Harming Birthing Women in the Name of Safety

iatrogenic - resulting from the activity of physicians; said of any adverse condition in a patient resulting from treatment by a physician or surgeon.

We currently have an epidemic of iatrogenic birth injury. Countless women are unnecessarily traumatised through their birth experiences. Sure, medicine has come a long way in terms of improved management of complicated births. But, while the mortality rates for mothers and their babies have significantly improved, the incidence of an array of other harmful outcomes is staggering. In their quest to control the birth process, healthcare professionals have failed to appreciate the psychological and emotional trauma that accompanies medical management of what is meant to be a very empowering and spiritual experience.

This blog post reveals my concerns about the insidious nature of common birth interventions and how few women understand what a powerful threat they pose to their birth experience (and that of their baby). A healthy birth experience is not simply one where the mother and baby survive, it requires that physical damage is minimal, bonding between the mother and her baby is nurtured, and the mental and emotional wellbeing of the mother remain intact. Countless women are needlessly suffering due to traumatic birth experiences, not because birth is painful and hard-going, but because unnecessary interventions do damage to the hearts and minds of their victims. What is more, this damage occurs at the time in women's lives when they most need to feel strong and capable - the early days of new motherhood.

Birth interventions that are unwarranted and which do harm are justified under the veil of 'keeping birth safe'. What rubbish! Birth is safe. For the vast majority of healthy women, giving birth happens without complication when the birthing woman feels safe and is trusted by her birth companions to be able to do the job! Unfortunately, there are an abundance of meddlesome professionals who see fit to convince women that birth is something to be feared and medically controlled. What is done to the birthing woman in the name of safety is often, in fact, doing a lot of harm.

Safety is often considered only as a physical consequence of birth, denying women the right to feel and express the emotional and mental suffering they may have encountered and continue to struggle with as they mother their newborn. This is why the comment, "At least you have a heathy baby - that's all that really matters" can be so hurtful, undermining and disempowering for a traumatised mother to be told. Of course she is grateful that she has a healthy baby, but that does not make her suffering any less valid. The two are not mutually exclusive.

Other misguided comments that perpetuate the myth that birth is inherently unsafe and in need of medical control...

The 'YOUR BABY WOULD HAVE DIED IF YOU HADN'T HAD A CAESAREAN' lie.

While I don't deny that this statement is obviously true for some women, I am greatly cynical about the degree of honesty expressed by many healthcare professionals when justifying the use of medical interventions in childbirth. In my opinion, such sweeping and scary statements as, "Your baby would have died if..." are frequently part of the wider, insidious efforts of medical people to maintain a culture of fear around birth. With fear comes compliance - women are too scared to trust their self-knowledge, their intuition and their bodies to birth their babies safely. Without this necessary trust, they become dependent on the professionals to guide their birth process - to control their births. Women give away all their power because they are so full of fear. Of course it serves the hospital system and its medical staff to have such compliant, unquestioning patients* to efficiently drag through the birth machine. And it is, of course, counterproductive to worry themselves with the detrimental impact that such a system has on the women it serves. So they don't.

The 'AT LEAST THEY DID ALL THEY COULD' misconception.

Intervening with a healthy birth process is almost always detrimental to the woman's experience. As previously mentioned, the problem often lies with women being led to believe that the interventions that took place were justified when they likely were not. Regardless, according to their basic rights, birthing women should be given all the information that they need in order to make a fully informed decision about whether or not they give their consent for each intervention to be carried out. Instead, we hear women say, "They told me I had to..." and "I wasn't allowed to...". Rarely do women question this abuse of power, possibly they are not even aware that they had the right to an autonomous birth experience. But mostly, I believe, they are convinced (initially, at least) that whatever was carried out, no matter how painful, how damaging, how abusive, was done in the best interests of them and their baby. The choice to carry out those interventions was, however, never the medical professional's to make, and most likely, the subsequent trauma would have been lessened for the mother had she made those decisions for herself.

From all the reading I have done and conversations I have had with women about birth trauma, it appears that the underlying cause of their trauma was a loss of control over what was happening to them. When the power remains with the woman - the power to make decisions about her care, the power to choose where and with whom she gives birth, the power to trust her process and know that no-one will intervene without her expressed permission - she is no doubt much more likely to have an empowering birth, regardless of whether her birth experience matches the one she'd hoped for. 

The 'NATURAL BIRTH SUPPORTERS ARE AGAINST ALL FORMS OF INTERVENTION' fallacy.

I loathe the sentiments of some that suggest that natural birth supporters, like myself, put their desire for a positive and empowering birth experience ahead of the safety of their baby during birth. Whether we choose to birth at home or in hospital, whether we choose to be cared for by a midwife or a specialist or no professional at all, whether we accept or decline various interventions, we are all seeking the same outcome - a safe birth experience for ourselves and our babies. However, some, like me, also believe that birth should be as gentle, loving and natural as possible, that these things are important aspects of an holistically safe birth experience.

My book, Where the Heart Is: Stories of Home Birth in New Zealand includes examples of women who planned on giving birth at home, but who ended up believing that, due to unforeseen circumstances, it was in their best interests to birth in the hospital environment. Shelley's story, for instance, tells of her sudden onset of pre-eclampsia and the consequential transfer to hospital, medical induction of labour, and drugs to keep her blood pressure under control. For a woman who dreamed of a peaceful home birth experience, she was a far-cry from the labour she'd so desperately hoped for. However, because she maintained a strong belief in her birthing capabilities, and because she was supported in hospital by her wonderful home birth midwife, partner and mother, Shelley didn't end up feeling completely disempowered by her medicalised birth experience. She agreed to the interventions that she felt were necessary to keep her and her baby safe, and ultimately felt positive about the non-ideal birth that she had.

The 'ONCE A CAESAREAN, ALWAYS A CAESAREAN' trap.

Having undergone a caesarean with her first baby, it must be incredibly challenging for a woman to rebuild trust in her birthing body when preparing for her second birth. This would be especially true for the multitudes of women who were led to believe that their birthing body failed them (as opposed to their birth attendants failing them, which is no doubt the truth of the matter for most)... women who 'failed to progress', who 'failed to dilate' and who 'failed to go into labour on time', as if a little more time, patience, and trust from their birth attendants wouldn't have led to the normal birth that their body was designed to carry out! To add to their challenges, women are generally still encouraged to believe that a vaginal birth following a caesarean is risky business that requires all sorts of monitoring and management in the hospital. It takes a strong woman to overcome such big mental hurdles in order to get on with birthing her baby the way that she knows is right for her (a supportive midwife and partner help a lot, too). Thankfully there are many courageous, strong and inspirational women who willingly share their positive VBAC stories with others. Where the Heart Is includes four beautiful stories of women who were healed of their traumatic caesarean births through the empowering home births of their second babies. Such sharing is so valuable amongst the birthing community!

The picture I have painted of healthcare professionals in the birthplace has been somewhat grim. I should clarify that while there are some overtly abusive practitioners out there, there are also many brilliant ones. Also, many of those whose practice is inappropriately controlling probably genuinely believe that they are doing their best by the women they serve. If we attempt to put ourselves in the shoes of the obstetricians to whom I refer to throughout this blog for their unduly meddlesome and controlling practices, we can start to understand why they treat birthing women the way they do. My guess would be that most obstetricians have never, in their lives, witnessed a healthy, normal birth in its entirety. Day after day they encounter problematic pregnancies and births, they are a part of all the 'births gone wrong' - the stuck shoulders, the blue, limp babies, the haemorrhaging mothers, the deaths. And in that troublesome sea of nightmare births, with only a skewed reference point for what they judge to be a healthy, normal one, it no doubt becomes hard to view birth as a natural process. Trust fails, fear rules. Suspicious and fearful of the natural birth process, the well-meaning obstetrician believes the best way to ensure safe birth outcomes is to control the process... Control the onset of labour through medical induction... Control the progress of labour through numerous vaginal examinations and a syntocinon drip... Control the pain of labour through the use of analgesics and anaesthetics... Control the descent of the baby through the birth canal by way of episiotomy and forceps or ventouse... Control fears around the estimated size of an unborn baby, or the apparent lack of amniotic fluid, or the position of the baby in utero by caesarean section... the list goes on and on. 

Also, making the decision to 'do nothing', to not intervene with what is determined to be an 'unpathological complication' (or a variation on what is deemed 'normal' for most women), is an easy target for accusation/litigation when a poor birth outcome results. Birth attendants are no doubt fearful of potential litigation. It is rare for a healthcare professional to be charged with causing harm to a mother or her baby by way of an intervention they undertook, and not so rare for a charge to be laid against someone for 'not doing something' (regardless of whether 'something' was truly warranted or not, and regardless of whether the mother made the informed decision not to have that intervention, note: many charges against midwives are laid by other healthcare professionals). Again I would like to come back to the point that it is not the healthcare professional's job to control the woman's birth experience, it is their job to monitor the well-being of the mother and her baby, and to do their best to support the woman to birth the way she chooses to. Mothers, more than anyone, want a safe outcome for their babies. They will do their best to choose the path that they believe is safest for them and their babies. It is imperative that their birth attendants understand and respect this, regardless of whether it is synonymous with the way they would choose to do things for themselves.

To end, I just want to back up my negative view of 'the birth machine' with some interesting statistics. The US has one of the highest rates of birth interventions in the industrialised world, yet one of the highest rates of infant and maternal deaths. This article states:

A new report reveals that the United States has the highest first-day infant death rate out of all the industrialized countries in the world.

And this report states that: 

An American woman faces a 1 in 2,400 risk of death during childbirth. Only five other industrialized countries—Albania, Latvia, Moldova, the Russian Federation, and Ukraine—fare worse on maternal death rates.

Meanwhile, women who give birth at The Farm Midwifery Center in Tennessee, a practice based on the belief that pregnancy and childbirth are natural life events, fare much better. I have no doubt that their extremely low birth intervention rates, contribute to much safer outcomes for women and their babies. For instance, their caesarean section rate sits at just 1.7%, and their forceps rate, just 0.37% (visit here for more statistics). These statistics are comparable to the statistics I acquired recently from a friend who has been a home birth midwife in New Zealand for 30 years. Her caesarean rate was 3% (compared to a National average of 24%), her medical induction of labour rate was 0.3% (National average, 20%), and she has only ever had two women undergo a forceps or ventouse delivery. Needless to say, birth trauma is rare under such circumstances.

So, have we swung too far in the direction of medically managing birth in the name of safety? I would say yes. In doing all we can to ensure safe birth outcomes, have we inadvertently made childbirth a riskier experience than it would otherwise be? In far too many cases, I believe so. Just as contentiously, is our 'doing' causing the undoing of what would otherwise be a healthy birth? I am convinced that much of the time it absolutely is.

 * birthing women may not be ill, but given the harm that the interventions they are likely to encounter can do, they fast become patients once they enter the hospital.