Thursday, September 27, 2007

Do I really know what's best for pregnant women?

Last year I have to admit to getting quite despondent about midwifery and how I worked with women. I felt I was giving 110% to the women in my care, being passionate about continuity of care, informed choice and all the other features of partnership between pregnant women and midwives. But it didn't seem to matter what I said and did, women chose to have epidurals, induction of labour and so on. I seemed to loose my connection with women. What happened to the days when I worked alongside women in their homes and hospital to achieve a low intervention birth. I seemed to turn from being a hands-on midwife to a nurse, doing nothing but fiddle with machines. Don't get me wrong, I have nothing against medical intervention for women who need it. And the reason I believe epidural and induction of labour is problematic for women who have no indication for it is that it increases their chances of having instrumental births, cesarean section and all the connotations of that. But it had seemed so long since I had 'fought the fight' so to speak, with women who wanted to do it on their own and considered birth to be a natural event that they took in their stride without any great drama. What happened to women's fortitude?!!

Now, I know I'm going to get lots of comments from women telling me to get stuffed and that they should have their epidural if they want them. And yes, I quite agree. In fact, my question is: does it matter if women end up having an epidural? Does that make me any less of a midwife? Does my high epidural rate reflect on my practice as a midwife? Am I a 'bad' midwife because my alternative measures do not work, and by that I mean things like supporting women to labour at home as long as possible; keeping them upright and mobile; getting them to use water for analgesia. Who am I to say that women should not have their babies when they want them to fit in with their life plans? If they do not mind that cesarean section can be the outcome of induction of labour, why should it matter to me? After all, what's wrong with having a cesarean section?

I have come across a couple of references that show if women have an attitude where they are more likely to accept medical intervention, then they are more likely to have an assisted birth.

Have Women Become More Willing to Accept Obstetric Interventions and Does This Relate to Mode of Birth? Data from a Prospective Study. Green & Baston (2007), Birth, 34 (1), 6–13.

Hulst van der, L.A.M., et al. (2004) Does a pregnant woman's intended place of birth influence her attitudes towards and occurrence of obstetric interventions? Birth, 31: 28-33.

In some ways, this research has been reassuring because it emphasizes that childbirth is not all about me. Doh, you say, it's taken you nearly 30 years to come to that conclusion? No, I have always known that. What it allows me to do is be able to step back and take a more objective view of my role - to put boundaries around my practice, which in turn will guide my reflection and keep me safe from burnout. Yes, as a midwife I walk alongside women, pointing out the way. But ultimately, women are responsible for the decisions they make and I cannot wear their shoes for them.


Dot said...

Thankyou for your comment on my post. I thought I'd leave a return comment on this particular post of yours because it's talking about some of the same issues as your comment. It's interesting what you say about medicalised birth and women wanting epidurals: the epidural has a very high profile on pregnancy chat-boards and so forth, much more than other forms of pain management including drugs like pethidine. People get taught what to want and we've all heard of epidurals.

I've looked at various different popular, comic and journalistic accounts of childbirth and the angle often is something like this: pregnancy no. 1, attend yoga classes, practice breathing, labour turns out to be 16 hours of agony relieved only by blessed epidural; pregnancy no. 2, book epidural in advance, give birth in the car. The implication seems to be that those of us who are trying to prepare for a natural birth are just unrealistic. Another story that one encounters more through word of mouth is one about depressing feedback ('you're still only 3 cms') leading to giving in to the drugs - the gloss the woman telling this story often puts on it is that the hospital staff just wanted her to shut up. I'm interested in these stories because while on the one hand they constitute part of a stock of female wisdom that I can draw on, on the other hand they are generated as part of people's processing of their experiences after the event. The second story is very much about feelings of failure or guilt at accepting drugs, and I feel part of my mental preparation has to be not setting myself up for failure by being too rigid about my birth plan. The first story reflects the fact that birth undoubtedly is painful and frightening, if also extraordinary and transforming, and is dealt with in terms of comic polarization and exaggeration. But both kinds of story affect women's expectations of birth and of the hospital environment. I've thought it would be interesting to do a study of how birth stories circulate and how they reproduce and develop current attitudes to medicalised birth. Somebody probably has - I wouldn't know yet, having only just started to extend from the commercial bookshop baby shelves to the university library!

It was striking that, in that antenatal class I attended yesterday, of perhaps 12 women only two of us said we were aiming for an unmedicated birth. The midwife running the class was rather disappointed (which I found encouraging).

Anyway, this comment is turning into an essay, so I'd better stop! There's a lot more on your blog I'd like to talk about, being a lecturer myself as well as a first-time pregnant woman. Good luck with your 7000 word presentation.

Sarah Stewart said...

Hello Dot, thank you for leaving this comment. As you have said, there are lots of things to talk about and I often find it really difficult to put it in a logical order or make any reasonable sense of it. I am also conscious that a blog is a public forum so one has to be 'political' about what one says.

I must say that when I was thinking about what to look at for my PhD, other than e-mentoring, I was (and still am) fascinated about birth stories that people publish on the Internet. So I think your idea of looking at them is a great idea, particularly in relation to web-based publishing ie why do people publish their stories on the net, not just what they say.

Anyway, I wish you all the best with your new baby when she/he comes. Would love to keep in touch. Sarah

Carolyn McIntosh said...

I do agree that women's beliefs about birth are influenced by many and wider influences than their midwife. Their ideas about birth are formed from a very early stage and are based on many influences such as stories of family and friends and media portrayals both factual and fictional. As a midwife I have sometimes been able to help women to look at birth in a different way by talking with them in the early antenatal period. Sometimes this has led to women choosing to birth in a primary birth setting where previously they would have probably have chosen all the medical bells and whistles. Without access to a primary care birthing unit it is exceptionally hard for women to avoid the ever present attraction of epidurals etc, regardless of how they may previously have thought about birth. You are right though. Ultimately we have to support women with the care they choose to have. You cannot force a woman to have a birth experience that she is completely unwilling to have, nor would we want to do that. It seems to me however that, in the stories I hear, I more often seem to hear women saying they were not supported to avoid medical intervention than saying that medical intervention was not offered to them. The dilemma of options for care for a midwife who has to care for women having a primary birthing experience in a secondary care setting is enormous.

Sarah Stewart said...

Actually, Carolyn, I think you have hit the nail on the head. When I was writing this post I was comparing the women I looked after in Gisborne (small secondary unit with only one doctor on and very limited opportunities for medical intervention)and the women in Dunedin(working in a tertiary unit which is a teaching hospital with more doctors on duty who know what to do with themselves and 24 hour access to epidurals). I had much better outcomes (in terms of medical interventions) in Gisborne and I felt a much higher job satisfaction. So I think that it is vital to get low risk women out of environments heavily influenced by medicine. Please note that I said 'low risk' women-there is absolutely a place for highly medicalised care for women who need it.