Safety, Risk, Costs & Benefits:
Weighing Choices in childbirth
- Peter Brocklehurst: doctor, Director of National Perinatal Epidemiology Unit, UK
- Soo Downe: professor of midwifery sciences, UK
- Elitsa Golab: civil and constitutional rights lawyer, USA
- Hélène Vadeboncoeur: public health researcher, Canada
- Jennie Joseph: midwife, USA
- Jo Murphy-Lawless: sociologist and historian, Ireland
- Marieke de Haas: mother, Netherlands
- Robbie Davis-Floyd (moderator): medical anthropologist, USA
Peter Brocklehurst, head researcher of the Birth Place study, began the panel by presenting results from his research. This study followed women in the NHS in four birth locations: home, freestanding midwifery units, alongside midwifery units, and obstetric units.
Soo Downe spoke about how women in the UK are influenced to make choices, from newspapers to television shows (including One Born Every Minute and Call The Midwife. Although we have the data about birth outcomes, she argued, we don't have the belief in the data. She argued that we need to frame birth choices not in terms of home/hospital, but in terms of consequences.
She also mentioned a book chapter that she authored in 2010 called Towards Salutogenic Birth in the 21st Century--the book is now on my to-read list.
Hélène Vadeboncoeur spoke about VBAC. Do pregnant women have VBAC rights? She reviewed the situation in the United States, where expecting women have had to resort to legal means to gain access to VBAC. She mentioned some maternity organizations that have made significant contributions, including the White Ribbon Alliance work to ensure Respectful Maternity Care via its elaboration of the Universal Rights of Childbearing Women (PDF) and the International MotherBaby Childbirth Initiative. She concluded by discussing how evidence-based medicine has an unexpected negative consequences of leaving less space for individualization of care.
Elitsa Golab, an attorney who is involved with ICAN, spoke about the concept and historical development of informed consent in the United States. How a society upholds a person's right to informed consent reflects the values that a society places on a person's autonomy. One of the earliest important legal decisions was Schloendorff v. Society of New York Hospital, in which Justice Cardozo wrote:
Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.We currently have two standards of informed consent: a patient-based standard, and a physician-based standard. She called for moving away from a physician-based and towards a patient-based standard.
Golab also discussed what a pregnant woman can do if her informed consent is violated--does she have any legal recourse? She called for a cultural recognition that birth is an important process and that women need actual choices to be able to give informed consent.
Jennie Joseph, a British-trained midwife who currently works in Florida, argued that poor women are left disenfranchised in our maternity care system. Her statement that "capitalism, racism, classism, and sexist will kill your baby, will kill you" received a standing ovation. The basic premise of her practice is that every woman wants a healthy baby. She provides access to every woman who wants care, no matter her ability to pay. She has witnessed incredible results in birth outcomes when women--many of who were high-risk because of poverty or race--receive supportive care.
Jo Murphy-Lawless posed the question "Who are the people/groups benefiting from our current maternity care system?" (Let me give you a hint: it certainly didn't have pregnant women at the top of the list!) She discussed the evolution of a health care system to a health care industry. With ever-tightening schedules of risk, the insurance industry profits from these constraints. Another by-product of the health care industry is increased centralization of maternity care.
She suggested borrowing from the environmental movement and using the process of "positional analysis" to make the necessary connections between trends in health care and women's needs in maternity care. We also need to be sure not to focus only on women's individual experiences of birth--which are very important--but on a collective approach that examines the values we transmit to the next generation.
Marieke de Haas, an anesthesiology resident, spoke about her choice to have a vaginal breech birth at home. Just last week, her resident colleagues laughed at her when she told them she loved giving birth and wanted to do it again a week after she had her baby. When she was pregnant with her breech baby, she didn't feel safe enough to explain her wishes to her hospital-based care providers, let alone try for a physiological birth--hence her choice to birth at home. She hopes for open dialogue between women and their care providers so women feel supported enough to be really open about their hopes and wishes.
At the end of the panel presentations, Robbie Davis-Floyd spoke how health care models that are too successful often get shut down. She presented the case of the Albany Practice in London, an all-risk NHS midwifery practice with fantastic outcomes--perinatal mortality rates were 4.9/1000 in the practice, compared to 11.4/1000 in the overall borough and 7.9/1000 nationwide. Remember, this group took on women from all risk factors in an underprivileged area; these were not cherry-picked wealthy white women by any means. The Albany Midwifery model also had a much lower cesarean rate and a very high home birth rate. Despite--perhaps because of--these excellent outcomes, the practice was shut down in 2009 by King's College Hospital.
Now a few of my notes from the very lively discussion and Q&A:
- A physiologist/pharmacologist commented about the need to study the long-term effects of drugs used in labor, especially oxytocic drugs.
- Karen Guilliland, a midwife from New Zealand, mentioned that they're doing a study similar to the Birth Place study and haven't seen a rise in adverse perinatal outcomes among nulliparous women. She posited that cultural/social context matters in birth outcomes, since she comes from a culture that supports midwives, women's choice, and place of birth.
- Soo Downe referenced a report finding that where women and midwives are respected in the culture, maternal mortality is at its lowest. (Trying to find the name of the report--can anyone help?)
- How can we restore women's autonomy here and now in the world?
- Is the legal route the only one, or the best one, to ensuring women's autonomy in childbirth?
- What happens when women are denied autonomy in childbirth?
- What about ethnicity and racial outcomes?
Rixa op-ed begins here: I strongly object to any approach that further penalizes, ostracizes, or coerces women and their midwives. It's the wrong strategy. Women who are already "obstetric refugees" because of a lack of options, previous traumatic birth experiences, or negative treatment by hospital staff, are not going to suddenly choose hospital birth if their home birth choices are further restricted. If anything, it will push these women further underground, further outside the system. It will definitely increase the rate of unassisted births.
Obstetricians have created a Pandora's box by creating an environment for childbirth that some women find unacceptably unsafe and hostile. Then, when women choose to birth outside that environment, obstetricians seek to punish the very women they were driving away. Talk about a double bind. It's like raping a woman and then punishing her for being raped.
Australian midwives are in agreement that a punitive approach is misguided. From Adelaide Now:
Australian College of Midwives' Dr Hannah Dahlen said the recommendation was concerning.If health care workers object to women choosing home births, they must realize that they have created the very conditions that drive women away from hospitals. One-third of all births ending in cesarean? Almost no chance of avoiding synthetic oxytocin at some point during labor or birth? Having to fight and negotiate for what you want, instead of simply letting go and laboring? Not "allowed" to have a VBAC or a vaginal breech birth? With these scenarios, home birth seems like a no-brainer.
"What I think that will do is push birthing underground as some mothers will now not go near a hospital for blood tests or scans (as they did previously)," she said. "The ramifications will make the system less safe, not more safe."
Dr Dahlen said the inquest was a lost opportunity to improve the health system to provide more options to pregnant women and many felt like "refugees" who avoided hospitals after negative experiences.