The birth wars
From Griffith REVIEW Edition 22: MoneySexPower
© Copyright Griffith University & the author.
Written by Mary-Rose MacColl
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Before chloroform was discovered in the mid-nineteenth century, women had no relief in childbirth. They died during forceps and caesarean deliveries; they died from pain. The uptake of chloroform was slow through the later nineteenth century. At times the debate turned not, as you might imagine, on the possible side-effects on mother or baby, but on the extent to which God would be denied the screams of women in childbirth needed to fulfil the curse of Eve.
If you are a woman having a baby in Australia in 2008, you can be fairly confident you will not be offered chloroform because it will harm your baby. But you will be offered mythology, mythology in spades, from one side of the birth wars or the other, whether it harms your baby or not.
The modern profession of midwifery is steeped in an ‘organic' mythology of pregnancy and birth. Midwives will tell you that birth is mostly normal and natural and that you are being forced to accept interventions that harm you and your baby. The profession of obstetrics has always been steeped in a medical ‘mechanic' mythology. Obstetricians will tell you that you need specialist medical care and sophisticated technology in order to ensure that you and your baby will be safe in what can be a high-risk event.
When I accepted a job to write up a review of maternity services in Queensland a few years ago, I knew nothing about the birth wars. I thought I had few preconceptions about maternity care, although, as I learned, when it comes to childbirth everyone has beliefs and preconceptions, however deeply they are hidden. I am not a health care professional or medical researcher. I am a writer, the daughter of two journalists who fostered in me a decided scepticism when it comes to any issue. I have done many corporate reviews. I am a mother.
When I started on the review, the sceptic in me trusted no one, not the most vocal protest groups, the College of Midwives and Maternity Coalition, wanting community midwifery and homebirth, which obstetricians say is unsafe, and not the College of Obstetricians either, promoting the need for safety as a standard rejoinder to concerns about increasing intervention in labour and caesarean births. We started working on an issues paper. Striving for objectivity, I wrote in the first draft that while birth was safe in Australia, the needs of women and families were not being met and the caesarean rate was increasing. I didn't think twice about saying birth was safe. Surely you only had to look at the statistics. Our record is enviable in Australia, with newborn baby and maternal deaths as rare as they are in any country that has a good hospital medical system.
The midwives disagreed. Birth was not safe, they said. Women were being injured by unnecessary caesarean surgery, interfered with through other forms of intervention and monitoring of their pregnancies and labours, and frightened into complying with the will of doctors. In the Netherlands, where babies were born at home, baby and mother death rates were just as low, and caesarean rates were a quarter of those in Australia. It wasn't the hospital medical system that saved mothers and babies. It was improvements in public health and sanitation. When I took out the word safe, the obstetricians said that safety, by any measure you'd like to name, was of a high standard in Australia, because of obstetrics, and that we were growing complacent because we'd forgotten what it was like to lose mothers and babies during childbirth. ‘Do we want to go back there?' they asked. ‘Then have your babies at home.' I changed the words many times to accommodate the two groups.
They have never been friends, these two selfless professions whose members get out of bed at all hours of the night to go to women in labour. As little as a century ago, midwives ran the table of pregnancy and birth care. It was a midwife who told me that the term ‘obstetrician' comes from the Latin obstare, meaning ‘to stand in the way', while ‘midwife' comes from the Middle English midwaif, meaning ‘to be with'. Obstetricians wrestled control of pregnancy and birth care from the midwives in the first half of the last century but now the midwives are fighting back. The training in medicine and midwifery reflects a growing schism in philosophies of care. While there are ‘organic' obstetricians and ‘mechanic' midwives and some from both professions who fall somewhere in between, the two philosophies do not currently co-exist to inform the care that's offered to women and families. Increasingly, midwifery is separating itself from the profession of nursing and its medical base, with new direct-entry courses for which nursing is not a prerequisite. According to the College of Midwives, midwives trained in these courses are ready to provide care for women in low-risk pregnancy and birth.
Members of the two professions fire shots at one another in the media, at clinical care conferences, over individual patients. In Queensland, an obstetrician called a midwife-led birth centre the ‘killing fields'. The president of the Queensland Branch of the College of Midwives fired back claims of unprofessional conduct against the obstetrician. Midwives are recreated as witches and demons and obstetricians are maligned for their ‘golf-driven' caesareans. None of this helps.
Women in Australia have no real choice when it comes to maternity care. They can go to a public hospital run by hospital obstetricians, where midwives do what they're told or operate an underground resistance movement – ‘He can't make you have an induction, you know,' a midwife might whisper when the obstetrician is out of the room – or they can go to a private obstetrician and give birth in their obstetrician's hospital, where midwives mostly work as obstetric nurses and have no voice. If women don't have private health insurance or if they don't live in a city, they may not even be able to choose between these options. Whatever the choice, once a woman enters the hospital system, she and her family have little power to make decisions about what happens to them.
When Teresa, a medical specialist, was pregnant with her first baby, she chose public care in the hospital where she worked. ‘I did some research,' she said. ‘I didn't want Syntocinin [the synthetic hormone used to start or speed up labour] because the data show that you're more likely to need an epidural and if you need an epidural, you're more likely to wind up with a caesarean. I didn't want any of that ... But once you're in there, they just take over. There was no way I could have resisted that system. I wound up on a Synto drip because labour wasn't going fast enough. It was okay in the end, but later I wondered what it must be like for women who aren't even part of the system.'
The alternatives to private or public hospital care – birth centre and homebirth care with a midwife – are only taken up by 2 per cent of the 270,000 women who have babies in Australia each year. They are dogged by concerns about safety and there is as yet insufficient evidence to know whether these concerns are well-founded.