From MIDWIFERY MATTERS, Issue No.95, Winter 2002
Author Denis Walsh
Denis Walsh presented the following at the Normal Birth Conference in Preston on October 29th 2001.
AN IMAGINARY conversation takes place between three midwives about what´s significant in childbirth.
The first says:
"The most important thing is not having a baby in an area where a baby has previously died".
The second one says:
"The most important thing is being with other women who have had babies".
The third says:
"The most important thing is being near specialist help like obstetricians and paediatricians if things go wrong".
The first says to the third:
"But it is very bad to have a baby where previously things have gone wrong".
And the second says to the third:
"The specialists you talk about have had babies themselves - right?"
"Oh no", says the third, "they´re usually men".
The first speaker bases her belief on 30,000 years of nomadic culture, for she is an aboriginal wise women living around 10,000 BC in Australia. The second bases her belief on 1,000 years of a highly successful culture, for she is a midwife living in Egypt in 500BC. The third bases her statement on 30 years of experience in a large, consultant unit in a dominant first world culture in the 21st century.
What kind of arrogance is this that in our life time, one generation at most, we claim the definitive model for human parturition? We are but a speck on the end of the tail of human history and we dare to say that our wisdom overrides tens of thousands of year of evolution. Do we really believe that human childbirth needs to happen in big buildings, in very unfamiliar surroundings, attended by strangers? This is a seminal rite of passage, one of life´s major milestones, where alongside a newborn baby is also a newborn mother, father and family - are we really saying that this is primarily a medical event above all else?
And given not hundreds, not thousands, but millions of years of hugely successful human reproduction on this planet, are we saying that women today need experts to oversee this reproduction, that because it so commonly goes wrong, women need rescuing?
We have developed to such an advanced stage of civilisation that our world would be unrecognisable to the generation of 200 hundred years ago, let alone 2,000 or 20,000. Our level of sophistication is unparalleled in human history, except for childbirth where risk management, experts and technology abound because this most primitive of instincts, this most basic of life skills, this formerly most trusted of physiological processes on which every race and nation relied implicitly, apparently can not deliver without assistance.
Let us use our imagination again to take a journey, to do some time travel, except this time we are being visited from the past. An indigenous Celtic woman awakes in a labour ward in the UK in the 21st century. She is labouring.
"Where am I?" she cries, "I must get off this table (the bed) and get off my back. This is very bad for my baby and me. I need to be upright and grounded but look, this place is built above the ground," as she stares out the window and down several floors to the earth.
"I need to get back down there".
Just then a woman comes into the room unannounced.
"Who are you?" our time traveller asks, "I don´t know you".
"I´m your midwife. Do you mind if I examine you to see if everything is going okay?"
"No need", replies the woman, "I know I´ve never had a baby before but my Mum and her friends have told me about what it´s like. I´d just like to see them, please."
"But I need to assess you so that I can tell the core midwife and doctors how things are progressing."
"I don´t know these people and, actually it is none of their business. Now, I´d like to leave and be with my Mum and her friends who said they would stay with me during this birth so that I can do it myself next time."
"What! Next time you´ll give birth on your own? I think that might be illegal," says the midwife.
Suddenly there´s a knock on the door but before anyone could answer, in come six people, three of them men. Some of the people are wearing strange outfits. It´s the consultant ward round. Horrified, our time traveller says to the midwife,
"Hey, get those men out of here. They should not be here. And, who are all these other people? I don´t know any of them. Get out of my birth space. Are you deliberately trying to upset my labour? Actually, better still, I´m leaving. I hate this place anyway. None of it is familiar. These white washed walls, these bright lights, what are these boxes on wheels for (the fetal monitor), and the furniture in this place is totally unsuitable for labour - starting with this ridiculous table I´m on. Surely women don´t give birth on this thing.
"If I stay in this place, I´ll tell you what will happen. My labour will stop because I can´t think of a worse environment for birth. Nothing is familiar, it´s full of intruders whom I don´t remember inviting and you all want to check me - why? Don´t you trust the birth process? Don´t you trust me to do it? You don´t do you? I can tell from the paternalistic, patronising look on your faces. I know how birth is done best. My mother told me and her mother told her and so and so on. In fact I´ve got thousands of years behind me of handed down wisdom and you come along with yours´of the last 30 and dare to tell me where I should have my baby. I´m leaving so I can have my baby in privacy, undisturbed, where I can plant my feet firmly on the ground, where people I love are around but not imposing themselves. And you know what´s most important. They love me because they know me and have cared for me since I was a little girl. They believe that I can do birth. Birthing in this place. What kind of ill-informed, under developed, backward looking, pessimistic culture would dream that up?"
Wouldn´t it be interesting if we could have such a dialogue like in our imaginary story with wise women from earlier civilisations and cultures? If we could compare experiences with women doing childbirth then and now? Apart from asking about how normal birth was accomplished, where I suspect they would have much wisdom, I´d like to ask them about how they handled death of a mother or birth of severely disabled baby - things that are rare in our culture, a rareity which we put down to the benefits of science and technology. What would they like to borrow from us about how we do birth? And of course what could we learn from them? For the tragedy is that when western birthing practices interface with indigenous ones, the change occurs in one direction only. Indigenous practices are modernised to conform to our standards while at the same time what´s good about their model is jettisoned and lost forever. When I first heard that aboriginal women in remote communities of Australia would not go hundreds of miles to birth in city maternity units because they believed it was bad to birth where there had previously been death and illness, I thought - I can see where they are coming from. It had never crossed my mind but this could be also to do with the expectations of staff who work in these places who so commonly saw complications and morbidity attached to birth that they had lost confidence in it as a physiological event.
Bridget Jordan´s study of Yucatan women living in small villages portrays this wonderful picture of the sacredness of the birth space and how women guarded it from intruders yet the pressure to attend big hospitals to give birth was already undermining their traditional ways.
What is it about this frenzy to centralise birth across the planet? At the very least we would expect it to be based on some rationale that made sense at some level. Surely it must have some evidence base. Surely this wholesale move from home and birth centre to hospital, a move that has become one the most successful policy decisions ever made in health services - in excess of 96% of women across the western world now give birth in hospitals and the developing world is fast catching up - surely this move had some research to back it up?
Well actually- No! Marsden Wagner, author of Pursuing the Birth Machine, has called it the largest uncontrolled experiment in history. The evidence for home and birth centres actually points the other way - these environments consistently result in more satisfying birth experiences for women and fewer birth interventions for babies.
Shall we leave the final word on this to Ian Chalmers and colleagues the original architects of Effective Care in Pregnancy and Childbirth, what is now the Cochrane Database? Before reviewing all the studies around childbirth, they laid down two fundamental principles for maternity care research:
1. Let us not do anything to childbirth unless we are certain that our intervention improves on the normal physiology.
2. Even if we do, let us be certain that our intervention does not have unintended side effects that outweigh its benefit
Sadly, as Marsden Wagner said, we did exactly that during the 20th century when we moved birth from the local setting to a centralised setting, for where birth occurs is the most fundamental intervention of all. You see, it is really very simple. There is one short phrase that captures so effectively what homebirth has over large consultant units.
Home birth
- Where the institutional is replaced with the intuitive.
- Where the public space is replaced by the private space
- Where the platitudes are replaced by the personal
- Where the labelling is replaced by love.
One insignificant phrase but with profound meaning:
My friends, when it comes to maternity care provision,
LW updated February 4, 2005