|November 21, 2007|
Volume 9, Issue 24
|Midwifery Today E-News|
“Interventions in Birth”
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In This Week’s Issue:
Quote of the Week
"Only about 15% of medical interventions are supported by solid scientific evidence…. This is partly because only 1% of the studies in medical journals are scientifically sound and partly because many treatments have not been assessed at all."
— Richard Smith, editor of the British Medical Journal
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The Art of Midwifery
Birthing without fear is not easy. Birth has an inherent mystery that easily invokes our fear. Our own little spiritual community in Missouri enjoys successful homebirth of diverse natures by facing fears and mystery through ritual and storytelling.
We talk in the health care world of fear of litigation, perhaps because that is easier than speaking of the fear of the unknown inherent in birth. Fear of litigation has become a way to talk about the fear.
— Sister MorningStar
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A Story of Interventions
The classification of birthing knowledge as "specialist" has prepared the way for the dramatized caricature represented in popular media. Drama is the key to capturing an audience's attention, and the media provides the desired product. Ina May Gaskin observes that "the demands of commercial television and film have led to the propaganda of many myths and misconceptions about labor and birth…. Women and girls raised on this sort of thing without a source of more accurate knowledge learn to equate labor pain with danger." These fictional representations of birth act as filler for the firsthand experiences women are denied the opportunity to accumulate. This results in women viewing labor pain as a negative element, rather than accepting it as a guide to optimal positioning and a vital element in the physiological feedback that releases additional endorphins and oxytocin, as the body requires.
Even television programs that claim to present the reality of the birthing process censor the natural event of vaginal birth…. Women never see the amazing natural ability of the vagina to stretch and open and are instead left with cliche fears about squeezing watermelons through lemons. Familiarity with the birthing process would allow women to learn, through personal experience, that birth is a normal event that their bodies are naturally capable of carrying out. In the culturally sanctioned absence of such personal experience, media presentations that highlight the natural beauty of birth would serve as a vital step toward relieving the fears harbored by many women.
Newly deprived of the safety net formerly provided by participating in births at the center, I have found myself drawn to the depictions of birth with which the majority of women educate themselves about the birthing process. I have focused my attention on the television series "A Baby Story," featured on The Learning Channel, a subsidiary of The Discovery Channel. The name of the channel implies that the viewer will receive valuable information steeped in truth. Thus, the average female viewer should be able to trust the depiction of birth as a testament to reality in the present day US. As the majority of women are receiving their understanding of the birthing process and the capabilities of their bodies through such programming, it is reasonable to assume that such a popular series has the potential to impact the views of many women. In order to indulge my fascination with how birth is portrayed to the average viewing woman, I began taking notes on the show's content shortly after the closure of the birth center.
I took notes on 145 episodes of "A Baby Story," which aired from 3:00 pm to 3:30 pm in the New York City area between September 9, 2003, and March 30, 2004. The cumulative depiction of birth was decidedly medicalized. A hospital was the chosen setting for 138 of the 145 births shown. That is, 95.2% of the shows depicted women who chose a hospital birth. The program did portray a few out-of-hospital births: five, or 3.5%, occurred in freestanding birth centers and two, or 1.3%, occurred in private residences. It should be noted that the percentage of hospital births reflected in the program is in fact slightly lower than the national calculation of 99 percent reported by the Centers for Disease Control in 2002. Nonetheless, the program reinforces the popular notion that birth is a medical event that should occur in a hospital setting.
On the other hand, the rate of cesareans shown exceeded the current national rate. Eighty-five vaginal births were shown, accounting for 58.6% of the sample. Sixty cesareans were depicted, accounting for 41.4% of the sample. It is shocking to note that currently the US is reporting its highest cesarean section rate on record at 26.1% [Note: The rate has since increased to 30% in the US], yet this program managed to depict an even steeper rate, heightening for the audience the sense that c-sections are frequently necessary to save women and babies from the birthing process.
Finally, 70.7% of women chose to have an epidural or anesthetic drug during labor (most commonly an epidural); these numbers do not include women given anesthesia for cesarean surgery. The frequency with which pain relief and surgery were portrayed sends viewers a strong message regarding the ability of their bodies to birth. It appears that nearly half of all women require their babies to be removed from them via a surgical procedure, and the vast majority of those attempting a vaginal birth cannot bear to do so in the absence of drugs. This is the message that is being sent to primiparas, who are likely to be watching such programs to gain an understanding of women's experiences in childbirth…. The media overwhelmingly both censors the natural ability of women's bodies to birth and distorts the process to reflect birth as a clinical event from which women need to be saved by medical representatives.
— Colleen Bak, excerpted from "Cultural Lack of Birth Experience Empowers Media Representations, Not Women,"
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Research to Remember
About 500 women participated in a study to determine the incidence of acute trauma symptoms and posttraumatic stress disorder (PTSD) that resulted from their labor and birth experiences. They were interviewed in their third trimester and then at 4–6 weeks postpartum, with a focus on medical and midwifery management of the birth, their perceptions of their care during the birth and the presence of trauma symptoms.
The researchers found that one third of the women had experienced a traumatic birthing event and had at least three symptoms of trauma, while 5.6% met DSM-IV criteria for PTSD. A high level of obstetric intervention during childbirth, along with a perception that intrapartum care was inadequate, was more likely to be associated with development of acute trauma symptoms.
— Birth 27(2): 104–11, June 2000
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The cost of having a baby, from the first prenatal visit to the baby's birth, averaged roughly $7600, according to the Agency for Healthcare Research and Quality. The total, in 2004 dollars, includes payments for hospital childbirth, prenatal office visits, prescription medicines and other services. Women with private insurance paid more than those insured by Medicaid.
— Medical News Today, Pregnancy/Obstetrics News, www.medicalnewstoday.com/articles/85891.php
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"Hope and Healing—Collaborating to Bring Midwifery and Mental Health Care to Women Who Are Survivors of Sexual Abuse" will be held in Ann Arbor, Michigan, May 7–10, 2008. Learn about the conference here. Ask our Advertising Director about exhibiting your services and products, displaying your ad in the conference program, and having your inserts distributed to attendees.
Question of the Week
Q: Do find in your homebirth midwifery practice that the rate of transfers and/or c-sections has increased in the last two to five years?
SEND YOUR RESPONSE to email@example.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.
Question of the Week Responses
Q: Some women experience technological birth as rape. Have you encountered this in your practice and what do you do to prevent it or deal with it when it comes up?
A: If some women experience technological birth as rape, then my first instinct would be to ask if their previous experience of life—whether family, work, education or social interaction—had coloured their view of childbirth. I would not instantly jump on the popular bandwagon of blaming "technology."
I am most emphatically in favour of encouraging women to allow their bodies to birth their baby. I feel if they have had a pregnancy with no major problems then there is no reason why birth should not follow naturally. However, I also see the occasional need for intervention; some may call it "technical" others may say "life saving," for example, a cesarean for placenta previa, or continuous monitoring for a baby whose mother has eclampsia.
In twenty years of midwifery I have seen and spoken to women who were traumatised by their birth experiences, perhaps because they were not prepared either mentally or physically, but I've only heard three women speak of their birth experience as a violation, two of whom had what could be described as a technical birth, i.e., a forceps delivery. The third mother had what most would describe as a "normal" birth. So you see, the terms "technology," "normal," "violation" and even "rape" in this context are subjective terms.
As midwives, our responsibility is to ensure that each woman is prepared for childbirth in the antenatal period. Remember, childbirth begins at conception. Good antenatal care is vital and women should feel fully informed and maintain as much control as needed during the birth of their babies.
— Brenda Docherty, Bsc, RGN, RM
A: As a midwife in the UK, I have witnessed technological birth as what I would consider a form of assault on the person causing actual bodily harm. By this I mean that the woman was the victim of physical assault by any independent observer's standards, but because of the medical setting the issue was ignored or even worse, justified, by those involved.
Let me give an example to clarify my thinking to you. When I was very newly qualified as a direct entry, mature midwife I was working on a busy, highly medicalised labour suite in an inner city hospital. I was caring for a woman who had hoped to experience an intervention-free birth. I enabled her in her wish to be mobile and to cope using her own personal reserves of courage and determination. However, as time wore on she was subject to the "timing" of her second stage and as it became "prolonged" the labour suite coordinating midwife involved the doctors. I (to my deep regret and subsequent learning through reflection) felt powerless at the time to help her. I stood by and watched things escalate to massive intervention.
I consider the assault and bodily harm—which could easily be likened to rape—occurred when the interventionist doctor decided that forceps were required (despite there being no fetal compromise in any way—just a scared and tired mother who had been terrified into believing she could not give birth now to her baby and may be compromising it by continuing to try). He performed an episiotomy with NO anaesthetic and no real informed consent, causing terrible pain and distress to the mother. Then the forceps were applied and the baby dragged into the world from an agonised mother who was frozen in her distress and unable to look at her child or hold it. I believe that this invasion of her body and the physical violence that she endured amounted to assault akin to rape—the coercion, lack of control and damage to her body, carried out by a man in front of others who should have been able to help her.
My ability to help this woman was severely limited at the time. I was, I realised afterwards, traumatised too—feeling a deep sense of uselessness and failure as a midwife. I still wonder what she made of it all, how she felt toward her baby and her partner and how she would cope with another birth—if she felt able to go through it. After the birth the next day I went to see her on the ward and she was obviously shell-shocked and lost within herself. When she looked directly into my eyes I could see her pain, but everyone around was cooing over the baby and full of excitement and cheeriness. At that time I felt unable to raise the issue and give her an opening to talk about it.
My advice on how to prevent anything like that happening to your client is to be a strong and confident midwife. Know your research to back up advocacy on behalf of the woman you are caring for. Believe in your knowledge and skills as a midwife; don't be afraid of medical staff and midwives who find you a threat or encourage an atmosphere where you are stereotyped as a madwife who takes wild risks with women and babies. You know that is NOT TRUE and WOULD NEVER BE TRUE OF YOU AS A MIDWIFE. Keep that in your head and heart.
Find out what your client really wants and what matters to her. Talk openly and honestly about what she may encounter in a hospital and medicalised birth to help her to prepare for it. Don't be afraid to tell it as it is and how it may be because you may be afraid of betraying your colleagues or former colleagues in hospitals—or scaring her. Your client is the immediate priority—you cannot ever take back what happens to her afterwards—but you may have been able to help her achieve her rights or learn to somehow accept the interventions from a position of strength and knowledge. That will help her to recover her sense of self and heal herself after trauma.
At a professional level, I would also consider putting in writing what you witness and sending it to the Head of Midwifery and the Head of Obstetrics at the hospital, as well as the staff involved.
I did talk to the arrogant doctor about the episiotomy he carried out without need, consent or anaesthetic. I asked him to consider what he would think of having his penis cut open with scissors without an anaesthetic—as an analogy for what he had done to the women whose vagina he had assaulted. Sadly, I think he just thought I was peculiar and a mad woman. He was such a misogynist that somehow the vagina was seen as not part of the woman, but a vehicle for the passage of a baby—to be treated in any way he chose. But think of that description of cutting the penis open and be prepared to use it, as I think it is very accurate for what is done to women's vaginas routinely.
As for helping the woman to heal herself from the trauma of childbirth assault or rape try the following. Give her the opening to talk and help her to understand that you believe in her and her view of what has happened as real and valid. Explain that assault and feelings of rape are commonly felt by women who have experienced what she has gone through and that you are there to help by listening and validating her experiences and helping her locate other help should she need it. Sometimes just having a witness to the reality and validity of your pain is enough to help you begin the process of healing yourself. So bear witness to what happened—don't try to explain it away or minimise it in medical justifications; it won't help her or you—although it is tempting because you may think it will help.
I hope my attempt to offer one possible answer to your question may prove useful in some way as you tackle this difficult area of midwifery care.
— Isabella Smart, NHS Community Midwife
A: I intensely experienced that my baby was being "raped" from my body due to the induction drugs used during the birth of my daughter. I walked out of the hospital saying, "There must be a better way to have a baby," and spent the next twelve years discovering that better way. Traumatic birth and posttraumatic stress caused by traumatic birth is the number one reason women are not continuing to add to their families and to our society. The introduction of my new book shows the consequences of this traumatic birth experience. Here are some additional reasons why it is vitally important to our society that women have a positive birth experience and what we can do to help the new mother:
A positive childbirth experience is necessary for the whole family in order for the family to be whole. A healthy pregnancy and a healthy childbirth will always yield a healthy mom and baby. This is the birth that creates a mother. This birth heals and bonds. This birth lets a woman know sex is good, birth is good, babies are good. A negative childbirth experience will leave the mother with the opposite feelings toward her body, her mate and her child.
Our medical community must stand up and pay attention to creating the atmosphere that will help to create this "birth of a mother" experience. A mother left with a "negative" childbirth experience does not return as a paying client for their services. Not only does this hit the bottom line of the services created to assist the mother, it is also an assault on the growth of our nation. Mothers refusing to have more than one child due to a traumatic birth are becoming far too common in our society.
What can our medical community do to enhance this positive experience?
A positive childbirth experience is necessary for the "birth of a mother" and for the future emotional and physical health of our society. It is time we all worked together to honor the birth of a mother and a baby.
— Gail J. Dahl
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Think about It
"In light of studies…that link use of drugs in labor with increased risk of addiction in adult offspring, it is interesting to note that an upsurge in cocaine addiction began around 20 years after the introduction of epidural drugs, all of which contain cocaine derivatives."
— Sarah Buckley
I am a young female photojournalist currently working at Fabrica, United Colors of Benetton's research center in Italy. I am presently in the process of organizing a global series of photo stories on women-only spaces around the world and other local feminist initiatives that are empowering women in their societies. This will eventually take the form of a traveling exhibit and book. I am very interested in finding a midwifery training program for women working in rural areas. I would like suggestions concerning where I might be able to find a midwife program and midwives who would be open to being photographed for this project. I hope to find midwives who are trained by other women. Any suggestions would be greatly appreciated. Some of my work may be viewed here: http://www.reportagebygettyimages.com/#p=featured_contributors/kitra_cahana/portfolio
— Kitra Cahana
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