Monday, March 02, 2009

CHOICE?

A birth made to order? What a joke

Author: Lucy Beaumont
The Age Opinion March 2, 2009

"Women don't have a choice when the health system can't deliver."

Journalist Lucy Beaumont has written about her own devastating experience of birth. And she seems to have concluded that she was hoodwinked into believing that "this labour thing was going to be tough, but "good tough". More intense than anything I'd ever physically known before but essentially positive. And for some reason I felt entirely up to the challenge, supremely confident after a fairly stress-free pregnancy."

The memory of lapsing into unconsciousness as she haemorrhaged; of the doctor at the business end, and the midwife next to her giving her face a slap in an effort to bring her back - that memory will be with her as she approaches the birth of her next child.

I value the opportunity to reflect on this account, and am writing for those readers who are wondering how might this experience have been different.

Beaumont is right, "Women don't have a choice when the health system can't deliver."

But I would like to take that statement a step further. "Choice" in childbirth is one of the hugely misunderstood concepts. There is only one *choice*, that a woman either accept the work her body is doing, or accept the medical intervention. The only choice that this woman had, after experiencing prelabour for 48 or so hours, and the 'postmature' stamp, was to agree to induction of labour or to continue waiting for spontaneous labour to establish. Once you step over the line, into 'Plan B' I call it, you have very little choice. In fact, the idea of choice becomes a bit of a sadistic game: "Have you had enough of natural birth now? See, you can't do it yourself. Let's get this epidural in and move into the 21st century!"

We can all be wise with the help of hindsight. If I had been advising this woman at that time of her critical *choice*, would I have had the confidence that I now have in writing about choice?

The difference in my role is that usually I would only be involved in that *choice* if that woman had asked me, personally, to advise her as her primary carer. And that arrangement is usually set up in early pregnancy, giving us the opportunity over the months of the pregnancy to build confidence and trust in our shared decision making. It's called midwife led continuity of carer. It's the sort of maternity care that is based on good evidence! The Cochrane Review (Hatem 2008) not only confirmed the safety of midwife led care, but concluded that “All women should be offered midwife-led models of care and women should be encouraged to ask for this option.”

"All women ..." What a paradox we face at present in Austrlia today that the very providers (self employed midwives) of such a care option are facing deregistration because our government's reviewers of maternity services don't consider the women who employ us, or the midwives who work this way, worth protecting.

So if Lucy had been in my care (or any other midwife who accepts the 'caseload' primary carer role seriously, whether employed or independent), we would have been able to explore what was important to her. I could have encouraged her with words like, "You and your baby are well. You are obviously getting ready for labour. There is no valid reason for us to interfere with your body's preparation for spontaneous labour."

I know these things are true, because any mother or baby who were not in good shape at the beginning of the induction process would not have proceeded to a vaginal birth.

There are times when a woman in a midwife's care decides that her best choice is to step out of 'Plan A' into 'Plan B'. The known and trusted midwife continues working with her, using her knowledge and skill to promote normal birth. The partnership between the woman and her midwife is often the key to maintaining good progress, or alternatively, to moving into further appropriate medical or surgical management.

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