Knowing about birth and interventions: Women's role

A recent study by Klein et al, sought to discover the knowledge and attitudes of women pregnant for the first time to their own roles in their pregnancy and towards the use of technology in birth. The report was written up in the Los Angeles times as Pregnant women show an amazing lack of knowledge about childbirth options, study shows - latimes.com . You could be forgiven for thinking that modern childbearing women were obviously failing in their duty to be informed and either submissive or unintelligent.

So who were these women that Klein et al studied?

The sample of 1318 women was a convenience broad based sample of "mainly well-educated, middle-class women" whose planned place of birth

"ranged from home to hospital, and from rural centres to large city hospitals ... 13.2% of respondents were in the first trimester, 39.8% were in the second trimester, and 47.0% in the third"

A good range of sites for birth, so who was their primary care giver?

"Overall, 42.6% were under the care of an obstetrician, 29.3% a family physician, and 28.1% a registered midwife; 18% planned to engage a doula."

OK, nearly half had a private obstetrician, plus nearly 30% who had family physicians makes nearly 3/4 of the total number of women 'under' the care of a medical practitioner.

Now here is something very interesting in this study:

"Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women’s roles in their own delivery, regardless of the trimester in which the survey was completed"

What do you suppose could be going on there? There is no doubt that some women access medical care because they want the assurance of the ready availability of intervention if they 'need it'. Some choose to have intervention from the start, but that number is considerably less than is touted by mainstream media or medical rhetoric. Part of that orientation however, comes from the steady undermining that goes on at every antenatal visit with many of our medical colleagues. Comments such as 'small pelvis', 'large baby', 'getting stuck', 'bleeding to death', plus the steady supply of 'horror stories' and hype about birth danger that women are regaled with by the doctors as they seek to validate their interventionist perspective are ubiquitous. The orientation that 'doctor knows best' is also very much alive in our community and the way that antenatal care is organised so that the women wait for hours and get seen for minutes feeds the belief system that doctors are 'so busy' and 'don't have time for women's petty concerns' - so women don't raise them in visits - that silence from the women aided and abetted by the 'not wanting to be a bother' stereotypical stance of many women.

Another lens on this phenomenon is provided by this study from 1995 which reported that privately insured pregnant women were more likely to experience interventions and surgical birth than comparable women in the public hospital system, but that the rate of intervention was greater for those women:

"who in late pregnancy were thinking clearly, had high self esteem, mature means of dealing with anxiety, were confident in their knowledge of childbirth procedures and in secure relationships with highly educated men"

A paper in 2000 by Roberts, Tracy and Tracy explored the differences in intervention between public and private hospitals maternity services offers some insights for the higher level of intervention for women in private medical care. Litigation fears, physician convenience factors and theatre staff availability are suggested as reasons for the increased rate of interventions and surgical birth in private hospitals. But what if there is something more 'underbelly' about the way intelligent, articulate women with supportive, educated husbands are subjected to increased rates of intervention? What if it is a situation of putting uppity self assured women in their place? Women will always preference their baby's well-being over their own, so it is easy to undermine them and when they are told that the 'fluid around the baby' is 'suspect' therefore induction is a good idea "I'll book you in for tomorrow" or "you have a placenta praevia (actually low lying) and I'll take the baby at 37 weeks because we don't want the placenta ripping and the baby being short of oxygen" how many women are going to challenge that? So many of the women who are induced for spurious reasons are told after 8 hours of desultory but painful contractions that they aren't going anywhere and may as well have the baby now rather than later when they are even more tired and the baby gets stuck  " I can just take you upstairs/downstairs/across the hall and it will be all over and you'll have your baby in your arms" - who is going to argue then? Anyone who has worked or is working at a private maternity unit can relate similar stories.

This comment is interesting:

"Women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women’s roles"

The fact that these women have a better understanding of women's roles in childbirth is heartening and affirming, as midwifery care is all about capacity building and information sharing. The fact that women who access midwives as primary care givers are less interested in technology comes as no surprise as that is usually one of the reasons women seek out midwifery care. Another important point is that midwives use stories too. Midwives use stories to inspire and instill confidence in a woman's sense of self and ability to birth and parent well. 

The finding that women attending family practices had opinions that "fell between the other two groups" is encouraging, but could clearly be better:

Now, this final finding that:

"For eight of the questions, “I don’t know” (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy".

is very concerning. There is some comfort in the fact that:

"Women in the care of midwives consistently used IDK options less frequently than those cared for by physicians".

as that demonstrates that midwives role in information sharing and discussion about labour and birth is clearly occurring, even though there is scope for improvement. One of the benefits of midwifery care is the longer time for antenatal visits, where thoughts, feelings, stories and information can be shared and discussed. Perhaps the room for improvement here is with models of midwifery care that have short antenatal visit times scheduled and discussions are limited.

The conclusion of the Klein et al study that"

"women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations"

is true in many regards, but not in all cases and not for all women. I've met many women who were privately insured and cared for by obstetricians, who were genuinely bemused and upset that they had unplanned intervention, I've seen others who argued that the doctor saved their lives (or the baby's) having (in my view based on observation and experience) created the problem in the first place.

Most people aren't that interested in finding out about pregnancy and birth until it becomes an immediate reality. School, parents and friends provide a particular perspective and background to people's information and knowledge about birth and babies, the media certainly provides another. Many women and their partners have never held a newborn baby until they hold their own. The primary care provider, be it midwife, family physician or obstetrician has a duty of care to provide opportunities to explore information, knowledge, understandings and experiences with pregnant women/couples who access their services.

To say that women are ignorant of options and interventions says volumes about their health care provider. What do you think? 

A coroner's perspective on the death of a baby

The coroner, in his report released today on the intrapartum death of a baby girl at a private hospital in Queensland, was critical of both the midwife and the obstetrician involved in the labour and birth care of the mother.

The care was found to be substandard by the coroner on many levels.  The midwife was found to have altered the woman's medical records after the event; did not follow hospital protocols regarding monitoring and documentation and did not refer to an obstetrician in a timely manner. The coroner will be reporting the midwife to the Director for Public Prosecutions.

The coroner found the doctor's response to the clinical situation to be ''inadequate" and recommended that he be reported to the hospital board.  I wonder why the coroner is not reporting the doctor to the Director of Public Prosecutions too?

The coroner made 21 recommendations from the content of antenatal education and the way they are formatted to the essential nature of good collaborative care for safe care of mothers and their babies.

The president of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Dr Rupert Sherwood commented that this case highlighted the reasons why the college "has always insisted on collaborative arrangements between doctors and midwives".  He further claimed that there were two aspects of good collaborative care: adherence to protocols and timely referral. Those aspects, while very important, are not the key to what constitutes either collaboration or safe maternity care.

There is no doubt that collaborative maternity care is the safest for both mothers and babies. I have had the supreme good fortune of working collaboratively with a number of skilled, compassionate and insightful obstetricians. I have sadly, had the misfortune of working with the others too. The key to collaborative maternity care provision is the way the organisation is structured. There are two aspects to that positioning. One, that the organisation overtly recognises that birth is a normal natural event which sometimes needs expert and timely intervention. The other, fundamentally crucial aspect is the acceptance and promotion of the woman's right to self determination, evidenced by the woman being treated as an equal partner in the care planning and giving. A woman centred maternity service, where both obstetrics and midwifery AND the organisation has the woman, her wellbeing, her desires, needs & requirements at the centre of their practice leads to the leveling of hierarchies and the destruction of professional 'silos' which engenders an atmosphere of trust with optimal communication.  I found in my research that without that organisational structure creating the culture of collaboration, with warm, trusting relationships of mutual respect and woman centred practice, both doctors and midwives lose their emotional and social competence, they act stereotypically, the turf war is in full swing and mothers and their babies suffer.

The loss of this little baby Samara is a tragedy for all concerned.  The fact that with good collaborative care, this baby's death could most likely have been avoided is heart wrenchingly tragic.

This coroner's report is a must read for everyone associated with maternity services, from caregivers to managers as it contains important directions and information regarding staffing, culture and practice.

Power and Agency in Childbirth: Women’s relationships with obstetricians.

Trust, Power and Agency in Childbirth: Women’s relationships with obstetricians.

This great article by Monica Campo, a feminist sociologist and scholar, needs to be shared. Monica is doing her PhD at La Trobe University, in Victoria, and this article is part of her work for her PhD. The article is published online at Outskirts: Feminism along the Edge. Monica explains the content of this article this way:

"This paper has a twofold argument: that women participating in this study enter into a relationship of trust with their obstetrician based both on their class positioning and their belief and entrenchment within the hegemonic biomedical model of birth; and that their confidence and trust in their own ability to birth without medical expertise is subtly eroded in the medical encounter as well as through cultural fears surrounding birth. I use this evidence to make a wider claim regarding the limits of choice and agency within the obstetric encounter. Women in medical systems of maternity care are not ‘passive dupes’ of obstetric hegemony but their autonomy is nonetheless constrained by their relationship with their obstetrician and an increasing normalisation of medical birth".