some airtime.

Kirtstie began the programme by asking how society has gone from being thankful for the birth of a healthy baby, to ‘desiring an experience’ at the time of birth. Good question I suppose. But then should women not expect what they plan for, with some understanding that there may be deviations? I have to wholeheartedly agree with Rebecca Schiller  (@HackneyDoula) who was part of the panel on the programme, when she reminded listeners that how women experience birth plays a huge part in how she bonds with her baby. Indeed, childbirth has far reaching consequences on the whole family. Whilst a positive birth is what women and her childbirth carer should be aiming for, we know that most women want a normal or straightforward birth; one with minimal intervention.  This is usually one of the main reasons pregnant women (and partners) attend childbirth preparation classes. Kirstie debated childbirth preparation sessions, and their content, during the programme, in a quest to discover why women are frequenly ‘disappointed’ by their birth experience.

BUT I didn’t feel the matters discussed really addressed the issues of ‘why women don’t often get the birth they want’. I believe the reasons are far more complex and go unnoticed by most, and yet are staring us in the face. I am going to use an example of a birth that demonstrates some of the detail and dilemmas that potentially lead to a negative birth experience, or a sense of ‘disappointment’. The story is not unusual. In fact, it is incredibly common.

My good friend’s daughter recently gave birth to her first baby. This is what she told me.

I had done a ridiculous amount of research into childbirth.  From the moment I found out I was pregnant, my whole focus was on the birth, the birth, the birth, and if I’m honest, not so much on what came after.  I decided quite early on, that is was very important for me to be in a calm environment to ensure a good flow of oxytocin.  I have always been pretty sensitive to my environment, and not a huge fan of hospitals.  Therefore,  my husband and I, after a great deal of thought, decided that home would be the most natural place for me to stay calm and relaxed throughout.  I liked the idea of being in control of my birth, and creating a calming sanctuary to bring our new boy into the world.  As the weeks went by, excitement mounted as we  prepared for the big day.  The community midwives (all of whom were very experienced midwives) were all very pro-home birth and made us feel really excited.   We had the birth pool up, gas and air delivered, millions of towels and waterproof coverings, candles  and even a selection of cakes to keep the midwives going.

Johnny came 6 days late.  My waters broke at 4am and I knew straight away that something wasn’t right as the water was a funny colour.  Staying calm, we rang the hospital and spoke to a lovely midwife who told me to save sanitary towels and call the community midwife first thing in the morning.  She said it could have been the ‘show’ causing the strange colour.  At this point, I remained extremely calm and felt excited that things were moving and our boy was on his way.  

So the contractions were regular throughout the early hours of the morning, and by 9am, they were coming every 6 minutes.   The community midwife called at 9.30am, took one look at the sanitary towels I had saved, and told me it was meconium in the waters, and I would have to go straight into hospital.  Instantly, I felt anything but calm.   My plans for a home birth shattered, we headed straight to the local hospital, and sure enough my contractions had stopped as the adrenaline kicked in. 

At hospital, by 10.00am ish, I was measured at 2cm dilated and told I would have to go to delivery suite as lots more greenish-tinged fluid was coming out of me.  I knew that this was the doctor-led unit and continued to try to remain calm in an anxious state. The very young male doctor told us we would have to have to have a synthetic -Oxytocin drip, to speed up labour as there was a 1 in 4 chance that the baby was in distress.  From prior reading, I knew that interfering with my own oxytocin could be problematic, and despite my husband and I questioning the doctor asking if it was absolutely necessary, we really felt backed into a corner.  It was our first baby and we were being treated as though it was an emergency, that we must get the baby out as quick as possible.  The contractions I had felt in the early hours of the morning had still not come back and we really didn’t feel as though there was any other option.

The drip made the contractions stronger and more painful, I was told, and I would probably want an epidural as most women do in these circumstances.  Already my labour was already proving to be the exact opposite to what I had envisaged.  The one thing I could still control was my pain relief.  So, despite not having the active birth, subtle lighting, birth pool, hyno-birthing, calming music, I battled through the pain with no pain relief other than gas and air, a tens machine and controlled breathing with my husband and mum for moral support.  At least I was in control of something. 

The contractions came strong and quick and I soldiered through them despite the anxiety-inducing sounds of the monitor transmitting Johnny’s heart beat, interrupted frequently by various midwives/doctors anxious that our baby’s heart beat and oxygen levels were dropping. 

At one point, the heartbeat machine stopped picking up Jonny’s heartbeat. The doctor suggested it could be the TENS machine, so I had to stop using it. Then the staff decided to place a tag on Johnny’s head to monitor him more effectively. The worst point of the whole labour was when the young male doctor, accompanied by a young female doctor (whom he was training it seemed) burst into the room declaring that they needed to take a sample of blood from the baby’s head as they were worried about oxygen levels and needed to make a decision on whether an emergency Caesarean was necessary.  Legs in stirrups, their poking around was the single worst experience of the whole birth. So utterly painful.

During this episode, they told me I was fully dilated.  Thank God.

The pushing stage started as a relief as it felt much less painful.  I got on to all fours on the bed, and pushed with all my might. However, it took a long time (2 hours) for Johnny to come out, and I didn’t feel very encouraged by one particular midwife, who kept telling me I needed to push harder with no acknowledgment for the serious pain I had just endured and the effort I was giving to push my baby out in such an unnatural environment.

Johnny arrived at 20:50 after around 12 hours of labour. They had turned me onto my back, and placed my legs in  stirrups, to perform the episiotomy.  There were 8 people in the room including my mum and husband. As soon as he was born, the cut was cord immediately by a medic and he was whisked away after a brief moment on my chest.  I had requested that the cord stop pulsating before it was cut by my husband.  However, they were so anxious about the baby that it was all done so quickly to check that he was okay. 

Despite all this, we were elated to see our son who was a completely healthy little boy, with Apgar scores of 8 and 10! We are grateful for the care we had received.  However, on reflection of the whole labour and birth experience, we both, despite all the anxiety, had had a strong feeling all along that he would be okay.  Was this because we were in the safe hands of the medics in hospital? Or did we instinctively know he was safe?   Could we have had the natural home birth we had planned? 

So many thanks to lovely Kate and husband Nick for allowing me to use the story of Johnny’s birth.

My thoughts:

I do feel that Kate’s transfer to hospital was appropriate. But I do question the increasing use of intravenous synthetic hormones (Oxytocin in UK). Whilst there were clinical signs that her baby may have been compromised (this is debatable, and more information can be found here), the detail in Kate’s story around being induced is often similar for women with pre-labour rupture of membranes or those being induced for post-dates. We know that the use of Oxytocin to induce or augment (speed up) labour ‘has an impact on the birth experience of women. It may be less efficient and is usually more painful than spontaneous labour, and epidural analgesia and assisted delivery are more likely to be required’ (NICE 2008). Yet in general, women are happy to be induced.

When there is a risk that all may not be well with baby, and dependant on how this is articulated, labouring women will naturally go along with suggestions from midwives/doctors. Midwives and doctors follow hospital guidelines or protocols, with the mother and baby’s best interests at heart. But they are also protecting themselves, and are frequently fearful of reproach.  I fear that in many circumstances there is over treatment, and defensive practice.  My intention is not to blame maternity care workers, but to highlight the fact that the maternity care system doesn’t help them or the families they care for, and neither does the legal system, nor the media.

For childbearing women and partners

Try to find out as much as you can before you go into labour. There is so much positive information out there to help you, and as Milli Hill of the Positive Childbirth Movement says, DON’T BE AFRAID TO PLAN FOR THE BIRTH YOU WANT! 

For midwives/doctors:

How can you make sure you know and understand the evidence base to share with families you care for? How do you pass on the evidence? Do you give unbiased and balanced information in an accessible way, or do you use ‘protective steering‘ because you feel anxious about the choices women may make?

Kate’s labour stopped due to the release of adrenaline associated with unfolding events, and going into hospital. This happens on a daily basis, everywhere. Have you ever ‘walked in the shoes’ of a labouring woman coming into your maternity service? What does she see, hear, smell? Who greets her? What is the environment like when she enters the birth space?

We know that Syntocinon puts more pressure on baby, so should it be used when a baby is deemed already compromised? Do you tell that to women when advising the drug? By using Syntocinon, do you consider that you may be replacing one risk with another?

Kate was directed to push during her labour. What is the evidence around directed pushing?

Why did the CTG machines (heart rate monitor) need to be audible (and even too loud), even when there is no healthcare professional in the room?

Do TENS machines interfere with CTG machines? And are we focusing on the machines here, instead of women?

If a woman is pushing on all fours (and having an intervention because of fetal compromise) would you encourage her to lie on her back with legs in stirrups, to perform an episiotomy and ‘deliver’ her?

If Kate had agreed to an epidural (should this be offered?), do you think the outcome would have been different?

Do you think the baby was in good condition at birth because of the intervention, or in spite of it?

In response to Kirstie’s radio programme:

Should Kate not have expected or planned to have a home birth in the first place, free of intervention, then she wouldn’t feel disappointed? Next time Kirstie, can we address some of these issues?

And finally, a note for our Governmental Ministers

The shortage of midwives that persists, and is letting mothers (and babies) down. You gave promises to increase numbers, and your lack of attention continues to influence the experience of childbirth. The effect of this is both short and long term, and is both physical and psychological. As a midwife, mother and grandmother, I plead with you to  really listen.

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19 comments on “Why women don’t often get the birth they want: my thoughts on the topic

  1. A (German) midwife told me that doctors are judged on what they do and criticised for what they don’t do. So, if there’s a choice of intervention or not, most doctors will do it because if they do and it doesn’t work, they won’t be as harshly judged as they would had they done nothing. If this is true – and I can see a truth in it, but I am not involved with medicine, so don’t really know – then it will be hard to change anything until this attitude is changed.

    I didn’t like the broadcast. I found it rather disappointing: far too many opportunities missed.

    • Thanks for your comment Anna; I’m not sure this applies in England…but I think HCPs will follow guidance and protocol more often than not, without being able to justify it or articulate the risk/benefits. I do believe fear prevails, and they are afraid of recrimination. It will be hard to change, but we have to keep trying. Nurturing environments, flexibility, collaboration is what we need to work on to make things better for all women. :)

  2. As an aspiring student midwife I read this with enthusiasm. My ambition is to one day practice with the concept of “normal” at the forefront of my mind. That said, I give great thought as to how best to communicate that, lending to it being interpreted and perceived appropriately. I must admit to disliking the need to equip women with self-fulfilling prophecies such as the idea that induction usually lends to epidural as immediately it is condemning the pain to be negative and unmanageable. Having spent some time with a registered hypnobirthing practitioner recently I feel the “knowledge is power” approach is really valuable to equip women with coping strategies. They can have an ideal, why not? It’s just dangerous to lead them into this without a nod towards necessary intervention and the possibility that it may arise. Why can’t it be a positive thing in the appropriate circumstance.

    From personal experience I gave birth twice in a hospital setting, and it was alien to a woman in her late twenties having never had any ill health so i love the idea of walking in their shoes and identifying those sensory triggers that may inhibit. We associate the clinical setting with being vulnerable so it’s of no real surprise that some women report a slowing or halt of their labour. Seems to be the fight or flight reflex can really inhibit. That said, I progressed well during my second labour until a very unpredictable shoulder dystocia when it came to directed pushing. Eventually Resolved by at least 12 healthcare practitioners entering the room, the delivery suite ringing with calls for a crash team, being moved quickly into McRoberts and eventually ending with Woods Screw manoeuvre to dislodge. Baby born with Apgar of 0, progressing to 7 at 5- to 9 at 10. He required full resuscitation and cardiac massage and there were concerns about a query fracture to his clavicle. Quite considerable intervention. The ability to bond with my thankfully healthy baby afterwards was greatly assisted by the communication skills of an exceptional midwife- debrief followed debrief followed debrief followed chat followed extra reassurance, totally highlighting the need for attentive postnatal care. I knew the who, what, where, when and whys which is exactly why I don’t underestimate the communication of “WHY” any intervention is necessary is vital.

    Definitely food for thought! Thanks for sharing.

    • Oh Kate what a lot of personal experience and wise words. I agree positive approaches to labour pain ie ‘working with pain’ as Nicky Leap calls it, is a valuable philosophy. And definitely, medical intervention is life saving, and thank goodness we are fortunate enough to have it….but we always need to remember the WHY as you say, and potential harm. Thank you so much for commenting and adding to the debate Kate :)

  3. Great article! I liked all the questions that you asked of the midwives/doctors. As a maternity nurse, I try to make sure that I can answer any and all questions about what is going on, preferable as it is happening, but if not as soon as possible following the birth. In my unit in particular, I can say that there are some Drs that have a “certain way” of doing things, for instance directed pushing, and they are not likely to change any day soon. So my way to help through this is to talk about this as we get closer to the delivery and address concerns questions ASAP. And do I disagree with the directed pushing, in theory – yes, in practice with this particular OB – no because I have seen the success that he has with this method. Most of his patients, even primips give birth with no episotomies and no or minor tears due to the perineal massage he uses during pushing and most give birth in less than an hour. He is encouraging and supportive and is always open to discussion as to how he does things. And discussed on another article, I like women to PREPARE for the birth they want, to do everything they can or want to lead toward the positive experience they desire. I will do everything in my power to help them use what they learned to get them a positive experience, but it is hard for me to follow a “plan.” I want us to work together through the bumps in the road to get to a space she can feel positive about.

    • Hi Charlene, I gather from your comments that you work in the US? Thank you for taking time to add your thoughts! We all see different practices-in all countries, states, towns, services. Some make our hearts sing, others less so. It’s encouraging that you try to encourage and support women in your care, and I love your analogy of working together on a bumpy road. Great stuff. Keep strong and keep up the brilliant work!
      Sheena :)

      • I actually work in Northern British Columbia, Canada. We don’t have a lot of options for women up here for care providers. The closest midwife is 1 1/2 hours away at least and in a different province. So you have the choice of General Practitioner Doc or an OB. We are the central site for many communities that no longer do obstetrical care. Some women drive almost 2 hours to see a doctor or to have their baby at our hospital. Presents alot of interesting problems and successes. Our group (nurses and doctors) try really hard to provide an environment that women want to have their babies in. And out work is paying off because last year we were #1 in Northern Health and #5 in British Columbia for providing maternity care (as named by our patients). Thanks for the great articles!!

  4. Thanks for a thought provoking post on a topic I spend a lot of time thinking about and discussing. I agree – it is very complex. Women are ‘preparing’ for a physiological birth and then attempting to do it within a system that is set up to manipulate them to fail. Once women step into the system during the’ vulnerable’ experience of birthing, the cultural (ritual – my thesis was about this) influences are stronger than any preparation or previous resolve could be. This should be the focus of childbirth preparation for women birthing outside their home – how to navigate the system, legal rights, how cultural influences impact on birth, etc. They don’t need to know how their cervix opens or how to breathe. Just my thoughts :)

    • Hi Rachel, I couldn’t agree more. Even recently when I was with my daughter during labour (and I was a senior midwife in the service until I left) I felt vulnerable at times, and she did most of the time. Because we knew and trusted her main care givers it was mostly extremely positive, but there were some blips in between…when things nearly went out of control. So even the most confident, strongest, knowledgable women and partners can be consumed by the system. I have to agree with one of the previous comments, we must keep asking WHY? Because very often there isn’t a valid explanation.

      Thanks so much for joining in,

      Sheena :)

  5. If your friend’s daughter had 1-on-1 midwifery care maybe the cascade of intervention may not have happened as it did? Though the rates of intervention in NZ show that more is needed to turn the tsunami that is disturbed, technological maternity ‘care’! The birth story most women across the world tell demonstrate widepsread lack of understanding/appreciation and experience of undisturbed birth especially by those who should ‘know’.
    The hormone Oxytocin was so named as it means fast birth and when produced naturally it has no side or adverse effects. If our culture understood how to produce it naturally women could rescue themselves as well as be healthy and happy after their birth!

    • Thanks for your comment Denise! Lots to be done, and each day there are more revelations of the benefits of endogenous Oxytocin, for mother and baby. I think one day, society will look back and ask ‘why’ did we use so many synthetic hormones?
      Sheena :)

  6. Another NZ midwife here, hijacking your site! As Denise said, the one-on-one care by your own Lead Maternity Carer, can result in far better outcomes. Our hospital policies here in Auckland would have encouraged/given this mum an opportunity to walk around/up and down stairs, for 2-4 hrs before vaginal reassessment, as long as the CTG tracing was normal. Denise and I are both committed homebirthers….although I also used to book women wanting hospital birth as well. The last 3 years of my LMC practice I had an induction rate of 5% despite taking ‘higher risk women’ as well, my epidural rate was under 10%, episiotomy rate nil (and no 3rd degree tears), vaginal birth rate of 96%, an exclusive breastfeeding rate of 100%. My antenatal appointments for 1st time mums were an hour, 45 mins for subsequent birthers. I did VBACs at home if they lived within easy reach of the hospital and I never ever had to transfer anyone in with a ruptured uterus or ‘failure to progress’.

    The key to most women attaining the birth they want, is to engage either an experienced doula, or an Independent Midwife! Put the time in antenatally on relaxation techniques and really understand how your body works. Keep your mind open to anything, but if anyone suggested anything, always ask the following questions first;
    1. Why are you suggesting this to me right now?
    2. What are you basing this suggestion on? I need evidence-based practice for myself and my baby, and all the pros and cons to consider and discuss with my partner.
    3. What are the alternatives?
    4. What happens right now if I say, “No, I don’t really want this procedure done to me/my baby?”
    5. I’d like a second opinion before deciding please.
    Sometimes things just don’t quite go as you’d hope, but at least you’ve been fully informed and feel more in control of the decision-making. Ask the midwife to be your advocate for you if she doesn’t appear to be!

    Focus on staying as relaxed as you can possibly be and enjoy as much of the parts of labour and birth that you can. For some mums it is the rests in between the contractions, for others it’s the power you pull from some hidden place during the second stage, for some it’s the first sight of your baby on your chest….

  7. Hi Eleanor…thanks for your lengthy and valuable comment! You are not hijacking my site…I love it when comments arrive, and folks join in the debate. Makes the post more interesting! Whilst I don’t quite agree with your suggestion that the key to women getting the birth they want is to engage a doula or IM, I love the set of questions you propose that women ask. Brilliant. In England, most women are cared for by NHS midwives, and therefore need other strategies as ‘key’ factors to achieving their goal. Although I am sure IMs and doulas help enormously, and have high rates of success (like you!)
    Sounds like you have lots of positive models of care in NZ.
    Lovely to hear from you, and thanks again!
    Sheena :)

  8. Pingback: Why women don’t often get the birth they want: my thoughts on the topic FEATURE by Sheena Byrom - Birth Balance

  9. Hi Sheena,

    I posted this on twitter too.

    I love this! My own EMCS and then VBAC experience was what led me into the birth world. I was so afraid in my second pregnancy that any planning was going to lead to more disappointment, so did my Mum! But actually I realised I wasn’t ‘planning’ exactly what would happen…. I was just giving myself and my baby the best chance of a natural birth, which is still the safest way for mum and baby.

    By preparing and learning about birth I wasn’t trying to ‘get an experience’, I was doing my best to ‘avoid one’.

    Much love
    Susan x

    • Thanks Susan, I asked you to post here, as I love the quote ‘By preparing and learning about birth I wasn’t trying to ‘get an experience’, I was doing my best to ‘avoid one’.’

      Congratulations on the birth of both your children, and I appreciate you sharing your experiences with others on my blog :)
      Sheena

  10. Hi Sheena, thanks for the thought provoking blog and thanks to Kate for sharing her birth experience with us. There are many all round lessons to be learned from this story. I believe we need to seriously give consideration to – what we mean by choice,how we work better with women and keep them feeling in control and how we advocate with and for women when things physically change either in the antenatal period or during labour affecting their birth plan and choices.
    There is also something cultural about some professionals seeing care only via guidelines and protocols and although important regarding safety these need to be used sensibly and in partnership with women. The midwives rules and standards are the tools that give midwives empowerment to support women and I think we sometimes forget to read and use them.
    For some midwives articulating the evidence and sharing this with women can be a challenge as they may not feel confident and there’s a real need for the profession to teach midwives easy steps to be able to articulate what the evidence says then let the woman consider this and make a real informed decision.
    I am finding that there is a lot of confusion in the UK on what we mean by choice as its not always clear but policy makers are delivering ” nice to do ” policies without mandate and lack of resources.

    Congratulations to Kate and I hope she enjoys every second of baby Johnny as we all know babies ” grow up” very quickly .

    Thanks again for a fab blog.

    Jacque

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