Reclaiming every woman’s birth right Excerpted from Gentle Birth, Gentle Mothering: The Best Articles on Gentle Choices in Pregnancy, Birth and Parenting by Dr Sarah J Buckley, (One Moon Press, 2005) Birth is a women’s issue, birth is a power issue; therefore birth is a feminist issue. My logic may be correct, but the issue of birth has been at the bottom of the feminist agenda in western countries for some years, well behind matters such as equal opportunity, sexual harassment, bedroom politics, abortion, and body image to name but a few. Feminism has championed many other women’s health issues and resisted the medicalisation of menopause, the other major rite of passage in our culture; however, there seems to have been no equivalent analysis of birth. Yet most women in our culture will give birth at some time in their lives, and for the majority it is their first experience as a hospital patient, with the loss of autonomy implied in that role. Many will feel the conflict between their own desires, needs, and ways of knowing, and the technology-does-it-better approach that the medicalisation of birth has produced. This medical approach, which I believe reflects our culture’s infatuation with technology in general, has not benefited birthing women. Australia has one of the highest rates of operative birth (caesarean, forceps or vacuum delivery) in the world; in 2002, 37.8 per cent of birthing women experienced an operative delivery.1 In the US in 2002, 32 per cent – around one in three – women gave birth by operative delivery,2 and this figure was almost identical (33 per cent) in the UK3 and in Canada (34.9 per cent)4 in 2002–3. In Queensland, Australia, caesarean section rates in private hospitals (which serve around one-third of birthing women) are approaching 50 per cent,5 compared to World Health Organization recommendations of 10–15 per cent.6 Even women who have a so-called normal birth are experiencing significant interventions. One study of first-time mothers in Melbourne in 1997 found that only nine women out of 242 gave birth without any medical procedures during labour and delivery.7 In the US, according to the authors of the 2002 Listening to Mothers survey, “…there were virtually no ‘natural childbirths’ among the mothers we surveyed. Even mothers having a vaginal birth experienced a wide array of medical interventions…”8 And all of this is happening in an extremely healthy population, where some estimate that at least 70 to 80 per cent of women should be giving birth without intervention. As a family physician and a mother, I ask myself why women are tolerating this situation. Why are educated, articulate women, who are prepared to battle for their rights in their personal and professional lives, so accepting of the high intervention rates that characterise this group in particular? Why we are not at least advocating for ourselves and our babies at a time when science is discovering what mothers have known for years: that a newborn baby is a highly sentient being, exquisitely sensitive to its emotional and physical environment, and that a baby’s experiences during labour and birth – for example exposure to some drugs – can have life-long consequences?9 Perhaps there is a perception among women that there has been improvement. After all, there are now birth centres in many countries; even though they are politically precarious in almost every setting, demand for public birth centres can outstrip supply by more than 7 to 1,10 and up to two-thirds of women using a birth centre may be transferred to a labour ward before the birth.11 Labour wards are looking more comfortable and homely, with fathers’ presence being allowed – even expected – during labour and birth. However, cosmetic changes do not guarantee a low-technology philosophy and the fathers’ presence at birth may be a mixed blessing. Some men may be disturbed and frightened by seeing their partners in the endorphin-altered state that is natural for a labouring woman, and is due to high levels of these naturally produced pain-killing chemicals. It has even been suggested that the increased use of epidurals for pain relief parallels the advent of men into the labour room, reflecting a subtle pressure on women to behave more ‘normally’ in labour. Perhaps the lack of birth activism also reflects our small families and our busy working lives, which give each of us less motivation to lobby for improvements. A bad birth experience can be forgotten in the intensity of the early months, and then we go back to our careers where we feel safe and life is more predictable. Yet I feel that there is an enormous amount of disappointment and hurt among mothers around giving birth. As a pregnant woman I noticed that other women told me overwhelmingly negative stories about their own birth experiences. I wonder, too, about depression after birth, which affects up to one in five women, and which Australian researchers have linked to forceps and caesarean births,12 and early separation of mother and baby.13 However, I am not advocating one particular type of good birth, nor even birth without intervention. A woman’s satisfaction with her birth experience is related more to her involvement in decision-making than to the outcome.14 But women need all the information to make informed decisions, and this requires that doctors and midwives take time to listen and explain, and that women and their partners take their share of responsibility. This informed choice approach to birth is a prescription for lower rates of litigation, which at present are frightening obstetricians into defensive and often interventionist practices, benefiting neither doctors nor women. This approach also implies that parents can be trusted to make good decisions, and is a radical departure from the paternalistic attitude that has been prevalent in obstetrics. It is welcome, too, because many current obstetric practices are not supported by evidence of effectiveness or cost–benefit. For example, an evidence-based analysis, based on the best of international research, shows that models of care that prioritise women’s choices such as home birth and midwife-only care are as safe as conventional obstetric care, while offering high rates of satisfaction.15 16 Consumers now have access to evidence-based information through the work of the UK-based Cochrane Pregnancy and Childbirth Group. This group produces the regularly updated book A Guide to Effective Care in Pregnancy and Childbirth17, and their information is available on the Cochrane Library website,18 which is freely accessible in many countries. Both resources provide an excellent base from which to assess choices in birth anywhere in the world. Perhaps the most exciting aspect of evidence-based obstetric care is the possibility for institutional change that it implies. Murray Enkin, one of the authors of A Guide to Effective Care in Pregnancy and Childbirth, states: The only justification for practices that restrict a woman’s autonomy, her freedom of choice, or her access to her baby, would be clear evidence that these restrictive practices do more good than harm.19 If all involved in birth were to take these premises seriously, profound changes would take place in the birth room. Birth is women’s business; it is the business of our bodies. And our bodies are indeed wondrous, from our monthly cycles to the awesome power inherent in the act of giving birth. Yet in our culture I do not see respect for these extraordinary functions: instead we diet, exercise, abuse, conceal, and generally punish our bodies for not approximating an unrealistic and unobtainable ideal. This lack of trust and care for our bodies can rob us of confidence in giving birth. Conversely, an experience of the phenomenal potential of our birthing bodies can give us an enduring sense of our own power as women. Birth is the beginning of life, the beginning of mothering, and of fathering too. We all deserve a good beginning. A previous version of this article was published in The Age (Melbourne), 29 Nov 1996. This version updated March 2005. References 1. Laws P, Sullivan E. Australia’s mothers and babies 2002. Sydney: AIHW National Perinatal Statistics Unit, 2004. 2. Martin J, et al. Births: Final data for 2002. National vital statistics reports. Hyattsville MD: National Center for Health Statistics, 2003. 3. Department of Health. Statistical bulletin: NHS maternity statistics, England: 2002–3. London: DoH, 2004. 4. Canadian Institute for Health Information. Giving Birth in Canada. Ontario: CIHA, 2004. 5. Queensland Health. Perinatal data collection quarterly report, Anonymous Private Hospital, Jan to March 02. Brisbane: Queensland Health, 2001. 6. World Health Organization. Appropriate technology for birth. Lancet 1985;2(8452):436–7. 7. Fisher J, et al. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust N Z J Psychiatry 1997;31(5):728–38. 8. Declercq E, et al. Listening to Mothers: Report of the First U.S. National Survey of Women’s Childbearing Experiences. Executive Summary and Recommendations. New York: Maternity Center Association, October 2002, p 4. 9. Jacobson B, et al. Opiate addiction in adult offspring through possible imprinting after obstetric treatment. Br Med J 1990;301(6760):1067–70. 10. Health Department Victoria. Having a Baby in Victoria: Final Report of the Ministerial Review of Birthing Services in Victoria. Melbourne: Health Department Victoria, 1990. 11. Hodnett ED, et al. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005(1):CD000012. 12. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Aust 1992;157(3):172–4. 13. Rowe-Murray HJ, Fisher JR. Operative intervention in delivery is associated with compromised early mother–infant interaction. Br J Obstet Gynaecol 2001;108(10):1068–75. 14. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynaecol 2002;186(5 Suppl Nature):S160–72. 15. Waldenstrom U, Turnbull D. A systematic review comparing continuity of midwifery care with standard maternity services. Br J Obstet Gynaecol 1998;105(11):1160–70. 16. Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database Syst Rev 2000(2):CD000352. 17. Enkin M, et al. Effective Care in Pregnancy and Childbirth. 3rd ed. Oxford: Oxford University Press, 2000. 18. Cochrane Collaborative. The Cochrane Library: John Wiley, 2005 19. Enkin M, et al. Effective Care in Pregnancy and Childbirth. 3rd ed. Oxford: Oxford University Press, 2000, p 486.