Sunday, September 23, 2012

Women's rights in childbearing

I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday.  The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic. 

The issues around women's rights in childbearing have been promoted by many writers and film makers.  A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to  criminal proceedings against doctor-midwife Agnes Gereb.

Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.
Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.

The Childbirth and Law Forum will begin at 2pm with presentations from  two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)

It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system.  Barrister Elizabeth Prochaska wrote:

A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy).  A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer.  AIMS put a coupe in contact with me who had been promised a home birth by the hospital.  With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)

The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care.  Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth.  For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth.  Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.

In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them.  They are no longer 'low risk'.

Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate.  A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance.  The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be). 

Midwifery services today use the term 'evidence based' without challenge.  The exclusion of women from birth centres and homebirth programs is considered 'evidence based'.  Rarely does anyone ask, "what evidence is that?"

A recent update of the Cochrane review , the centre of excellence in medical evidence, states:

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. 

An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards.  Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.

In 'Women's rights in childbearing'  (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth.  The article reports that  UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."

Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present.  The limits of responsibility in such a situation are in no way defined or clear.  It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife.  Unfortunately it will take adverse outcomes to test the limits of women's rights.


Anonymous said...

You can continue to ignore what is happening here. Support Agnes who deserves it but shy away when this exact thing already happened in Australia. Plus they treated the woman so badly that the authorities with held her baby until she gave evidence just 2 weeks after her baby died. They raided her house and her care providers house. They lied in parliament and on national news. They were hounded by the press until it was impossible to leave home. The childbirth and the law forum in Australia is a joke. They wouldn't let the people who have first hand accounts of these abuses speak as it was deemed too controversial. Get out of your ivory towers and face up to the fact that you have all become part of the problem. No amount t of waxing lyrical will solve it while you all think it couldn't happen to you because you are safer, better, risk adverse, registered, insured, accredited or whatever. Women have the right to birth where and with whom they want. Fight for that.

Joy Johnston said...

That's probably the essence of the problem, Anonymous.

Women *may* have the right to birth where and with whom they want.

Midwives, on the other hand, are required to practise in a way that protects the wellbeing and safety of that mother and child. If that's an ivory tower, then I'm OK about it.

Thankyou for your comments.