UK’s new birth agenda: “Maternity Matters”

So, I didn’t think I’d be doing much blogging over my holiday, but as luck would have it, there’s a big debate about birth occurring in England right now—so big it’s been splashed across the pages of many of the newspapers I’ve been reading, and absolutely impossible to ignore. UK Health Secretary, Patricia Hewitt, recently released a new document entitled Maternity Matters which outlines the UK’s proposed new agenda to provide consistent, individualized midwifery care and increased birth choices within the NHS by the year 2009. Looking through the document and the changes it proposes, I can only cheer; Maternity Matters is aiming to provide improved safety, accessibility and continuity of care to all women in the UK, including a choice gaurantee:

    “By the end of 2009, women will be able to have:

    – choice of how to access maternity care – women will be able to go directly to a midwife or via a doctor.

    – choice of type of antenatal care – women will be able to choose between midwifery care or care led by both doctors and midwives

    – choice of place of birth – depending on their medical history and circumstances, women and their partners will be able to choose between home births, or giving birth in a midwifery unit or with midwives and doctors in hospital

    – choice of place of postnatal care – women will be able to chose how and where to access postnatal care.”

If these changes are adopted, homebirth in the UK will become a viable option again for many women with uncomplicated pregnancies who meet certain low-risk criteria. From a London Times article on the subject:

    At the moment just 2% of deliveries in England take place at home but midwives believe this could increase to a third of all births.“The proportion of overall deliveries at home remains static at 2% and we believe that, given a genuine, properly-supported choice many women would choose a home birth,” said Lewis.

    “Part of this strategy is to ensure that a home birth becomes a serious and realistic option. …“We know that, if we look at the evidence from other countries, where women have the confidence and support to make this a safe option, there is evidence of a significant increase in women choosing home births.”…

    In Holland a third of all women give birth at home. In Wales, where 3% of deliveries are home births, the Welsh assembly has set a target of 10% by the end of this year. In Scotland 1% of births are at home while the figure for Northern Ireland is 0.4%. Devon is the English county with the highest number of women giving birth at home, with a rate of 5%.

    Belinda Phipps, chief executive of the National Childbirth Trust, said: “If Holland can manage 30% of all births taking place at home then Britain can do the same.

Of course, this will require a careful assessment of the resources available, as well as a large increase in the number of midwives in the UK (right now, the Royal College of Midwives estimates that the UK is several thousand midwives short of what will be needed to implement these target goals), but listening to a BBC radio interview with Health Secretary Patricia Hewitt, I was encourged to hear how carefully customized the approach will be, examining the needs of each primary care trust, and assessing what resouces are needed to make these proposed changes reality by 2009. If these changes are implemented as proposed, I think the results will be absolutely outstanding.

I say “if”, however, because while I was in England, I was amazed by the amount of negative press I kept seeing on this proposal. If the media’s very loud, very uninformed voice is able to sway public opinion on this matter, I fear these changes will never become reality. Nevermind the BBC interview above, where the interviewer began bullying and interrupting Patricia Hewitt before she could even finish explaining what the proposal was all about—other authors have written even more poorly researched and grossly stereotyped articles. For example, Alice Miles’ London Times article Natural birth! Hello? This is the 21st Century:

    Yet we must do more than chuckle, for Maternity Matters is no joke. It is the next stage in a midwife-led campaign to limit the choice available to women giving birth. …A “normal” birth . . . birth without medical intervention: why? Why should we? This is an extraordinary conspiracy against women, a sort of quasi-religious belief in the virtue of pain, which Ms Hewitt is bafflingly encouraging. …We are not expected to have our hips fixed naturally. We are not even expected to endure a mild headache without a paracetamol. Yet somehow the deeply painful and, for some, traumatic experience of giving birth is forced upon woman after woman in the name of some Earth Mother concept. …These midwives trained to help women give birth are for some reason trained only to help them give birth naturally. They are the chief conspirators against us. Please, let us have fewer of them, not more, Ms Hewitt.

Good gods! She’s on a mission, that’s for sure. And while I do feel that on some level this article is motivated by a deep-seated fear of pain, there are several things which must be addressed here. First of all, no one here is proposing to FORCE a woman to have a natural childbirth. Nor do I think it’s the normal modus opperandi of midwives to ignore a woman in pain, or to ignore her desire for pain relief; yes, midwives are trained to help women give birth naturally—we are specialists in normal birth—but I can’t imagine any situation where pain medication would be refused, if that’s what a woman wants. It seems to me that what this proposal is doing is trying to offer more choice, not less. Birth with epidural anesthesia is already widely available and the norm for many women in the UK; for those women who feel very strongly about pain relief, they have the option of planning for a birth in the hospital, with their epidural waiting for them on arrival. They have always had this option, and no one is going to take that away. But for those women who would prefer to have their child at home, and who often encounter resistence of difficulty in pursuing this option, the UK’s new proposal is simply intending to make this choice more readily available to them as well.

While Miles seems to be painting homebirth as a backwards, Luddite option, something akin to squatting behind a bush, and a choice only made by ludicrous, fringe elements of society—earth mothers and hippies—in actuality, research has shown that a planned homebirth for a low risk woman, with emergency transport arrangements made in advance and trained care providers (that would be those natural-birth obsessed midwives, Ms. Miles) attending, is just as safe as hospital birth. Period. In painting homebirth as a choice made by the fringe, she’s mocking and alienating all of the women who make that choice, and who probably wouldn’t consider themselves earth mothers or hippies at all. And who in their right mind would compare childbirth to having your hip fixed? In one case, something is seriously wrong, and needs immediate repair; in the other case, usually nothing is seriously wrong, your body is going about a perfectly healthy, normal process that it has, in fact, been painstakingly designed to do (from an evolutionary perspective), and which often works best when medical intervention is avoided.

Maybe a “predictable, pain-free [cesarean] birth…with a sugeon I had met and trusted, accompanied by lots and lots of drugs” is what Miles would advocate, but the entire point of this is informed consent. Advocating for planned cesareans across the board is just as obsessed and single-minded as painting all women who choose homebirth or pain-free birth as freaks. Nevermind the fact that solid research has shown that cesarean birth is nearly four times as risky as vaginal birth; what about the postpartum pain? A cesarean is major abdominal surgery, with a very slow, very painful recovery period afterwards. If you’re trying to avoid pain, it seems like having a cesarean is a very poor way of going about it.

Birth is always a surprise, and doesn’t always go the way you expect it to (sort of like parenting); those who plan homebirths sometimes end up having to go to the hospital. Those who plan natural childbirth sometimes find that they need pain medication. Those who plan to get an epidural the second they walk through the hospital door sometimes end up having their babies in the car on the way to the hospital, or arrive fully dilated and pushing, and deliver before they can even ask for pain relief. Things don’t always go as planned: that’s part of the beauty of birth. But scheduling a cesaraean before you even know if your birth will medically require one is signing up for major abdominal surgery, point blank, with all of the risks inherent in that, and not even giving your body the chance to try to deliver normally (i.e. vaginally).

Cotton-Pickin’ Days makes another good point in response to Miles:

    Guess what, honey? All those drugs and a pain-free birth is just momentary denial. Childbirth and parenting are meant to be painful. It’s what makes you appreciate your children so much more. What’s worth doing in life takes effort and if you think that it’s possible to glide through childbirth, you’re sadly mistaken. Even if a c-section appears to be the tidiest way to go about giving life to children, it isn’t. And it’s wrong to tell women who’re considering their options that your way is the best.

And meanwhile, over at the Guardian, another of Britain’s largest newspapers, Catherine Bennett was also hard at work slamming Maternity Matters in her column: While women in the developing world are dying in childbirth, why are we fetishising doing it at home? While I think the root of this article is lodged firmly in the time-honored tradition of grousing about NHS expenditures, and the decision to prioritize, and therefore spend more resources on birth and on women’s satisfaction with their births, the article nevertheless comes off as poorly researched and highly patronizing.

Bennett begins by focusing on how dangerous birth is, stating that the “consequences [of birth] for at least 529,000 women a year are fatal”. While she acknowledges the inequalities in these statistics, where the risks are obviously higher in undeveloped countries versus developed countries, the underlying message is that despite these advances in developed countries, birth is still a dangerous and risky business, and the women and organizations which support homebirth and the idea that birth is not a medical condition are clearly deluding themsevles, recklessly and arrogantly putting their own lives and the lives of their children at stake. “Such is the hostility to medicine among some natural-birth enthusiasts that doctors are presented as a greater risk to a mother’s health than childbirth”. Which then, of course, leads her to the crux of her argument: how selfish and willfully negligent it is to demand or want a satisfying birth experience, and why should the NHS be spending its limited resources on womens’ satisfaction?

    ‘Sometimes, even the most fanatical home-birthers have to accept that natural isn’t synonymous with safe. “Our own birth story was as far from perfect as we could have envisaged” posts a mother whose home birth was replaced by a caesarean, following a diagnosis of pre-eclampsia. “My overhwlming feelings in the 48 hours after the birth were of failure.” The baby, you gather, was completely fine.’

Ah, yes. The baby was fine. That classic, soul-destroying argument of “you have a healthy baby, why are you complaining?”, as if a healthy baby, and a healthy outcome, is the only imporant criteria by which satisfaction can be measured. How many times have I heard this used against women? How many times have I seen this argument whipped out to quiet, or perhaps comfort, a woman’s sense of disatisfaction or failure or guilt regarding her birth? You have a healthy baby, shut up and be grateful.

Which is not in any way to deminish how important the health of the baby and mother are, of course. There are certainly times in birth when things don’t go as planned, and a diagnosis of pre-eclampsia is certainly something which must be taken very seriously, but trying to silence a woman’s grief by focusing only on the baby implies that her grief is selfish and egotistical. She becomes caught in this strange paradox where her own feelings are unacknowledged and unaccpetable, and why does she feel so sad and upset when everything turned out just fine? Our society’s constant focus on the baby, the baby, the baby as the only measure of a successful birth is one of the chief contributing factors to our society’s high rates of postpartum depression and birth-related post traumatic stress disorder. So long as we continue to use the health of the baby as the only criteria of a successful birth, we will continue to see advances in “fetal-rights” which place the importance of the baby over the rights of the mother. One has only to look at the fetal rights movement in our own country to see the terrifying implications of this, where pregnant women are losing their constitutional rights and blaming and prosecuting pregnant women in the name of their fetus is becoming de rigeur.

Comparing birth in undeveloped countries to birth in a developed country is a fruitless endeavor, and I still don’t understand why Bennett decided to even mention this in her article in the first place. Unfortunately, women in undeveloped countries are often grossly malnourished, receive little or no prenatal care, have limited access to skilled birth attendents, are often remote from emergency medical care, and practices such as female genital mutilation and epidemic disease, such as HIV, are often rampant, all of which make birth a much riskier undertaking. A low-risk birth in London is a world away from a low-risk birth in sub-Saharan Africa; the two are not comparable, and quoting WHO statistics on world maternal mortality has very little bearing on the fact that a homebirth for a healthy, low-risk woman receiving prenatal care from the NHS, with swift and immediate transport to medical facilities as necessary, can be just as safe as giving birth in a hospital, and is, and should be, a viable option for women in England. As for the argument regarding precious NHS resources, a homebirth is always going to be less expensive than a cesarean, and avoidance of a hospital-stay, which uses hospital staff and resources, will probably prove to be highly cost-effective.

In the end, all I can say is this: best of luck to you, England! Whether Maternity Matters is a success or not (and I certainly hope it will be!), you get huge props just for proposing such changes in the first place. The very idea of individualized, universal midwifery care, with increased choices and rights for birthing women, including homebirth as a real and viable option for low risk-women, is something that the US is years, if not centuries, away from embracing.

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