Friday, December 18, 2009

“Normal” “Natural” “Humanized” “Good Enough” ~ What do we call childbirth in 2010?

Much of what childbirth educators have been preaching about for the last two decades is finally making its way into the mainstream media. Childbirth educators have been talking about the evidence: the evidence that shows that the increase in medical interventions during birth does not improve infant mortality/morbidity or maternal mortality/morbidity.

A Consumer Reports article from October 2008 had this to say about medical interventions during birth in the U.S.:

The report found that, in the U.S., too many healthy women with low-risk pregnancies are being routinely subjected to high-tech or invasive interventions that should be reserved for higher-risk pregnancies. Such measures include:

*Inducing labor. The percentage of women whose labor was induced more than doubled between 1990 and 2005

*Use of epidural painkillers, which might cause adverse effects, including rapid fetal heart rate and poor performance on newborn assessment tests

*Delivery by Caesarean section, which is estimated to account for one-third of all U.S births in 2008, will far exceed the World Health Organization's recommended national rate of 5 to 10 percent

*Electronic fetal monitoring, unnecessarily adding to delivery costs

*Rupturing membranes ("breaking the waters"), intending to hasten onset of labor
Episiotomy, which is often unnecessary

In fact, the current style of maternity care is so procedure-intensive that 6 of the 15 most common hospital procedures used in the entire U.S. are related to childbirth. Although most childbearing women in this country are healthy and at low risk for childbirth complications, national surveys reveal that essentially all women who give birth in U.S. hospitals have high rates of use of complex interventions, with risks of adverse effects.

In the face of this increase in intervention in childbirth, “normal birth” is promoted by the World Health Organization, national governments, professional bodies (such as midwifery, childbirth and doula groups) and other organizations around the world. A recent article in Nursing Inquiry (“Normal”, “Natural”, “Good” or “Good Enough” Birth: Examining The Concepts by Susanne Darra; 2009; 16:297-305) discusses the titles placed on birth processes and the confusing overlap of definitions:

To some degree, the prevalent birth culture in the US is women’s misplaced fear of their baby will die, yet they don’t worry about the risks of inducing labour. They worry that the pain will be unbearable, yet they don’t worry about the side effects of epidural anesthesia. They accept continuous fetal monitoring as safe and effective, yet they don’t worry about a medically unnecessary cesarean section.

Lamaze and other organizations and birth journalists have embraced the term normal birth with a widened range of variations of normal. Like midwives, normal birth advocates focus attention on the strength and education of the expectant parents for the normal birth scenario to be played out. Yet, how can a normal birth occur if hospital educators continue to teach to the “good enough” birth level?

Darra refers to the work of Winnicott (1953) and the theory of the “good enough mother” from which the good enough birth is derived. The good enough birth is a birth planning on the reduction in medical interventions within the dynamic and unpredictable process of childbirth. Using Winnicott’s theory, therefore, mothers are capable of adapting and coping with the challenges of losing control in labor ~ allowing for others to be in control (enabling disempowerment).

Counter to this way of thinking comes Marsden Wagner from his landmark writing “Fish can’t see water: the need to humanize Birth” International Journal of Gynecology and Obstetrics 75: s25-37.

Humanizing birth means understanding that the woman giving birth is a human being, not a machine and not just a container for making babies. Showing women---half of all people---that they are inferior and inadequate by taking away their power to give birth is a tragedy for all society.

By medicalising birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her, the woman's state of mind and body is so altered that her way of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result it that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what 'non-medicalised' birth is.

Why is medicalised birth necessarily dehumanizing? In medicalised birth the doctor is always in control while the key element in humanized birth is the woman in control of her own birthing and whatever happens to her. No patient has ever been in complete control in the hospital---if a patient disagrees with the hospital management and has failed in attempts to negotiate the care, her only option is to sign herself out of the hospital. Giving women choice about certain maternity care procedures is not giving up control since doctors decides what choices women will be given and doctors still have the power to decide whether or not they will acquiesce to a woman's choice.

There is, therefore, a tremendous disconnect between what is evidence-based information that is taught by childbirth educators and written about in journals such as midwifery journals or the Journal of Perinatal Education, and that which is embraced by the medical community.

Of this, Wagner also writes:
Another reason for the gap between evidence and practice is the excuses often given by physicians for why they reject evidence in their medical practice. These excuses include: the evidence is out of date; collecting evidence is too slow and prevents progress; I use clinical judgment and my experience; using anecdotal 'horror stories' to try to prove the need for an intervention which the evidence has found unnecessary; quoting evidence which is of poor and/or inadequate quality; 'trust me, I am a doctor'; 'stop doctor-bashing'; evidence erodes physician autonomy. In addition to these excuses, in maternity care common excuses include: our women have smaller pelvises (no evidence), our babies are getting bigger (no evidence), our population is not as homogenous (no evidence).

So perhaps the term should be physiologic birth? The definition of physiologic birth is essentially the midwifery model of care: every pregnancy and every birth is different and unique in its own normal/natural way. Care should respond to the physiology of birth and include emotional and physical support of the mother and her immediate partner. The mother should be educated so that she can respond to labor in her own way.

Case in point: Joy Szabo who moved 6 hours away from her home to get the VBAC she wanted and needed. Why should mothers have to fight for physiologic birth?

To this, Wagner would comment:

The final solution is to evolve new social and political forms for the medical profession and for medical care. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people.

So 2010 should be the year of the Childbirth Educator? A renewing of vows to educate with evidence-based information both the expectant parent population and the nursing/medical population who are admittedly busy yet are in desperate need of this information. While as a group, childbirth educators make up only a small portion of the US population, we are a passionate and committed and unique group of individuals.

"Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has." - Margaret Mead

1 comment:

Jo said...

I too was interested in Darra's piece. But I was a little confused by her attempts to link Winnicott's theories with childbirth. Do you think there is anything in that idea ?