The birth wars

by Mary-Rose MacColl

BEFORE CHLOROFORM WAS 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.

 

MATERNITY CARE NOW is no entrenched in the hospital medical system it is hard to believe that pregnancy was ever regarded as anything other than a medical condition that requires a hospital and a doctor. But until the early decades of the twentieth century, women mostly birthed at home or in small nursing homes. They were cared for by experienced but untrained midwives, and sometimes – or if things went wrong – by doctors. Many babies were born. Statistics from the time are unreliable, particularly around cause of death, but death rates among both mothers and babies were much higher than they are now.

My grandmother Meta was born in 1898 in her parents' bed on her family's farm in rural Queensland with help from the midwife, Mrs Fryer, who was a well-known figure in the local community. Mrs Fryer attended all seven of my great-grandmother's confinements and the sound of her horse and sulky – there were particular bells attached to the horse's bridle – signalled that someone's ‘time' had come and a new baby was coming to my grandmother's community.

Mrs Fryer was never formally trained, although she attended hundreds of births. She called in the local doctor when there were complications. If he wasn't available, she did the best she could. My great-grandmother's births were uncomplicated, although I believe she miscarried one baby. Mrs Fryer encouraged women to walk around to deal with pain. She used back massage. She made my great-grandmother rest for a week after each birth. All the babies were breastfed. Mrs Fryer stayed on for a few days after each baby. My grandmother remembered her hair being brushed by Mrs Fryer before school in the morning following the birth of a younger brother.

My mother Rosemary was born in 1932, in a small hospital on Wickham Terrace in Brisbane, run by Matron Crotty and Nurse Kelleher. For her four births, my grandmother was attended by a doctor. She had a late miscarriage between my mother and my mother's younger brother, who was born at home in Fortitude Valley, with Nurse Kelleher and the doctor who was a friend of my grandfather. No one in my mother's family remembers my grandmother ever saying anything at all about her experience of childbirth, except that when my youngest uncle was born, his older brother, on hearing his mother call out in pain, tried to get into the room and was told by his father, a doctor himself, ‘You can't go in there boy.'

I was born in 1961 at the Royal Women's Hospital in Brisbane where my two older brothers had been born. My younger brother was born in a little private hospital in suburban Corinda. ‘You went to whichever hospital the doctor told you to,' my mother said. She never contemplated an alternative, and at any rate, by then there were no alternatives to contemplate.

 

DURING THE 1920s, Australian governments, driven by an imperative to populate or perish, set goals to reduce newborn baby and maternal death rates and to increase the birth rate. The Commonwealth offered its first baby bonus, five pounds for every live-born child. State governments established and funded maternity hospitals staffed by doctors who were assisted by midwives trained in the hospital system. In the 1930s, medical intervention was a subject of inquiry, primarily because while hospitals and doctors had all but taken over childbirth, there had not been the expected reductions in mother and baby deaths. Initially death rates increased. Medical historian Irvine Loudon, who has written extensively on death in childbirth, believes this was because more babies were injured when untrained and inexperienced doctors used forceps. Some doctors reported using forceps in 80 per cent of their deliveries. There were also more infections for mothers, because operating doctors were slower to take up the principles of asepsis in obstetrics than in other areas of health care. The data bear this out, with steady increases in deaths of mothers Australia wide in the 1920s and 1930s, corresponding with the move of birth from homes and nursing homes to hospitals.

In the late 1930s and 1940s, obstetrics found its place in medical curricula. Training for doctors improved in the mechanics of intervention in birth. As doctors took over responsibility for the management of birth, hospital-trained midwives took on the role of obstetric nurse, responsible to a doctor. The midwifery profession was regulated as part of nursing so that experienced but untrained midwives could no longer practise. Births almost always took place in a hospital.

By the 1950s, when all those Boomers were being born, hospital care was run like the army. A woman was given an enema and pubic shave on arrival at the hospital. For second-stage labour, she was strapped to a narrow delivery bed where a doctor administered chloroform or ether. Forceps and episiotomies were common. She woke up alone some time later to find it was all over, her baby separated from her and cared for in the nursery by the midwives. Obstetric epidemiologist James King writes of the beginning of his training in Australia during this period, ‘I can remember watching in horror as women's wrists were strapped to the side of the metal delivery frame, so that "the patient would not contaminate the sterile field", prior to an operative vaginal delivery, which we were summoned to observe. Forceps rotations and other manipulations were the hallmark of the skilful obstetrician, the highest compliment for whom was "he is great with his hands".'

In the 1960s, when my mother was having her babies, clinicians in Europe and the United States – mostly men – were starting to see that something was lost when pregnancy and birth moved from homes to hospitals. They put it down to a woman's state of mind during childbirth. They suggested a woman should feel relaxed to give birth and that they could aid this. There was Fernand Lamaze, who believed in pain-free childbirth through breathing; Grantly Dick Read, who believed in pain-free childbirth without fear; and Frederic Leboyer, who believed in pain-free childbirth in water.

The European writers on childbirth were followed in Australia by women, at first physiotherapists and then obstetricians. They may not have believed in pain-free childbirth, but they could see that something wasn't right. Childbirth education became part of pregnancy care. Slowly, women themselves began demanding changes. The consumer-led Childbirth Education Association began to run courses and meetings for pregnant women. Over time, with community pressure and better scientific evidence, some unhelpful or harmful practices – chloroform, pubic shaving, enemas, the routine separation of newborn babies from their mothers – were discontinued. Hospitals began to allow partners to attend the birth of their child. More recently, some have remodelled their maternity units to look more like home environments, hiding oxygen and the other accoutrements of a high-tech hospital behind light fittings and innocuous prints on pink walls. Some people see this as revolution. I am not among them.

The review of maternity services I worked on received hundreds of submissions from women who had had the most appalling experiences of contemporary maternity care. Women had been abused or bullied by obstetricians because they did or didn't want a particular kind of pain relief during labour. One woman had an episiotomy a midwife described as a ‘hindquarter resection' because the obstetrician was in a bad mood about the woman's birth plan. In some hospitals, women had their babies taken from them and placed in nurseries as a matter of routine. Babies were fed formula when women had made it clear that they wanted to breastfeed. Other women were treated like pariahs by midwives because they weren't breastfeeding. Women were punished and abused and neglected by doctors and by midwives just because they wanted something their carers didn't like – to hold their babies straight after birth, to bury their placenta under a full moon, to save their cord blood. The hardest submissions to read were from the women who'd had babies who had died. In most hospitals, they were cared for in the maternity ward. They heard babies cry all night, watched new mothers breastfeed. They had to explain over and over again to newly rostered staff that yes, they'd already had a baby, a boy or girl, but their baby had died. When I asked the midwives in one hospital why these women couldn't be cared for in another part of the hospital, they said, ‘They've had a baby. They have to be in a ward where there are midwives not nurses.'

‘Couldn't the midwives go to them?'

‘I suppose so, but that's not very practical.'

 

DEATHS AMONG MOTHERS are now so rare it seems impossible to believe that a little less than a century ago, when births first moved into hospitals and doctors took over maternity care, seven hundred Australian women died every year because of something that happened to them during pregnancy or birth, leaving two thousand children motherless. Deaths among babies have continued to decrease, although critics of contemporary obstetrics, of whom there are many, say initial reductions were because of improvements in public health and more recent reductions are because of newborn baby care rather than obstetrics, which seems singularly unable to do anything but meddle.

Although death rates among babies have continued to decrease across the population, death rates among babies of Aboriginal and Torres Strait Islander women remain more than twice as high as those among babies of non-Indigenous women. This is the case whether the babies are born in remote areas or in cities with access to advanced medical care. This bald fact floored me when I first heard it and I remember I had to ask the researcher to repeat it, to show me the data, to explain what it meant. It means you have more than twice the likelihood of dying at the start of your life just because you are born into one part of the community and not another.

 

BIRTH IN HOSPITAL – where 98 percent of babies are born in Australia – remains a medically managed process. Prints on walls and husbands in the delivery room pay little more than lip service to the notion that women and families might have a voice in deciding what happens to them. And while medicine is now an evidence-based profession, many of the practices in place in maternity hospitals were determined long before evidence-based medicine existed. Most maternity care runs along lines determined by what was a largely male obstetric profession in the first half of the twentieth century, relying on clinical experience – doing more of what worked and less of what didn't – rather than scientific evidence or family needs. Feminism, which has freed women in so many ways, has hardly touched maternity care.

While some of the changes to maternity care have been in response to demands by women for different births, others relate to improvements in technology. If post-war birth was managed like the army, twenty-first century birth may favour technocracy. Electronic foetal monitoring, the use of artificial hormones to start or stimulate labour, epidural anaesthetic and caesarean births – now preferred over forceps – all result from technological changes. Some of these crept into clinical practice without evidence as to their efficacy and evidence is now showing that some of them do more harm than good.

Anthropologist Brigitte Jordan is interested in how knowledge gains authority in various settings. Jordan observed a contemporary hospital birth in which a labouring woman was desperate to push. The nurse looked not at the woman but at the foetal monitor. She was waiting for the doctor who was the only one who could decide whether the woman was ready to push: ‘... every time the woman tries to get her desire – her expressed knowledge about the state of her body – acknowledged and made the basis for proceeding with the birth, her version of reality is overridden, is ignored, is denied, or, most frequently, is sidetracked, deflected, and replaced with some other definition of reality ... as might happen to an obstinate child whose parent opts for distraction rather than confrontation'. In the contemporary birth environment, according to Jordan, authority rests with the doctor and the knowledge delivered by technology. The woman's expressed knowledge about her body does not even rate as knowledge.

Evidence-based medicine has brought important changes to most areas of health care. Put simply, it means care is based on the best available scientific evidence. It may surprise you (as it did me) to learn that until relatively recently – as late as the 1970s for obstetrics – clinicians did not base their clinical care on scientific evidence. Rather, they looked to clinical experience and their senior clinical peers to work out how things should be done. And while medical courses now are firmly entrenched in evidence-based medicine, as recently as 1998 a study of obstetrician opinion revealed that clinicians were still more likely to rely on senior colleagues for guidance than on systematic reviews of evidence.

The overall caesarean rate topped 30 per cent of all births in Australia in 2005 – over 40 per cent in the growing private sector – making Australia's the fifth highest rate of caesarean birth in the Organisation for Economic and Cooperative Development, increasing faster than any other OECD country. Canberra obstetrician David Ellwood says that if increases continue at the current rate, we will soon reach a tipping point. ‘We could be close to 40 per cent by 2010,' he said. ‘From there, things will accelerate quickly. Before we know it, vaginal birth will have become that quirky old thing our species used to do. Once we have lost the skills, we will never be able to go back.'

Until recently, concerns about caesarean rates were framed in the media as little more than propaganda from the organic side of the birth wars. But now several large new studies in other countries are showing a higher death rate among both mothers and babies following caesarean birth. These studies take account of pregnancy risk factors. You might expect death rates to be higher in high-risk pregnancy, but the studies also found that even in low-risk pregnancy, death rates among mothers and babies after caesarean birth are two to three times higher than those after vaginal birth. The risks are still very small in absolute terms but the difference is concerning. Moreover, caesareans beget caesareans – if a woman has a first baby by caesarean, she almost certainly will be advised to have subsequent babies by caesarean. Even though there is now good evidence that caesareans do more harm in low-risk birth, it will be hard for the evidence-based profession of obstetrics to halt the juggernaut it has helped to create.

Postnatal depression now affects one in seven new mothers. A 2007 Australian study reported that suicide is the leading cause of death among mothers in a baby's first year of life. Post-traumatic stress disorder is being named as a post-birth complication. It may be years before evidence connects these trends to pregnancy and birth care but I have a hunch the connection is there, just waiting for someone to ask the right research question.

 

IN THE 1970s, French obstitrician Michel Odent established a three-way partnership among doctors, midwives and women at Pithiviers Hospital outside Paris. Odent and his partners worked together to provide safe care that also respected women and their families. The organics and the mechanics of birth co-existed. Women came from all over Europe to have their babies at Pithiviers. Odent's book, The Farmer and the Obstetrician (Free Association Books, 2002), compares the industrialisation of birth to the industrialisation of agriculture. He says both have damaged society, but childbirth hasn't yet experienced anything on the scale of mad cow disease or foot and mouth, which might bring about a revolution in practice.

Odent brings together research from many disparate disciplines and makes intuitive leaps. He suggests most contemporary hospital environments have no appreciation of the physiology of birth and the bodily needs of a birthing woman who is, at her core, a mammal; no appreciation of the child whose project is love as well as survival. He objects to the routine use of Syntocinin and other artificial hormones that mirror oxytocin, which he says is one of the hormones of love. He says interfering with birth hormones interferes with love. He believes those first few hours and days between mother and child are critical.

Odent says that when he wants to know how safe he will be in a city in the world, he looks at the birth practices there. He says crimes of violence will be high in places where birth and its natural rhythms are not respected. In some warring African cultures, women are forbidden to look into the eyes of their newborn babies for several days. Odent believes these cultures know why they do this, to make their babies grow into warriors, not human beings.

According to Odent, bright lights, foetal monitors, interventions and noise will engender release of the hormone adrenalin that can slow or stop labour. This is of key importance when failure to progress in labour is the most common reason for caesareans among first-time mothers. Odent tells the story of a caesarean he performed early in his career which saved a child's life. The midwife looked at him afterwards and said, ‘Oh Doctor, what a marvellous rescue operation'. This is what caesareans are, he says, but they are for rescue, not routine.

 

WE CANNOT GO back to birth on my grandmother's farm with Mrs Fryer because Mrs Fryer is gone. But right now, there is no clear way forward for maternity care in Australia either. Hospital care is not meeting the needs of women and their families and doctors are powerful. Every time changes to maternity care are suggested, the College of Obstetricians raises the spectre of safety and ends all debate. The alternatives that have emerged in Australia – birth centres and a new generation of independent homebirth midwives – can only exist by locking out the more powerful profession of medicine. They deliver a different brand of ideology, one that is no less damaging. A Cochrane review of research into the outcomes of maternity care in home-like settings conducted in 2005 pointed to a higher rate of baby death in home-like settings compared with low-risk birth in hospital settings. The study was not powerful enough to draw conclusions, and ‘home-like' settings are not the same as birth centres and other models of midwifery-led care, but the researchers were concerned enough to warn that ‘an over-emphasis on normality may lead to delayed recognition of or action regarding complications'. The most tragic story I came across during the review of maternity services I worked on was the death of a baby girl named Lillienne which was at least partly the result of midwives in a birth centre and doctors in a birth suite within one hospital failing to work together to provide care. The family of this baby, her mother, her father, her siblings, will be affected by their loss for their lifetimes.

The birth wars matter. One way or another, we are involved in a conflict that will result in the most significant social changes the next generation of mothers will see, on a scale akin to the rise of the nuclear family and the move en masse to institutional child care. How we care for pregnant women and babies speaks not only the society we are but the one we will be. Childbirth is a moment of heightened risk and it is a moment of epiphany. And yet maternity care in Australia cannot accommodate these two moments at once. The Commonwealth review of maternity services, expected to report in December 2008, headed by the Chief Nurse and Midwifery Officer, is leaning heavily towards increasing midwifery-led care. This will do nothing to address the fundamental conflict at the heart of the birth wars. It may make matters worse. The organics and the mechanics should be working together to provide safe, responsive care, but in Australia the birth wars show no sign of ending, despite their awful and ongoing casualties.

From Griffith REVIEW Edition 22: MoneySexPower © Copyright Griffith University & the author.