Sunday, May 10, 2009
There has been much buzz on natural childbirth blogs and forums lately concerning a growing group of women in industrialized countries who are choosing to birth without the assistance of a trained childbirth attendant. This type of birth is called Unassisted Childbirth, and is hotly debated.
Recently a huge UC advocate in Australia laboured for five days at home, unassisted, before transferring herself to hospital and delivering a deceased baby. Some forums are silent following this event, and others are in an uproar. One of my blogosphere friends, Rachel, asked me how I felt about this post by the Navelgazing Midwife, criticizing this UC advocate for her choice to labour unassisted just days after the death of her baby.
Being a fledgling birth advocate myself, I hesitate to criticize anyone's birth choices, or at least to do so loudly or with any assumption that there is any weight to my opinions thereof. But I have to say that Unassisted Childbirth seems counterintuitive to me. What I know of labouring women, experientially and from texts and blogs and birth stories I have read, is that above all women need support in labour. Whether this is emotional support from a doula (or mom who acts as a doula, as in my case), labour support from a midwife or nurse when labour or second stage (pushing/delivery of baby) needs guidance or suggestions or nudging along, physical support staying mobile or trying different positions, or medical support with infant resuscitation, maternal hemorrhage, maternal exhaustion, tight fit through the pelvis, or interventions. Apparantly there are some women out there who really, really feel violated by the presence of others during birth. And there are others who cannot find (or are legally barred from employing) the skilled birth attendants they need to have the birth of their choice. For example, in many US states midwifery is outright illegal (or covertly so, as is the case in New York, where midwives must be legally overseen by a physician but all physicians are under strict instructions by insurance companies NOT to oversee midwives at risk of losing their malpractice insurance), making it incredibly difficult for women to choose the safest, most desired option when birthing their babies (evidence is clear that midwife assisted births have lower unnecessary intervention rates and similar low maternal and infant mortality outcomes as physician attended births, at least in Canada). Midwife assisted homebirths are often cited as even safer than midwife assisted hospital births, due to the cleaner environment and deeper relaxation achievable by labouring mothers (and other factors). It is easier for me to see how a mom who desires to have a safe birth and thus wants a midwife assisted birth (at home or elsewhere) and is legally barred from doing so would then perhaps choose to give birth at home, unassisted. I don't agree with it, but I see how that could be so. Most people don't find hospitals to be safe, clean, inviting, or comfortable places to be; why would that be any different when women give birth?
But there are many states where midwife attended births and homebirths are legal, and midwives are available and covered under medical insurance (insurance companies are starting to realize that lower intervention rates are cheaper for them and many are covering midwifery care as a result). In Canada midwifery is legal, though not all provinces/territories fund midwifery care as of yet. The only thing that will change this is consumer demand and the fact that midwifery is cheaper to fund than physician attended care. It costs the same to pay a midwife for prenatal, birth, and post natal care as it does to pay a physician, but physicians have higher intervention rates, and interventions are costly. Astronomically so. When medically indicated, these interventions save lives, and all good midwives will refer patients to obstetricians and other specialists when it is medically necessary. But the truth is they refer less often than physicians do, and intervene less often than obstetricians or physicians. In a funded climate that endorses homebirths as a viable, safe option, it is more difficult for me to understand why women would choose to give birth unassisted. If a midwife determines a woman is high risk and thus transfers her care to a doctor and the woman wants a home birth so badly that she then chooses to give birth at home unassisted, I would venture to say that the experience of giving birth is being too heavily prescripted. You cannot write your own birth story. You set yourself up for the best birth evidence can support you to have, and you choose what is right for that birth at that time, and then you actively watch it unfold. Babies and bodies have minds of their own and sometimes, they write births that are different from ideal.
Riley's was different from the ideal in that he was born very flat, did not move or breathe, and was a greyish purple colour. He was whisked away and resuscitated fully, and then returned to my arms as soon as possible afterwards. Though he was returned quickly and I gave birth naturally, it was not my ideal birth. I had wanted that moment of giving birth to slip easily from labouring to mommying, and for us not to be separated at all. I wanted Riley's first moments outside me to be gentle, calm, and reassuring. But his birth story wrote itself, and I actively watched it unfold. I regret nothing, despite it not being ideal.
That said, I respect women and I think that if they are choosing en masse to give birth unassisted, that is something I need to pay attention to. As a doula, as a future midwife, and as a woman. What is it women are seeking? What is the system lacking? Is there any way we can supply these women with what they need and want with regards to birth and still have them choose skilled birth attendants?
In response to Rachel's question regarding the Navelgazing Midwife's chastising letter to Janet Fraser, the woman who laboured unassisted for five days before delivering a deceased child, I would have to say that anyone who uses the death of a child for political gain is performing a violent act toward that child's memory and its momma. A death is not a political statement, and it makes me angry that Navelgazing Midwife chose to be voilent in this context. In no way are women, and by extension, babies, being served by further alienating UCers.
I wanted some statistics to help guide me as I formed my opinion in response to this Unassisted Childbirth movement, and to the cyberbuzz surrounding its expansion. So in search of some trustworthy stats and meta research regarding birth attendants I visited the WHO website, and I had an epiphany. The WHO website is quite clear that the presence of a skilled birth attendant is what makes the difference in maternal and infant mortality rates around the world. The thing that makes it so difficult for many countries to tackle their high death and injury rates is ACCESS to skilled birth attendants. The model advocated by the WHO is midwifery care with hospital based backup physician attendants. Okay. My epiphany was that around the world, millions upon millions of women do not have the option of choosing a skilled birth attendant to support them as they give birth. There is a poverty of skilled birth attendants in the world, and here we are in our developed nations quibbling over to choose or not to choose a birth attendant. It makes me think of Marie Antoinette's "They are hungry? Let them eat cake!" We have so much we don't realize how priviledged we are. Instead of buzzing around gossiping about the birth of one UCer's baby in Australia, we should be standing up and shouting for the rights of women in countries around the world whose babies and who themselves are dying by the thousands because they don't have the option to choose a skilled birth attendant.
Here are some quotes from the WHO website that impacted me most:
"Investing in Human Capital such as midwives for childbirth is the wisest investment that we can ever make, to ensure sustainability, ownership, fulfilment, and consistently high results" said Joy Phumaphi, Assistant Director-General, Family and Community Health, WHO.
All women and babies need maternity care in pregnancy, childbirth and after delivery to ensure optimal pregnancy outcomes. However, around the world, one third of births take place at home without the assistance of a skilled attendant.( 1) WHO strongly advocates for “skilled care at every birth” to reduce the global burden of 536 000 maternal deaths,(2) 3 million stillbirths and 3.7 million newborn deaths(3) each year. Countries measure the proportion of deliveries assisted by skilled attendants frequently since it is one of the indicators of progress towards Millennium Development Goal 5, which aims to improve maternal health.
(1) Proportion of births attended by a skilled health worker – 2008 updates. Geneva, World Health Organization, 2008 (http://www.who.int/reproductive_health/global_monitoring/data.html, accessed 14 August 2008).
(2) Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008).
(3) Neonatal and perinatal mortality – country, regional and global estimates 2004. Geneva, World Health Organization, 2006 (http://www.who.int/reproductive_health/docs/neonatal_perinatal_mortality/index.html, accessed 14 August 2008).
The current number of skilled attendants is critically insufficient. An estimated 700 000 midwives are needed worldwide to ensure universal coverage with maternity care, but there is currently a 50% shortfall. In addition, 47 000 doctors with obstetric skills are required, particularly in rural areas.(5) Worldwide, 4.3 million health workers are lacking.(8)
WHO / EMRO
Given the global shortage of health workers, existing human resources need to be employed most effectively and new health workers need to be recruited. Further, new resources must be raised to recruit, train and retain additional health workers with midwifery skills. This also means providing more incentives to work in midwifery such as satisfactory pay scales, improved status and respect within the health system and career advancement opportunities. They also need adequate equipment, supplies and medicines to help women and babies.
However, training programmes for traditional birth attendants have failed to reduce maternal mortality in the past. The short trainings were not adequate to teach an otherwise unqualified person the critical thinking and decision-making skills needed to practice.
Enhancing the care-seeking behaviour of pregnant women is required in addition to increasing service provision. Read more about “Involving individuals, families and communities to improve maternal and newborn health”.
(5) The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en, accessed 14 August 2008).
(8) The world health report 2006 – Working together for health. Geneva, World Health Organization, 2006 (http://www.who.int/whr/2006/en, accessed 14 August 2008).
Source: the WHO website, maternal and newborn health topics