Sunday, June 16, 2013

more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.

Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:
"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."
Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:
  • spontaneous onset of labour, and
  • spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.


Michelle said...

How many children does a woman have to have before becoming other than low risk? My third child, I lost at 7 1/2 weeks, due to miscarriage. One miscarriage isn't a risk factor for anything insofar as what I've read. I have two live births under my belt, and have noticed how my body labors. Quickly and intensely. I tend to have my baby, if free from any interventions, within 6 hours or less. Yes, I'm "fatter". But again, that's the only risk factor I'm noticing - except for the fact that I can't afford professional assistance. It's going to take more than that to convince me to go into the hospital. Convince me I'm high-risk - truly. Then I will head on over to Spectrum when I go into labor.

I understand your concern for those who don't have assistance. You're right, a mother can't always know if something's wrong. But you're leaving out the communication between mother & baby that happens the entire pregnancy. I got it a LOT from each of my babies. With my first, I didn't know enough to listen during labor. However, I suspected a boy - & he is a boy. I knew my second was a girl - before the ultrasound confirmed it. My lost baby, I suspect a girl & will find out when I see her in heaven. I wouldn't be surprised if I was right. I also knew something was wrong with that pregnancy. I kept getting assured that I'd only have a miscarriage if I thought about it - but I knew better. My MW even told me not to worry, probably to prevent me from worrying. Yet I wound up holding that baby in my hand, on my fingers. By the way, I had her unassisted, at home. Should not a miscarriage warrant a comparable level of care as a live birth (when there's forewarning), especially seeing as emotions are difficult to control & identify?!

I am NOT saying having an unassisted childbirth is safe for all women, or even most low-risk women. I AM saying that years and years before there were midwives, OBs, and doulas, women birthed with the assistance of mere family members. Perhaps it's not as dangerous as you think. Or as studies show - because, as we all know, studies can be made to show anything, depending on who funds them.

You also don't give sources for your statement that having assistance is safer than not. While I'm all for giving your own opinion, I also believe it should be based upon facts. This is not satisfied within your article. You give the autopsy report as a source, but it is only ONE birth, and a vbac at that AND it was assisted! Vbacs are higher up on the scale of risk than a vaginal birth after two full-term babies and one lost baby of approximately two months' gestation. You also quote an article (essentially someone else's opinion, hopefully based on facts). Yet again, you're leaving out sources for us to refer to. If unassisted birth is so unsafe, there should be proof. Do you have cases where you knew someone was birthing without the professional assistance you believe is required? Or maybe your colleagues know of someone? I'm not talking about those who know they are high-risk but go it alone anyway. Nor VBACs. I mean more than one low risk mother/baby who died because they were unassisted during the process of labor and birth.

Let me reiterate - we are all entitled to our opinions. But they need to be based on facts. If it weren't for the internet, I wouldn't know about the harm vaccines do - does that make it uncredible? No. It's when we do one-sided research that it loses credibility. My research will remain open, so I can accurately decide if I should go to the hospital. But I also want to accurately make the choice of staying home as well. And I will have my boyfriend there, who will know what I know, so if he recognizes something I don't, I can transfer.

Joy Johnston said...

Thankyou Michelle for writing here. I'm not sure that I can answer all your questions, but will comment on a couple.

There is a lot of research evidence of good quality - not just someone's opinion - that demonstrates the safety of homebirth with midwifery support, and a plan for transfer to hospital if needed. I have linked to a recently published professional paper in my post. There is no similar research to support unattended birth.

In Australia all births attended by midwives at home or in hospitals are reported through government statistics agencies. This does not happen with 'free birth', because they are essentially underground. Some are recorded as 'born before arrival' - along with the ones that were truly in a hurry to arrive.

My opinions are based on facts. I am professionally accountable, and if I wrote something on a blog that was not defendible, I could be investigated for unprofessional conduct.

For the record, I disagree strongly with your statement about vaccines. From all the science and evidence I have seen, vaccination is a life-saving and essential health issue in any community.

Michelle said...

As far as vaccines go, that's an entirely different debate - but know I've heavily researched and continue my research on the subject, and this has led me to and reinforces my stance.

I'm in the US, and we have no such thing with blogs here. Thank you for setting me straight. I didn't mean to question your professionalism at all.

Like I said, I completely understand your concern. You put up valid points as well. But don't discount the mother's intuition and mother/baby communication. No, it can't be proven or studied - it's an individual thing, but it IS real. I've had too many instances of it happening to say otherwise.

Please know that I'll be constantly researching my decision, and, if I feel it's best, to the hospital I'll go.