Birth in the fast lane: the road to motherhood in a society on Speed!

Todays fast-paced society has reinforced in us the tendency to hasten almost everything we do. How we as a society deal with childbirth is no exception. The idiom speed in the above title refers in its literal sense to the current norm of hurried lifestyles but, more aptly, as a metaphor it suggests that society suffers side effects of post-modernity similar to those of an amphetamine user for whom anxiety and paranoia are symptomatic. This essay aims to demonstrate how the fundamentals of the childbirth experience have been lost in a system in which throughput; efficiencies and financial targets are prioritised, and in which the perceived threat of risk has led to the medical and technological management of labour and birth to the detriment of women, their babies and society in general. It also examines what birth activists, sociologists and midwives have for many years shown to be blatantly obvious the positive effects of getting the birth culture right. We have become a risk society as penned by Beck (1992) where the complexity of materialism and consumerism is matched by a decline in emotional and spiritual support. The illusion of choice and agency in the post-modern era puts new pressures on us to take responsibility for risk limitation. Lupton (1999) explains how risk applied to populations is individualised and influences how we conduct our lives. Life is no longer predictable as it was in pre-modern times thus leading to high levels of uncertainty in work and private life of which risk avoidance has become part.

We make choices within safe parameters as defined by scientific knowledge which presents risk data as superior to human judgement and intuition. Edwards (2005) asserts that choice in maternity care is a pre-defined set of alternatives laid down through medical discourse from which women must select; and that informed consent equates with agreeing to a prescribed course of action which is presented as the low risk option.

Nolan (2007) believes that four hundred years of indoctrination on the perils of childbirth made women compliant and even grateful for the protection afforded by the medical profession. Of late there has been a sea change; women are becoming less biddable because of increased access to information, user involvement in healthcare policy and with informed consent becoming a prerequisite to any treatment. Lupton (1999) states that lay people are becoming more reflexive and sceptical of scientific knowledge about risk, as much of it is contradictory and does not solve the problems it has created. Individuals when assessing risk must distinguish between measurable, relative and fantasy risk, and those who challenge scientific opinion do so with little support. If something goes wrong the individual is blameworthy for not conforming to the system. When the system fails there is little accountability. Edwards (2005) tells us that women face opposition when trying to plan home birth despite its sanction by governments and healthcare providers. Societys need for certainty has allowed medicalisation of birth to thrive and has inhibited alternative practice despite evidence to support its safety. Katz Rothman (1982: 163) described the ideology of medicalised birth as the body is a machine, the doctor is a mechanic, an ideology which influences how maternity services are provided. Irelands Fordist system of maternity service excelled in its efficiency when ODriscoll (1986) put forward the medical view that labour is the most emotionally disturbing event in a womans life. His and Meaghers introduction of active management of labour in that year, guaranteed to women a labour no longer than 12 hours, i.e. a maximum of 10 hours for the first stage. Speed was the key to a satisfactory birth experience in ODriscolls view. In 2007 the then Master of the Rotunda Hospital in Dublin, Dr Michael Geary stated in an Irish Times article that the journey down the birth canal is the most dangerous journey any of us will undertake.... being born still tops the list of things likely to kill you. He justifiably claimed excellence in the care of high risk mothers and babies whose complications can be identified, but went on to state that low-risk women are at risk because they are not screened in the same way as high-risk women. This paradox echoed ODriscolls hypothesis (1986). The medical discourse deems all women as potentially having complications and it is only in retrospect that birth is considered normal (Murphy-Lawless, 1998). 2

ODriscoll advocated the pre-empting of complications in labour with medical and technological interventions.

David-Floyd (2001) describes how the application of technology gives the illusion of safety: that controlling nature reduces risk; yet evidence shows aggressive interventions leading to short-term results actually generate more problems than are solved. As Wagner (2000) shows, many technologies and interventions were brought into the labour ward without proper testing. Once in place it is difficult to reverse the patterns of use as the perceived risk of doing so is flagged, despite strong evidence that the technologies are harmful in the first place. Martin (1987) describes how the powerful force of scientific thinking within an institutional setting has the effect of reducing womens agency; her reproductive organs become isolated from her being, diminishing the prospect of taking an active part in her own labour and birth.

A classic example of this is the widespread use of continuous electronic fetal monitoring during normal labour (Alfirevic, Devane & Gyte, 2010). According to Beck (1992), as cited by Edwards & Murphy-Lawless (2006, 39), unless scientists advise us of risk it is perceived not to be an issue. The same can be said of medical practices such as artificial rupture of membranes, induction and augmentation; yet the perceived risks of not performing these procedures are sold as valid reasons for their practice. Mander (2007) suggests that harm visited on a woman to avoid risk is done so as to avoid risk to the practitioner.

Globalisation and neo-liberalism have become dominant forces in our society. Profit and economic growth take priority over social and moral good. Privatisation of public services including health services is creeping in, with governments taking less responsibility and economics becoming the driving force for allocation of resources. The Department of Health handed over responsibility for the health of the nation to the HSE in 2004. It is run on a commercial basis with substantial financial reward for those whose brief it is to prioritise targets and efficiencies over and above the wellbeing of those it serves. Health has become a commodity. Pharmaceutical and technological companies as well as private medical personnel utilising public resources are the beneficiaries. 3

Wren (2003) points out that how the state spends money on health care is as important as how much it spends. A two-tier system such as exists in Ireland causes inequity. Regardless of how much money is allocated there will always be waiting lists in public healthcare. In maternity services there can be no waiting lists. Thus the production line increases its pace. The KPMG Report in 2008 affirmed that our health service was understaffed and made clear recommendations for improvement of maternity services. Centralisation and the corresponding curtailment of staffing resources have created fragmentation so that pregnancy, labour and the postnatal period are all treated as separate components. Each process is completed and passed on to the next stage of production complete with a new set of paperwork; a whole new set of tasks to be completed and boxes to be ticked, which inevitably loses the essence of childbirth along the way.

Kennedy (2004) described the progression from home to hospital birth and with it the trend towards centralisation of maternity services which she believes, leads to ever-increasing medical interventions. The World Health Organisation (1985) recommended an induction rate of no greater than 5% with no induction for convenience, minimal interventions and no unnecessary mother/infant separation. Prior to hospitalisation of birth, Kennedy contends, these issues did not exist. There is clearly a co-dependency of active management and economics which is fuelled by the fantasy of risk.

Resources dictate that pregnant women are not seen antenatally before the end of the first trimester. Dating scans give the definitive due-date on which all future decisions regarding labour are made. From the outset a woman is told when her baby is due even though she probably knows the pattern of her menstrual cycle and perhaps when conception occurred. She is persuaded that science can make judgements that are far superior to her own. Already, her own self-belief is eroded. According to Block (2007:11) an expected date of delivery should be expressed as a due month. The term post-dates was once understood to be gestation beyond 42 weeks. In the US, Block states, induction of labour is now standard at gestation on or before 41 weeks. When one considers that a mere 5% of births occur spontaneously on their due date, the argument for induction is rather lame. The rapid decrease in maternal mortality in western society caused a 4

shift in focus to reducing perinatal mortality and the urgency to bring about birth to dispel possible risk, but as Murphy-Lawless (1998) shows, active management does not save the lives of infants, nor does it reduce the rate of cerebral palsy. Reduced perinatal death rates are a result of medical and technological advances in neonatal intensive care rather than obstetrics. Induction of labour is regarded as innocuous but leads to what is widely described as the cascade of intervention (Inch 1989, as cited by Donna, 2010: 164, 206, 457) and favours the efficacy of the health service with little regard to the physical and psychological impact on women and babies. There is a continual upward trend in national induction rates. The 2008 report of a Dublin maternity hospital shows an induction rate of 33.8% among primigravida women with a corresponding rate of 58.9% assisted or caesarean birth.

The active management regime means women are subjected to generalised policies whereby time constraints are applied in labour regardless of individual circumstances. Women are under pressure to perform within the prescribed timeframe which can cause anxiety, a condition which Ina May Gaskin (2007) believes has the effect of slowing labour further. Active management of normal labour is designed to manage potential risk but in itself puts labouring women at real risk of interfering with their bodies natural ability to birth and at real risk of after effects from the violation of their bodies.

Delays at any stage in the birth process are deemed risky. Augmentation ensures completion of labour within set time parameters. Terms such as failure to progress, poor maternal effort and ineffective uterine action, all reinforce the urgency with which birth must take place. The analogy of a racetrack has been used by a fellow student to vividly describe the second stage of labour, with an over-enthusiastic punter (midwife) eagerly willing a racehorse (labouring woman) over the line as though a large bet was at stake! This regular scene of valsalva pushing which is intended to speed up production has been proven to prolong the second stage of labour and decrease maternal satisfaction (Yildirim & Beji, 2008), yet the practice continues.

The technocratic model of birth ignores the crucial importance of the mother-infant relationship. Physical and emotional wellbeing is vital to enable mothers to nurture 5

their offspring (Edwards & Murphy Lawless, 2006). Awareness of the need to let labour and birth happen at their own pace if progressing normally, and of the importance of the immediate postnatal period, is lost in the production line that is our maternity service. Midwives rarely witness the benefits of allowing a woman time to birth as nature intended and to witness the building of a relationship with her baby as it responds to her voice, her smell and the warmth and feel of her skin. After brief skin-to-skin contact, which is policy in most hospitals, babies are whisked away to be weighed, tagged, dressed, and when they fail breastfeed within the allotted time they are fed artificially to avoid the risk of a drop in blood glucose levels. When a well baby is left with its mother its body temperature will self-regulate, its blood glucose levels will remain stable, its senses will be heightened, and if not under the influence of the drugs of labour, the baby will in almost all cases spontaneously breastfeed if left undisturbed with its mother for a minimum of fifty-five minutes (UNICEF, 2009). Michel Odent (1984) in his practice in Pitheviers, had no clocks in the birthing rooms. He believed that time spent during the period immediately after birth should not be rushed. Ina May Gaskin (1977) describes beautifully the sense of awe and spirituality; the deep connections that are made during what she calls quiet birth. Michel Odents philosophy of maintaining close physical contact between mothers and babies shows beyond doubt the physical and psychological benefits of this practice without the need for randomised trials to prove it.

The ecstasy for a mother and her partner during this special time cannot be substituted yet the urgency of cleaning up after the birth, completing the paperwork and despatching the new family along the proverbial conveyor belt to the postnatal ward takes precedence. All evidence of the wonders of the birth is cleared away. Disempowered women who have had little or no control during their labour are rushed through the system, unaware of what their experience might have been. They may not know what they have missed; yet suffer from postnatal depression as a consequence (Goer, 1999). Cronk (2000) as cited by Leap & Edwards (2006) in Page & McCandlish (2006: 104) believes that the ability to make positive decisions around birth enforces a womans ability to care for her family. If her autonomy and sense of control in labour are taken away her confidence is diminished and this interferes with her ability to make future decisions. 6

Higgins (2002) describes the current situation where the medical model of care, efficient use of bed space and use of drugs in labour have interfered with the normal birth process and mother-infant attachment which she feels is harmful to society as a whole. The risk that medicalisation purports to prevent is in itself generating not only risk of damage but actual damage to mother-infant relationships. It is out of the hands of carers who must dance to the tune of a system that is economically, medically and technologically driven, where time is the currency in which they deal. She is concerned that as the majority of midwives work primarily as obstetric nurses, it will be difficult for pre-registration midwifery students, who she believes will be better equipped to provide appropriate midwifery care to gain appropriate experience, as most of their practice placement will be in large obstetric-led institutions where labour and birth are actively managed. This situation has come to pass. The experience of the author and her fellow students is indeed as Higgins predicted. These students must endeavour to carry the torch of those who have tirelessly worked to support midwives in making birth better for women. They must hold firm to the ideals which in time will prove the long-term value to society of getting it right.

Pockets of change have developed in Ireland but like the Albany Midwifery Practice in South London which met its demise in March of this year despite its overwhelming benefits to that community, and with perinatal mortality rates well below the national and local averages (Albany Midwives, 2010), midwifery-led services here are under continual scrutiny from the establishment. Nolans 2002 assessment of the 1993 UK Changing Childbirth seminal report shows that women of all social classes desire a return to normal birth. Nolan (2007) believes that maternity services improve when women and midwives work together and that childbirth organisations that advocate for better services do make a difference though the pace of change is slow.

Murphy-Lawless (1998) at the launch of her book Reading Birth and Death, proposed that we redefine our labours and the moment of birth not as empty time to be got through but as a sort of happiness, an intensity, a completeness, a memory that in its crystal clarity lives as long as we do. The mindsets of women, midwives and medical personnel need to change in order to effect change at 7

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Wagner M. (2000) Technology in birth: First do no harm. Midwifery Today. Retrieved from http://www.midwiferytoday.com/articles/technologyinbirth.asp on 16 May 2010. Wagner M. (2001) Fish cant see water: the need to humanize birth. International Journal of Gynecology and Obstetrics 75, S25-S37. World Health Organisation (1985) Having a baby in Europe. Report on a Study. The Office, WHO Publications Centre, USA. Wren M. (2003) Unhealthy State. Anatomy of a Sick Society. New Island, Dublin. Yildirim G. & Beji N.K. (2008) Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth 35(1), 25-30.

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