Saturday, April 30, 2016

thoughts on motherhood

Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  

The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

  • The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
  • Once interventions have occurred it may be difficult to return to the natural, healthy process.
  • Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.

Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  

And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.

Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.