Caroline Flint offers us a healthy dose of her characteristic wit and wisdom in this inspiring article. She shares her reasons for feeling optimistic about birth and the opportunities that midwives and women can grasp even during the COVID-19 crisis.
After years and years of despair, decades of seeing maternity services being made less and less suitable for women, more and more caesareans, more and more postpartum haemorrhages, ever escalating post-traumatic stress disorder following childbirth in men, women and midwives, I am beginning to feel more optimistic. “Why?” You might ask. What has changed?
A Feeling of Optimism
Actually nothing ostensibly, it is just swirls of threads of conversations, articles in the newspaper, blogs, research and a general feeling.
It is not only old midwives like me who are dismayed with how childbirth is going. The Royal College of Obstetricians and Gynaecologists say that many doctors are feeling “burnt out”. They are worried about the state of Britain’s Obstetricians. In a problem almost entirely of their own making I might add.
Here is a lovely sounding Obstetrician called Nathan Riley MD:
“Today is my last day as an Obstetrician […] My disillusionment stems from the realization that the hospital treats the entire life cycle – the same process that I found magical back in medical school – as pathology, and as a result, it has been stripped of humanity […] Deep down, we know that more medicine doesn’t help most birth. Most birth happens whether or not I’m there to ‘deliver’ the baby, and our collective OB/GYN gestalt tells us that the more we do, the worse the outcome.”
On My Departure From Hospital-Based Birth: A Reflection
Nathan Riley MD
Tragedies and Investigations
Then there are the tragedies – and so many of them. Hard working and committed midwives and doctors found wanting after the deaths of women and babies in childbirth. East Kent (26 baby deaths being investigated), Shropshire/Shrewsbury (1,170 maternity cases being investigated), Morecombe Bay (11 baby deaths and 1 maternal death being investigated), Romford (5 maternal deaths being investigated) – you name it, it sounds like a list of First World War battles – beautiful young people – all doomed.
What is going on?
What is the official answer to this list of ghastliness? Always the same response – more monitoring! More guidelines. More supervision of already over supervised staff. More inhumanity – more, more, more! It has to stop, unevaluated practices being used to try and repair a glaring wrong.
In the Times 13/03/2020 the Care Quality Commission is quoted as saying “Maternity services stand out as one of the core services we inspect that is not making improvements in safety fast enough” They specifically refer to “poor working relationships between obstetricians, midwives and neonatologists posing a barrier to safe care”. Perhaps it is because they are asking midwives and the maternity services to do things which are impossible and ridiculous.
Perhaps it is time to go back to basics.
Women are mammals
As a species, mammals are exceptionally good at protecting their unborn babies. They don’t spray eggs on a passing rock in the hope that some wandering male will fertilise them, they don’t lay eggs and then abandon them in the hope that they will flourish. As do all mammals, we nurture our unborn babies inside our own bodies. When the time comes for that little mammal to emerge, our bodies undergo intense hormonal changes and everything relevant to the birth becomes softer, stretchier and more able to accommodate the baby’s passage through.
When labour starts (and we still don’t know exactly what triggers it off), the human body, like all other mammals, undergoes a hormonal bombardment, which is followed by physical changes enabling the baby to emerge safely and healthily.
So if so much catastrophe is happening to labouring women in hospital, maybe, just maybe, hospital is not the right place for a mammal to be in labour. We know by observing other mammals that they need privacy and usually darkness, being overlooked stops the labour and compromises it.
In the Times 14/03/2020 Nigel Farndale describes cows in labour being overseen by CCTV “The heavily pregnant cows look more relaxed than they do with a farmer loitering around waiting for them to get on with it. They find a quiet corner and if they get stuck, help is soon at hand.”
If we can afford this dignity to cows, surely we can afford it to women. Mammals cannot progress properly in labour in a public space.
If all women began by labouring at home, able to contact a midwife they had built a relationship with, many women would continue there. Labour pain is more easily managed at home but if it was too much the woman and her midwife could transfer to hospital when and if necessary. Many labours are only a few hours in length – what is the point of getting dressed, getting a cab, moving to an alien and inhospitable environment which most likely puts you out of labour when you can stay at home with your trusted midwife and give birth there? In private, no nasty bugs, no bright lights, no bossing about, no interference without consent. Much safer and much more comfortable.
And now, in that illustrious medical journal The Lancet April 2020, a meta-analysis of half a million women booked to give birth at home. Despite actual place of birth, having booked initially to give birth at home there were enormous benefits. The outcomes for the health of mothers and babies was the same whether the women were booked for home or hospital birth but there were big differences with other outcomes.
When women were booked for a home birth (regardless of where they actually gave birth):
- 40% less needed a caesarean section
- 50% were less likely to have an instrumental delivery
- 55% were less likely to have an episiotomy
- 40% were less likely to have a 3rd or 4th degree tear
- 75% were less likely to have an infection
Somebody who cares about finances, much less women’s health, must eventually recognise that these outcomes are much more cost-effective.
#MeToo in the Birth Room
The other reason I am feeling optimistic is #MeToo. #MeToo is the recognition of inappropriate sexual behaviour towards (usually) women. #MeToo happens a lot in hospital obstetrics but it isn’t usually identified as such because it is done in hospital by health professionals, to be fair the motive is not usually sexual but it can leave women feeling invaded and violated during a time of high stress and the process needs to be examined because a lot of it is inappropriate and cannot be justified.
What is this obsession with inserting things up a woman’s jacksie in labour?
A usually very, very private place. Inserting things into the vagina goes against the flow of labour – which is to allow things to come out of it. If it isn’t fingers then it’s amnihooks, if not them then it’s probes or monitoring equipment.
In hospital fingers are put up women’s vaginas every two hours, or every four hours, or even every hour. Why? Once labour has started it progresses. Sometimes it progresses slowly, sometimes very quickly, but whatever, IT DOESN’T MATTER. If labour lasts 24 or 48 hours, fair enough, it is tiring and women get fed up, but it really isn’t relevant to the safety of the baby. There is no research which shows that a long labour is detrimental to the baby or even to the woman. In long slow labours women doze between contractions and as long as they are kept hydrated and fed, they manage well. Most women would probably have chosen to have a shorter labour but this is not a choice available to them.
And now coronavirus – well even that is for me a source of hope. The last place that any sensible person will go to at this fraught time is hospital. Women and doctors and midwives will all realise that the place for women to be is at home. Labour will then become less fraught, less interfered with, less painful and traumatic. The Albany statistics of a Midwifery Practice which practised in Peckham from 1997 – 2009 serving a very deprived community, 57% from Black, Asian and Ethnic Minority communities. 79.8% of women gave birth unaided, only 16% had caesarean sections and 43.5% gave birth at home. Their outcomes were magnificent. Women were encouraged not to plan for where they would give birth but to decide at the time when they were in labour by which time they could see what the labour was like. Such a successful model which NHS England is trying to roll out at this moment.
Homebirth is the Safest Option
Childbirth is the most researched area of medicine – all research shows that home birth is the safest option for most women. The obstetric and neonatal lobbies need to be ignored in favour of proper scientific research and women’s interests. It is too important to be left to professional vested interests and rivalry, women must be respected and given truthful information – giving birth at home is the safest option.
Caroline Flint has been a midwife for 40 years and an NCT Teacher for 47 years. She is the author of 6 books – the first being “Sensitive Midwifery” and the most recent “Do Birth – a Gentle Guide to Pregnancy and Childbirth” which has just been reprinted. Caroline has been an ARM member since 1976. She lives in London with her husband of 56 years.
First published in Midwifery Matters Summer 2020