Wednesday, June 25, 2008


Or, Why continuity choice and control are not enough

Sue, whose life-changing experience of giving birth to Jack last year, wrote: “
And also for me, what is missing, is the focus on the heart. There is birth education out there, but too much of it misses the heart, getting women back in touch with themselves, their inner voice, and waking that up.”

Sue, I totally agree.

The message that women want the three C’s, continuity choice and control, emerged in the UK with the publication of the House of Commons Health Committee’s Report on Maternity Services (1992). Together with the Changing Childbirth Report (1993), these documents set out an agenda to make maternity care more woman centred, to facilitate midwifery care for homebirth as a standard option for well women, and to normalise childbirth in the UK. Caroline Flint (1993) published the book ‘Midwifery teams and caseloads’, with the frequently repeated mantra in words and pictures “get to know her”. Continuity of carer – a caseload - became a goal for many midwives.

Women told the Health Committee that they want *choice* of care and place of birth. I and many other midwives and birthing activists have chorused ‘choice’ since that time. Yet choice is a slippery entity that easily moves out of reach when in reality the availability of a particular model of care, or a place in a birth centre or even birth at home is easily overruled by other factors. Furthermore, I am sad to acknowledge that in recent years the pendulum has swung in the other direction, with women ‘choosing’ elective caesarean surgery.

Women expressed the desire to have *control* over their own bodies at all stages of pregnancy and birth. Of course, this element is readily agreed to by the midwifery profession, and supportive theories of partnership and cultural safety have emerged. Yet midwives know that the natural processes in giving birth demand a surrender or relinquishing of mind control so that the deeper hormonally mediated forces in a labouring woman can act unhindered. French obstetrician Michel Odent has written books and papers, and taught the midwifery profession about the importance of subtle hormonal influences at all times through the childbearing continuum, and the first year of a child’s life. The term ‘undisturbed birth’ is now used for a birth in which the mother is able to progress without interruption. But a mother in advanced labour, in a quiet, familiar, unstimulating space, cannot give any attention to control. The mother who feels a strong need to control may instead choose regional anaesthesia or even surgery, rather than allowing herself to go “out of control” in a powerful hormonally driven state.

With my mind juggling these thoughts I read the new issue of Women and Birth, the journal of the Australian College of Midwives (Vol 21:2, June 2008). New Zealand midwife Joan Skinner’s Editorial titled ‘Risk: Let’s look at the bigger picture’ is a critical look at what more is needed to achieve better maternity care. “…we [midwives] in New Zealand, where the midwifery-led model of care is now the norm, are learning that autonomy and continuity of midwifery care are not, of themselves, the solution to the rising intervention rates in birth. Despite having developed a strong and autonomous midwifery profession, which now provides most primary maternity care, we have not succeeded in making a significant dent in our risk framework. Our intervention rates and our medico-legal environment attest to this. …we need to FIRST attend to changing hearts and minds, not JUST the model of care. We need to open up to possibilities of collaboration with others, rather than focusing on professional autonomy.” The writer suggests that midwives, in seeking to turn the tide of maternity care from a techno-rationalist to a truly woman centred care, need to engage with other knowledge frameworks, including biosciences, human geography, and architecture.

While midwives can strongly assert our role as guardians of normal birth, and can seek to effect this through primary care caseload midwifery, we do not have ‘ownership’ of the birthing terrain. Neither, for that matter, does the mother, although her ownership of her own body and her experiences is supremely important in a functional society. The whole society has an interest in the next generation, and whether a person is looking from the perspective of a sociologist, an architect, or a farmer, their knowledge is valuable to the society’s provision of services around birthing of children.

Without changing hearts and minds of pregnant women, future parents, fathers, grandparents, hair dressers, shop keepers, and people in all ages and stages and walks of life, the midwife’s skill in promoting and protecting normal birth will not be valued.

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