Here are some quotes and brief synopses from the afore-mentioned magazine articles on this subject:
North/South, “Is Caesarean Safer? The Evidence for and against Natural Birth”
“Fear of childbirth plays a huge part…fear of pain, fear of the outcome for the baby. Women have a lessening faith in their own bodies that they’re able to birth normally.” — Michelle Wise, OB
“While the initial fall in maternal and infant death has stabilized, caesarean rates are still rising…despite efforts by district health boards to reverse that trend because of the pressure it places on strained resources, from theatre capacity to hospital beds needed for longer post-natal stays.
“Whether all pregnant women should be offered a caesarean, says Wise, is ‘a complex issue for society to debate… Personally I don’t think that’s the way to go. At the end of the day, the safest thing for the mother and her baby is a vaginal birth….We’ve seen the rate (c-section) go up every single year. And with the number of women coming back for repeat caesareans, it will suddenly feel like everyone’s having one. There’s no doubt at some point the whole system has to rejig.’
“New Scientist reported in July that doctors in the UK are now considering whether pregnant women should be officially warned about the danger of leaving it all up to nature. ‘Medical evidence is on their side,’ the magazine claimed, ‘planned c-sections are the safest option for the baby, because they avoid any chance of brain damage from a vaginal birth and the not-insignificant risk of stillborn after 39 weeks. A planned c-section is also the only guaranteed way to avoid a risky emergency c-section. And they are cheaper in the long run once the costs of caring for injured mothers and children are taken in account…sometimes medicalization is best.’
“Elective c-section advocates say women aged 35+ years and having their first baby should be routinely offered. ‘The older someone is at first birth, the likelihood of just about every complication in the book goes up’ says Peter Dietz Uro, OB. He goes on to explain the higher risks when women get older and there is an acknowledged reality that women are having their first baby later in life compared to two generations “ago. He also goes on to say older women are more likely to risk an emergency c-section, associated with increased risks. He feels women aren’t being given information about the risks and cannot exercise ‘informed consent.’
“Jenn Hopper, founder of Action to Improve Maternity in NZ supports families whose baby has been injured by ‘poor birth care.’ She says: ‘We’re told over and over about the benefits of vaginal birth and the risks of caesareans and nothing of the opposite for both. I’ve yet to meet a family unnecessarily harmed by a caesarean but there are those who could have benefited from one.’
“Professor Neena Modi says, ‘How can we impose this really quite major change in the way babies are born and not study it scientifically?’”
There are a number of creative ways that the medical profession is looking at making an elective c-section as beneficial as possible. There are no suggestions coming from the midwifery community.
Statistics in 2014:
- 1 in 3 women have a ‘normal’ birth…a spontaneous delivery without interventions.
- 1 in 2 had at least one intervention…induction 24%..augmentation 26%..epidural 27%…episiotomy 15%
- 1 in 2 are obese
- 1 in 4 had a caesarean. More common 35 years and older.
- Almost half caesareans were elective.
- Average age 30-34 years old
- Midwives lead maternity caregivers for 85%
- 4% homebirth
‘…It might be that you have a birth plan and if all goes well…but it shouldn’t be a vaginal birth at all costs.’ Smallbridge
The way a vaginal delivery is managed can also dramatically lower the risks of long-term damage to the pelvic floor.
Annabel Farry says you can’t compare a caesarean with vaginal birth without considering the context and whether it was a fully informed decision.She is involved in international research looking at fear of childbirth prior to pregnancy. 90% of women intend to give birth vaginally but “if current trends continue, fewer than half of them will end up achieving that.” She’d rather see money spent on free-standing midwifery-led birthing units than non-medically necessary elective caesareans.
Sarah Ballard believes the progression of labour and the natural timing of birth may be far more important than many people think, involving an intricate interaction of maternal and fetal hormones that ensure both mother and baby are physically and psychologically ready.
Adrienne Priday works with clients where the community sees childbirth as normal and healthy.
Sue Belgrave says, “…most women who request a caesarean are motivated by the fear of losing control and uncertainty around the outcome of natural childbirth.”
The Listener
Ellie Wernham, and Diana Sarfati study: “…babies delivered by midwives are 55% more likely to have oxygen deprivation during delivery, have a 39% higher chance of neonatal encephalopathy (abnormal brain function associated with asphyxia at birth), and have a 48% higher incidence of low Apgar scores.” Study looked at 240,000 birth outcomes between 2008-2012 (91.5% of women under continuity of care midwife). Study acknowledged that there were “many positive aspects” of midwifery care, including patient satisfaction and lower interventions rates. She goes on to say, “…the midwifery philosophy has always focused on the normal and that care should be provided in a primary care setting..in order to really understand that something is normal, you have to have a good understanding of what is not normal.”
OB John Tait said “…although some people said ‘I told you so’ we have a safe maternity system.” Tait goes on to say that the system works well and that NZ cannot go back, but this really gives us a good opportunity to get some decent research done to see why this is happening. But his solution is very “end game” to look at who intervenes when there is a problem, rather than look at how ordinary women (like people with diabetes, heart problems and obesity) can reduce the need for more medical care. Tait says there are a lot of OBs involved now because we have a 30% c-section rate and 12% forceps.
College of Midwives thinks it’s a resourcing problem. Their approach is to sue the government for more money for continuity of care providers. District health boards say that’s not the issue. Some OBs think that GPs were excluded and shouldn’t have been.
Bev Lawton did a study looking at births between 2005-08 and 30% more babies were at risk under first year midwives. College of Midwives sued her and lost. She believes there’s a mismatch between midwifery training and the patient group (older first-time mothers).
Pelvin, who is a midwife and the Ministry of Health’s senior adviser for the Maternity System says “Our whole system is predicated on choice.”
Wernham says that she was always aware of the philosophical conflict between midwives and medicine. “I’ve always thought it was unfortunate. It’s important for both professions to keep in mind we are aiming for the same end goal, the best outcome for mothers and babies and the inter-professional conflict only gets in the way of that.”
The Spin-off, Are We OK, Mum? A Deep Dive into the State of Maternity Care in New Zealand
Author Jess Berentson-Shaw:
“A so-called ‘normal’ birth in New Zealand is what we call a ‘spontaneous vaginal delivery’ without medical interventions. These births have the least impact on women and the health system. So labour is not induced, goes OK (although frankly that feeble little word pain does not even get close to encapsulating the appalling trial by fire that is labour), with no epidural, and ends with an intact baby and mother, a nicely delivered placenta yada yada. Awesome.
“Guess how many women have this birth in New Zealand? Only about 34% (fewer for a first birth). Perhaps someone really needs to rethink the use of that word ‘normal’?
“There are four things the Ministry of Health can do right now:
- Pay for the above research (prospective study to determine if there are differences in care – the just-published study was retrospective, limited to hospital statistics) to be done, and done well.
- Compare the optimal models from the existing research on models of care with what we are delivering in NZ right now.
- Compare the care factors in births that went wrong and those that went right.
- Ask some hard questions about how system is arranged. Here are some for a start:
- Is the current payment system set up to create disincentives for optimal shared care?
- Are we putting the right amount of money and support in the right way into midwifery services?
- Are we putting the right amount into specialist provision?
- Are midwives getting the optimum training and support following training?
- Are OBs being trained in the context of how care is delivered in NZ? i.e. ‘shared care’ not ‘doctors are the boss’ care.
- Could we use GPs more effectively especially for those women who are harder to reach and at greater risk?
- What can be done to break down hierarchies, improve communications, and address the issues that exacerbate hierarchies?
- Most importantly what can be done to address the massive inequalities in outcomes between different women and babies?”
“The Takeaway Message for Parents
“Having a baby in NZ is safe no matter what model of care you choose, compared to other countries like us. The rate of perinatal death (babies dying before, during and after birth) has been on a steady decline for many years. Women dying in birth is such a rare event that it is hard to create statistics on it.
“But birth is not risk free and it is a massive life event; being mentally prepared and feeling supported is important. If you feel uncomfortable with the care you are getting then do not hesitate to change – it is your legal right. Continuity of care is important but that can also come from a support person, friend, mother, or relative that travels your journey with you. So draw on your support network if your maternity caregiver needs to change.
“The research tells us that midwifery care is just fine for babies, and obstetrician care just fine for women under optimum conditions. If you feel conditions are not optimal, then find someone who can advocate for you. Offer to be an advocate for those who cannot advocate for themselves. Demand better of the system. Demand that Government support all clinicians in the system to deliver optimal care and all women and babies to receive it.”
What is the Message in these articles?
From the North/South and Listener articles it’s clear that something isn’t working for any of the three stake-holders: OBs, midwives, and families. Are the three stakeholders satisfied?
There is more shame, blame, guilt, disappointment and anger about birth since I’ve been involved with birth for 45 years. In NZ the vast majority of women love their continuity of care midwife but loving a care provider and having “choice” is still leaving too many families feeling birth is less positive than they had hoped or even planned for. In a midwifery-led maternity system the c-section rate has continued to rise at the same level as obstetrical-led maternity systems globally. Fear of birth and lifetime damage to too many women’s bodies play a significant part in the increase of caesareans, more medically assisted births and less subjectively positive experiences.
There seems to be little curiosity or imagination as to how to change things around, as I’ve discovered since I arrived in the mid-1990s and the issues were beginning to rise at that time. As shown by midwife Andrea Vincent’s statistics*, implementing a skills-based approach alongside a choice-based approach adds a huge positive element to this most important event. Doing so requires a simple protocol that all midwives can implement that takes very little effort, without increased work for already overloaded midwives.
Midwives/OBs can tell all their clients they need birthing skills and direct them to various resources and make a monthly notation in their charts about which skills were learned and then refer to those notes during the birth and encourage families to use the skills they learned. **
What are birthing skills, anyway? A set of learned behaviors, based upon knowledge of your own unique pelvic shape, that helps you cope with pain, open your pelvis and birth canal, and deal effectively with most problems encountered in labor, thus assisting your baby’s efforts to be born. Such a set of skills both empowers the mother and her partner and facilitates a quicker, easier birth in most instances. Birthing skills greatly reduce the incidence of unexpected c-sections. They also make labour more engaging and interesting for the woman and her partner, armed with a variety of possible positions, breathing techniques, visualizations, and exercises to use in constructively solving difficulties due to pain, to position, and progress, that may arise.
Briefly, the North/South article points out the two reasons women/health providers seek elective c-sections: fear of birth, and damage to vaginal area. Both can be reduced or prevented entirely with birthing skills. There are a number of creative assessments/solutions offered in the article by the medical community, but no mention of “birthing skills,” the role and responsibility of parents within the acknowledged “partnership” model. The midwifery profession is offering no solutions at the current time.
There is ample evidence that skilled women who take more responsibility for the health and wellbeing of themselves and their babies, and have a behavioral option in response to fear of birth and skills that can reduce or prevent many of the common problems that lead to more interventions, experience a more empowered birth and a more positive subjective assessment of labour. Whether a birth is “normal” –meaning easy, straightforward, with a good outcome – or “not normal” – requiring various medical interventions – with skills, more women can achieve “normal” births and the challenging births become empowered.
Can preparing our body for birth reduce or prevent damage to the soft tissue of our vagina? Of course, that makes common sense, really. Can learning to create space in our pelvis help some babies to move down, through and out more easily? Of course.
Can learning and using birth and birth-coaching skills help women and their partners cope, manage, deal with, work through, stay on top of, and in control of labour pains EVEN if they are afraid and hate it? Absolutely.
The Listener is about a study that shows poorer outcomes under midwifery care and rates “delivery of service” – whether GPs, midwives or OBs are best. No maternity care provider has any expectation of families beyond their expressed “choices.” How can this be?
Why is there no imagination or curiosity about what families can do to help themselves? People with obesity, diabetes and heart problems are now expected to help take care of themselves and not just rely on the “delivery of service.” There are public service messages everywhere about this. Not everyone follows it, and not every family will become skilled in birth, but many will. And, granted, birth is a one-off event, after pregnancy, within one year, and it is definitely not a disease requiring self-management over many years, if not a lifetime. However, birthing skills do have application beyond labor, throughout life,
*See Appendix, pp. 31-33, **See Appendix, pp2 29-30.
whenever pain is encountered. The communication skills developed between a woman and her partner foster deeper intimacy and trust, strengthening their relationship to the benefit of themselves and their children.
Childbirth outcomes can so easily change. The unique Partnership Model within the Midwifery Model of Care in NZ is uniquely placed to grow a skilled birthing population alongside women’s choices being respected. The present choice-based system has left too many midwives overwhelmed, exhausted and disheartened, and too many women feeling shame, blame, and guilt. The collective of women will not come to this realization on their own. There will be no movement of women seeking to become skilled. This must be midwifery-led. And they must do it for the survival of their own profession and for the benefit of families.
If we have a societal expectation, promoted by a united midwifery community, that learning, practicing, and using skills are part of pregnancy, birth preparation and the activity of giving birth, then we will have as many families skilled in birthing as can practice skills, get a license and drive a car. Skills and choice will be coupled: choices will be the preferences for one’s birth, while skills will be the actions and behaviors used in giving birth, to actualize one’s preferences.