Enabling a woman to give birth physiologically must surely be every midwife’s aim. The whole philosophy of midwifery rests on the knowledge that birth is a normal bodily function for a woman that requires a conducive environment and an experienced companion to watch for problems that may occasionally develop. This “experienced companion” has traditionally been the midwife.
The encroachments of the medical model in the birth process have deskilled many midwives and led to many becoming “obstetric nurses” who watch over the technical equipment and carry out the doctor’s instructions (i.e. the protocols).
They often interact as little as possible with the labouring woman herself. Our hospitals are full of “obstetric nurses”, though some of them would call themselves “midwives”, and this situation may be a major factor in the rising rates of intervention in birth. Where are the midwives who understand normal birth and are comfortable working with women to achieve a natural, normal birth without the need for drugs and technology? Are midwives disappearing?
The “active birth” concept grew out of a response to the “active management of labour” protocol, promoted by obstetricians enamoured of the Dublin model of birth1. Although unproven as a means of keeping birth normal, the inclusion of a supportive role by a midwife has been shown to be the one factor in the protocol that kept the caesarean section rate down2. The central involvement of the midwife in carrying out this protocol may have been one factor in their medicalisation as a profession and their loss of confidence in facilitating normal birth without drips, drugs and close monitoring.
What are the characteristics of an “active birth”? This approach to birth was originally based on a training program that women underwent in pregnancy that revolved around yoga3. As the fundamental concepts evolved through practical application and experience, a broader definition has emerged, that can be summarised in these basic principles:
Enable normal physiology during birth.
This principle relies on the caregivers having a sound understanding of normal physiology, including the role of pain in labour, the interaction of the hormones during birth and the wide range of natural responses that women may exhibit as they react to the natural forces inherent in the birth process. Midwives whose education and experience has been based in hospital settings will have a limited understanding of normal physiology due to the influence of the institutional environment on a woman during labour. This could be rectified by requiring midwifery students to have experience of home births during their education and qualified midwives to include participating in home birth as part of their registration requirement.
Do not disturb normal physiology
Birth is a normal body process for a woman, that is most effectively carried out in settings where she carries out her other normal bodily functions, i.e in her own home or appropriate community based settings. We don’t go to hospital to eat or sleep and especially not for our other reproductive activities! Disturbing the birth process can occur through the use of learned behaviours and also by direct intervention.
Learned behaviours can be initiated either by the woman herself or by caregivers. Women sometimes believe that using “the breathing” ( a prime example of a learned behaviour) will enable them to labour more effectively and reduce the pain. Applying an unnatural breathing pattern is an intervention that carries the risk of disturbing blood chemistry and it has not been proven to improve birth outcomes or reduce labour pain. Promoting “the breathing” also suggests that women’s bodies will not be able to manage this function automatically during labour, potentially undermining her confidence in her own body’s ability to give birth. It could also be seen as an insult to nature. The fact that many writers still incorporate strategies for “learning how to breathe during birth” into their books for expectant parents feeds into the notion that women are incapable of giving birth instinctively.
Learned behaviours applied by caregivers involve the use of the many protocols and routines that surround birth in hospital settings. When midwives routinely apply birth management protocols to every woman in their care, they are not only disturbing the unique nature of birth for each woman, but failing to carry out the most basic premise of their duty ; to first do no harm. Woman centred care, revolving around her unique needs is the best way to ensure safety and positive outcomes. The blanket application of inappropriate protocols is not only potentially dangerous for mother and baby, but is the hallmark of the obstetric nurse carrying out the doctor’s orders, rather than the midwife acting in her own professional capacity.
Interventons of all kinds carry the potential to disturb the natural flow of labour. These can take the familiar form of drips, drugs, ARMs and monitors, but also encompass less often considered social interventions. These include: requiring births to take place in a hospital; restricting the number of chosen birth companions; limiting food and drink during labour; encouraging women to wear hospital clothes; even the application of wrist band identification carries messages that underline the institutionalisation of birth.
When intervention is necessary, there must be a clear medical indication.
Almost all women (85 – 90%) have the capacity to give birth safely without the need for outside help. Nature has provided women with the necessary instincts and natural talents. It can be said that birth is so safe and easy that almost always, any woman anywhere in the world, with no special education, training or experience, is capable of producing the next generation.
There will, however, be some women for whom giving birth will be hazardous, and it is for these woman and babies that all the obstetric procedures have been developed. Unfortunately, the basic premise of obstetrics is proactivity in seeking out possible problems whereas midwifery is grounded in being reactive – waiting until the problems appear before taking the necessary steps to correct the problem. The conflict between obstetrics and midwifery revolves around this difference in approach. Perhaps the only way to ensure that unnecessary intervention during labour does not occur may be to remove birth from the direct and indirect supervision of doctors, and the re-skilling of midwives to facilitate normal births in community settings. In the meantime, the have a mounting body of evidence to guide practice, all of which says that keeping birth normal through the adoption of midwifery principles is the the safest way to approach labour and that all interventions must be justified in terms of risks and benefits.
Normal births rely on good midwifery practice
Defining good midwifery practice is probably as difficult as defining “normal birth”, given that birth is a high individualistic journey for every woman. However, if midwifery is based on the premise that birth is a wellness condition and not an illness, then good midwifery revolves around enabling and facilitating the individual journey for the woman. The midwife will not impose her own views, needs or expectations, and understands that flexibility and openness are the hallmarks of being “with women”.
In simple terms, perhaps the easiest way to summarise “good midwifery” is to look at how the midwife behaves towards the woman: woman centred care and enabling her needs to be met are central concepts. In practice, this translates into: understanding that labour pain is normal and important to good birth outcomes; that women’s intuition and instincts will be her basic guide to successful birth; that unless there is a clear indication of a problem, then the reactions and responses of women during labour are probably just variations of the wide definition of “normal. Any midwife who uses drugs or other rescue remedies during labour (TENS, Entonox and complementary therapies included) is not practising midwifery but nursing.
Belief and trust in nature
Underpinning the whole profession of midwifery must be the belief that by developing a robust system that almost always works (and works well) nature has evolved a process for ensuring the ongoing success of our species. Millions of years has gone into refining its intricacies. Assuming that we can improve on nature through the manipulation and control of birth is arrogant and dangerous.
Alongside the need to develop a robust trust in nature, a strong and abiding belief that women can manage birth themselves must also be developed. Nature has given women the necessary instincts in a non-discriminatory way. Every woman has the capacity for safe and easy birth and we must celebrate her innate talents – this is what midwifery is all about.
- O’Driscoll, K & Meagher, 1980, D Active Management of Labour, W B Saunders Company, London.
- Thornton, J & Lilford, 1994, R Active Management of Labour: current knowledge and research issues, BMJ 309:366-9.
- Balaskas, J (1983) Active Birth, Unwin Paperbacks, Sydney
- This article first appeared in The Practising Midwife, Vol 5 No 7, August 2002