Friday, March 06, 2015

in two minds: why 'choice' is often a mirage

Today I am looking at (the woman's) choice, decision-making (whether it can be called 'informed' or not), and the midwife's challenge which, by definition, includes the protection, promotion and support of healthy natural processes in birth and nurture of the baby. 

From time to time a book or an article promoting women's *rights* in pregnancy and childbirth comes to my attention.  A recent feminist blog is headed with a big question "Why is it still controversial to say that women should make the decisions about childbirth?"

The group Maternity Choices Australia, which emerged out of Maternity Coalition (an organisation in which I was active for a couple of decades) has placed strong emphasis on a woman's own choices in the maternity terrain.

Who is *in two minds*?  
The woman herself. 

What are the two minds?
The woman's intellectual mind and the intuitive mind.  The same brain has separate parts that are used differently.

Why is 'choice' often a mirage?
Choices that are made (using the intellectual mind) prior to the time at which the intuitive mind takes the lead (particularly in labour and bonding) can be irrelevant, but can trap the woman. 

Although I am critical of a great deal of the maternity choice campaign as I see it today, my criticism is based on my understanding of the physiology of birth, which describes the two minds and their interaction with each other; not on feminist arguments of women's rights or fetal personhood.

The person missing from the current arguments about a woman's own choice is the midwife.  Not the generic midwife, whoever is given the task of providing midwifery services at a given moment; the one midwife who is acting as the unique professional, dedicated to working alongside and in partnership with that individual woman through the pregnancy, birth, and postnatal.

I am ready here for someone to tell me that I am being idealistic.  How can health services provide a one-to-one partnership between each woman and a committed midwife whose skill and knowledge the woman is able to trust at any decision-point?

Yes, I know it's not easy.  I have recently ceased providing this level of midwifery care, because I have become too old; too weary.  I can no longer offer to stay awake past my bedtime, or get up in the wee hours; to put aside my own needs hour after hour for the sake of what I believe to be optimal care in birth.   I still see that as optimal, even though I can no longer offer it. 

The only way I can see a maternity world that protects women's ability to make decisions about childbirth is when systematic changes are made so that midwives and women can honestly explore any choices that are presented as time progresses.  When the woman, using her intellectual mind, can explore and grasp the complexity of decision-making in labour, and can trust her midwife-partner to interrupt her from her intuitive state only if she needs to bring a matter of importance to her (intellectual) attention.  

I want to caution here, that without effective partnership, midwives and maternity services, as well as mothers, can err in over-reliance on 'natural' birth.  A UK report highlights the need for caution.  Anecdotes are common and some lead tragically to coroner's reports.

A midwife who delegates decision-making completely to the woman is foolish, lazy, incompetent, unprofessional!
For example:
Midwife A says she believes the woman is free to make any choice she wants about how long to stay in a birth pool after giving birth. 

The woman B has progressed in harmony with amazing natural, physiological forces in her body to give birth unmedicated and unassisted to her baby.  This was just what the new mother B had wanted, and she had (in her intellectual mind) chosen this pathway as having real advantages for herself and her baby.   Midwife A had supported B's plan. 

In the minutes after the birth, B stayed in the birth pool, hormonally awash in the beauty of her newborn and the afterglow of her ecstatic experience.  Midwife A was confident that all was well, and said nothing about getting out of the water.  Baby C did what healthy unmedicated babies do: she found her mother's breast.

Mother B experienced painful uterine contractions, and about 30 minutes after the birth B experienced a gush of blood, and midwife A reassured her that her placenta was about to be born.  Nothing was said about getting out of the water.

More minutes passed, with further after-pains, further bleeding, but no expulsion of the placenta.  Nothing was said about getting out of the water.


Because Midwife A believed B would know when she needed to get out of the water.

Midwife A was wrong.  Mother B was using her intuitive mind as she nurtured and bonded with her baby C.  She had no idea of time, or any other aspect of expected progress that her intellectual mind had considered prior to the birth.  The only intuition about moving out of the birth pool came much later, when B became faint.  I don't need to spell out the consequences of this error in delegation of 'choice'.

In conclusion, I can say that it is still controversial to say that women should make decisions in childbirth.  The big challenge is that midwives and women are enabled to work together, in deep respect, and with freedom to find the best course as time passes.  Neither can do it alone.