[A shift of topic, of personal significance but also potentially of great significance to the state of our society.]
There has been for some time a vigorous campaign to effectively ban home births in Australia, including crude scare-mongering based on extreme cases, such as a recent article by de Crespigny and Savulescu. However the ground from which these campaigners operate is shaky, because of a dramatic rise in hospital interventions in the birthing process, and because obstetricians have an obvious conflict of interest. Medical hostility to midwifery in general, not just to home birthing, seems to be driven by a spiral of fear, which is abetted by many obstetricians’ relative lack of the skills and experience of midwives.
A calm assessment shows there is reasonable evidence that for low-risk pregnancies the incidence of difficulties is no higher for home births than for hospital births. There is general agreement that medical attendance is sensible for high-risk cases, and that ready access to medical backup is important for everyone.
However home birth offers large benefits to mother and baby that are frequently overlooked. These benefits need to be balanced against both the benefits and the negatives of the hospital experience. Also, women differ in their physical and emotional needs and preferences, and no single option can suffice.
A key part of the anti-home-birth campaign is to effectively prevent home-birth midwives from obtaining insurance. Recently health ministers extended an exemption in indemnity insurance for two years, which may allow supportive arrangements to be negotiated. However the Australian Medical Association is actively obstructing attempts to arrange collaborative medical backup for home-birth midwives. Internationally, collaborative medical backup of midwives is more the norm, so the attitude of medical professionals in Australia is anomalous.
My own involvement in this issue is through my partner and my daughter, both of whom had successful home births. Also as a scientist I am interested in the proper evaluation of evidence, and as a mature person I appreciate the importance of relating to the whole person, and the need to keep fears in proportion and to balance them with information and personal awareness.
People experienced in natural and gentle birthing know that birthing mothers need most to feel secure and “unobserved”. If the mother is anxious or afraid, or even if an anxious person is in the room, a shot of adrenalin may shut down the birthing hormones and inhibit the birthing process. If a mother feels observed or uncomfortable her attention may come out of herself and again the process may be inhibited.
In our technologically-conditioned Western society some mothers feel secure in the hospital environment, but other mothers find it alien. The latter mothers typically need privacy, quiet, soft lighting and helpers who are known, trusted, experienced and calm. These conditions may be found in a good birthing centre, or at home. With a mother thus cocooned, the birthing process can proceed through its richly and delicately choreographed sequences involving physical, hormonal, emotional, immunological and psychological processes, all honed over the aeons to support the successful birth, the bonding of mother and baby, and a good start to a well-adjusted and fulfilling life.
When my children were born, fully “natural” childbirth was commonly regarded, even among many of those inclined in that direction, as unnecessarily heroic. I had my eyes opened by my daughter, who said of the home birth of her daughter “The feeling of actually giving birth was very uncomfortable, and I roared a lot, but I was not in pain”.
A mother arriving at a hospital in labour may experience bright light, noise, confusion and a parade of strangers checking her and attaching things to her body – various monitors, a drip feed. The hospital staff are in a familiar environment but she and her supporter are not. All of this may induce anxiety, and it is a common experience for labour to slow or stop at this stage.
Even with empathetic nurses, a mother can easily feel overwhelmed and disempowered. An independent midwife gives one-on-one attention and care, and will stay as for long as it takes. Doctors are busy and often are not willing or able to wait indefinitely. A slow labour may begin to stress the baby. For these or other reasons some intervention may be suggested, commonly a drip feed of artificial hormone. This disrupts the delicate balances and sequences of natural hormones, which would get the job done very nicely if we stayed out of their way.
A cascade of further interventions can then follow. With labour slowed by anxiety, chemicals and disempowerment, and with increasing discomfort of the mother, pain killers may be added to the cocktail, and the natural process further disrupted. If progress is still slow, “augmentation” may be recommended, another level of chemical intervention. Ultimately a caesarian may be recommended if the baby is showing signs of distress. Labouring mothers typically are in no position to question or resist such urgings.
Many mothers, though not all, discover later that the hospital birth experience has been traumatic, even if it had been their choice. Some mothers realise at the time, and some describe it as hell, or abusive. Such emotional trauma seems to be not yet well known, but social workers are discovering that symptoms of post-traumatic stress, arising from hospital birth, are not uncommon several months after birth. This is often found to be an important factor in post-natal depression and/or anxiety.
If a mother has been traumatised, then of course it is likely the baby also has been traumatised. Physical distress during birth may have been measured, but the consequences of unnoticed emotional trauma may persist long after.
This is not to claim that all mothers are so affected, many are happy with their experience. Nor is it to impugn the motives or skill of most hospital staff, who of course are dedicated to the welfare of their patients. It is, however, to indicate looking carefully at the sensitivity of hospital procedures, and especially to challenge the push to eliminate choice.
Many experienced midwives know how to deal with situations that in a hospital may trigger interventions. Some can, for example, readily handle breech births (bum first) and the cord around the baby’s neck. Some know how to have the mother “dance” to turn a baby. Such skills ought to be encouraged and propagated.
Obstetricians are trained to handle emergencies. They are not trained in such nuances of midwifery. The point and value of obstetrics is to handle emergencies when they arise. The value of midwifery is to minimise the need for such medical interventions.
Emotive arguments citing extreme cases are not helpful – horror stories can readily be found both for hospitals and for home births. The welfare of the baby is not served if a mother is traumatised. Like all specialists in all fields, obstetricians need to be conscious of the limits of their expertise, and respectful of those with different or wider experience.
The limited range of obstetricians’ expertise seems to be feeding a spiral of fear, in obstetricians, hospital staff and mothers, that is creating an epidemic of unnecessary interventions. Rates of caesarians in Australian hospitals are commonly thirty or fifty percent, and increasing, whereas internationally rates of no more than ten to fifteen percent are regarded as reasonable.
What is needed is a range of birthing options, including hospital births, birthing centres attached to hospitals, local stand-alone birthing centres, and, for those who choose, home birth with full availability of the care of midwives and sympathetic hospital backup.
We also need to expand our view. The issue is not just the measurable physical state of the baby, with the mother a self-sacrificing vessel. We need to relate to the mother and child as whole beings, to nurture their precious relationship, and to be mindful of their physical, physiological, emotional, psychological and, for those who so regard it, spiritual welfare.