Tuesday, December 09, 2008


The headline on page 5 in today's Age is 'Fear of birth causes rise in caesareans'. This article is reporting on the newly-released Australian Institute of Health and Welfare (AIHW) report Australia's mothers and babies 2006.

The continuing rise in caesarean births, from 20% in 1997 to 31% in 2006, is an indicator of a maternity system in crisis. The AIHW report does not attempt to answer the question "why?"; it simply states the facts.

One reason for the increase in caesareans, according to Julia Medew, Health Reporter for the Age, is the 'fear of birth'. The non-medical reasons for caesarean include, according to Medew, psychosocial, patient choice, family history of vaginal prolapse or incontinence, the unpredictability of the birthing process itself, and the risk of an emergency caesarean.

I am sure the 'fear of birth' influences many of the medical decisions to proceed with casearean surgery. The 'fear of birth', an unpredictable natural process, that results in high rates of inductions, the cascade of interventions, and subsequent rescue of mother and baby by surgery. The 'fear of birth' that has robbed midwives of their skill in being 'with woman'; resulting in strong reliance on opiate pain killers, and epidurals, and thereby diminishing the ability of the mother-baby unit in achieving their natal journey. The 'fear of birth' that presents major abdominal surgery as a 'safe' option to the natural process.

I think it's true that many women experience a deeply significant 'fear of birth'. The way we manage that fear of birth is very complex, influenced by our knowledge about birth, our expectations, our belief system, our trust in our own bodies, the influence of family and professional carers, and many other factors.

Many women in my care have expressed their own 'fear of birth'. While I as a midwife use language such as 'working in harmony' with the natural processes, women write in their birth stories about reaching a place where they had to let go, to surrender to their bodies, come what may. Some speak of a very frightening place, a tunnel, a valley of the shadow of death. The 'fear of birth' is over-ridden by the 'fear of death'.

There can be no generalisations here: a woman's experience in natural birth is hers alone. While to one the letting go of conscious control becomes a powerfully thrilling journey into a new terrain, another might struggle to retain control, and be terrified, as a force she does not understand, and cannot accept, propels her child through her birth canal and out of her body.

A few days ago a mother told me that she has experienced what I understand as post traumatic memories since the birth of her first child, at home, in my care. This mother is now preparing for the birth of her second child. She told me she is afraid.

I do not remember anything about that birth that would have alerted me to this fear of birth. Labour progressed well, and a beautiful healthy baby was born through water. I am saying this to highlight the fact that the mother's lived experience may differ significantly from the professional assessment of the midwife or doctor who takes responsibility for the care. From my perspective, it was a good birth. From the mother's perspective, something was very wrong, and she fears it happening again.

I have reflected on this apparently enormous difference between the experience of the mother and the experience of the midwife. When I am 'with [labouring] woman', I find myself going through a physical and emotional partnering. I also experience transitions, and fears - not the same, but linked, to the woman I am with. I need to keep myself at the same time closely connected to the woman, yet objectively outside her experience, so that my professional assessments are clear. I do not know a woman's limits, but my duty is to know and hear her, and to hold a space that enables her to continue in her journey.

Theories of partnership and cultural safety in midiwfery place the woman at the centre of everything. The care I provide is culturally 'safe' if the woman, with her own culture and personal needs, feels that it is 'safe'. In partnership, there is an emotional 'safe' place - once again from the woman's perspective.

Returning to my initial claim, that the continuing rise in caesarean births is an indicator of a maternity system in crisis, I wonder if this reflection on the 'fear of birth' contributes in any way to addressing that crisis. Yes, I believe midwives hold the key. Midwives offering one to one partnerships with women hope that in doing so we can promote and protect normal birth, and enable wholeness and wellness in the majority of women in our care. Yet there will be some who, as discussed here, experience to a greater or lesser degree, ongoing 'fear of birth'. My strong belief is that, even though the 'fear of birth' is deeply ingrained in our psyche, and in our culture, there is no safer way to give birth than to proceed down the normal pathway. The natural process is 'Plan A'. Accepting the unpredictability of our bodies, and our lives, we are able to make the best choices from any that are available if 'Plan B' needs to be considered.

The mother who spoke to me about her fear is likely to read this entry. My heart goes out to her, and to others who experience that crippling fear, that you will be able to find new strength and enabling in the amazing gift of GIVING birth.

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