Reclaiming Midwifery Care as a Foundation for Promoting ‘Normal’ Birth

by Maggie Banks This paper identifies some essentials of midwifery practice and looks at how the woman who may have additional care needs receives woman-centred care. Breech presentation will be used by way of example to demonstrate the latter. Childbirth is neither ‘normal’ nor ‘abnormal’. It is, quite simply, a childbirth journey – a unique experience for each individual woman. The recognition of each woman as distinctly individual is fundamental to midwifery philosophy and the provision of woman-centred care.[1] Without such recognition, maternity care is practitioner- or institution- centred. It is frequently cited that eighty-five percent of women can give birth to their babies without interventions or problems. Yet maternal and perinatal morbidity reflect a different reality. The ‘norm’ of childbirth has shifted and the usual does not reflect the childbearing woman’s true capacity to give birth. Instead the norm is reflective of the aberration of medicalised childbirth and the many unnecessary interventions that are performed on women. Suzanne Arms calls this new norm ‘typical’ birthing. In her video, Giving Birth: Challenges and Choices, Arms lists withholding of food; artificial rupture of membranes; medical induction or augmentation of labour; intravenous fluid administration; epidural anaesthesia and perineal suturing amongst an extensive list of typical birthing interventions in America. She draws attention to the fact that there are few births that occur without at least five of these interventions. As medicalised childbirth has become entrenched the healthy process of giving birth has become more illusive and is seldom attainable for women in the readily available maternity service. The 1999 report of births in Victoria during 1988 and 1989, the Australian Senate’s Rocking the Cradle, states “only 11% [of women] had a spontaneous labour and a spontaneous delivery without an epidural or a tear requiring stitches”.[2] The New Zealand figures are less explicit only because data is not kept that specifically identify the number of women who give birth without any interventions. However the New Zealand Ministry of Health reports approximately sixty-seven percent of women did not have operative deliveries or Caesarian sections in the 1996/97 twelve month period. There were over 60,000 procedures performed during the births of just over 57,000 live born babies.[3] Clearly, New Zealand and Australia share a childbirth picture in common – interventions in childbirth are occurring when they are unnecessary and a medical model of birth is dominant. Given these statistics it is fair to say that if well women with well babies are unable to birth without unnecessary intervention and trauma with usual maternity services, it is highly unlikely that women with additional health care needs will be able to do so. Whenever women are allocated a risk label there will be an accompanying pathology that is anticipated. Care will be organized around the ‘risk factor’. All the woman’s uniqueness will merge into the background as her care centers around the fear entrenched and litigation driven principle of ‘just in case’. The only way to ensure that care remains specific to the individual woman is to encompass the foundations of woman- centred care which have been identified as essential, some of which are as follows:

Continuity of care & caregiver

Women wish to have continuity of care from a known and trusted caregiver throughout the entire pregnancy, labour and birth and postpartum period. Women do not want fragmented care from multiple caregivers who provide inconsistent and conflicting information.[4] This continuity of care encompasses:

• Pre-conceptual care
• Pregnancy testing
• Antenatal health care
• Preparation for birthing and parenting
• Care during labour, including the facilitation of birth
• Management of any necessary emergency measures until appropriate medical assistance is available
• Support and facilitation of breastfeeding
• Postnatal care for mother and baby for four to six weeks after birth
• Contraceptive/family planning care and education
• Transfer to ongoing well child services (as appropriate) following completion of the childbirth continuum.
• Consultation or referral to the medical specialists if additional health care needs necessitate their input at any stage in the continuum This may include a haematologist, cardiologist, endocrinologist, obstetrician, paediatrician and so on.

The appropriate caregiver

The most appropriate health professional to provide continuity of care in the healthy childbearing experience is the midwife. It is the midwife who has the complete range of skills necessary to provide the total maternity service for well women and their babies. The midwife is the only health professional specifically educated for this purpose and the only one who can organise her practice structure accordingly. While midwives can and do provide this whole service without obstetricians and/or general practitioners, these latter practitioners cannot, and do not, provide a total maternity service without midwives. When obstetricians are involved in birthing, women are more likely to experience the births of their babies as operative or surgical procedures. In 1996 the New Zealand College of Midwives undertook a study of 2,212 births to examine outcomes of the different maternity care providers. The study grouped women into the following:

• Those who chose full midwifery care and
• Those who had shared-care between:
  • A midwife and a general practitioner or
  • A midwife and an obstetrician.

The women studied were very similar to the usual childbearing population in age; number of children; socio-economic background and pregnancy related alerting factors, commonly called ‘risk factors’. Thus the study population was not selected on of the presence or absence of a ‘pregnancy condition’. There were more normal births; fewer Caesarian sections; fewer vacuum extractions and fewer forceps deliveries with sole midwifery care than in any shared-care type. Breastfeeding rates at six weeks were also highest and the perinatal mortality rate was lowest.[5] The care of the obstetrician is appropriate to provide ‘advice, support and expertise’ to those women who have additional health care needs.[6]

Informed choice and informed consent

To make informed choices and give informed consent a woman requires necessary and individually appropriate information to be given to her. This information needs to be based on unbiased evidence and to be given in a manner and at a time when she is able to consider and question its implications.[7] The most appropriate time for this process of exploration is the antenatal period when time is most available to repeat, interpret and expand on information. It is a major component of the antenatal midwifery process and fundamental to effective birth planning and the empowerment of women in childbirth. Whether a birthing experience has culminated in a natural birth at home or a Caesarian section in hospital, the woman who has had the opportunity and been supported to make her own decisions, is more likely to have felt in control of her birthing experience and to be in a position to start her mothering well.

Appropriate care

The World Health Organisation in its 1996 document, Care in Normal Birth: A practical guide, draws attention to a woman’s ‘birthing potential’, that is, the realm of possibilities that could eventuate given a woman’s individual circumstances. This birthing potential is dependant and interlinked with social, environmental and cultural factors as well as the physical characteristics of health. It notes that all valuable health care results from being guided by ‘alerting factors’ – things which may pose a problem for a woman and baby but which may not eventuate. [8] Thus it is possible to get past thinking of ‘risk management’ and the practice of subjecting a woman to unnecessary interventions that are performed ‘just in case’ there is a problem.

Evidenced-based practice

All maternity care needs to reflect ‘best practice’ principles. Evidence drawn from across the disciplines that shows a particular form of care has proven to be beneficial needs to be incorporated into practice. That which has proven to be unbeneficial should be discarded. However this still leaves a very large proportion of maternity care which, when one searches the authoritative sources of literature such as the Cochrane Collaboration, frequently states ‘there is not enough evidence to evaluate the effects of …’. Midwives working in continuity of care are well placed to take an in depth look at the implications of care for the individual woman. We are also well placed to employ the use of ‘thoughtful exchange’ to reflect on and critique appropriate care for women and their babies based on our experience.[9] It is this thoughtful exchange that, in the absence of definitive answers, is most likely to ensure care is beneficial. We need to inform women of any lack of definitive answers. There is an expectation that there are guarantees of perfect outcomes with childbirth. Maternity care providers have fostered the notion that ‘doing something is better than doing nothing’ since the introduction of a high tech approach to birth. It has lulled women and health professionals alike into a false sense of security that by providing the very best of appropriate care we can always avoid an unexpected outcome. It is this fallacy of guarantees and the unreal expectation of perfection in a process ultimately beyond our control that has fuelled the litigation apparent in maternity services today.

Woman-centred care and potential for additional health care needs

When one considers these tenets of midwifery care mentioned above, the presence of any alerting factor does not alter the integrity of woman-centred care. Considerations remain individually determined. To illustrate how this occurs aspects of the label associated with a breech baby will be examined. Rather than being subjected to a highly interventionist birth – an elective (but mandatory) Caesarian section – simply because her baby is presenting breech, woman-centred care exposes the flaws in such an approach. A picture can be build up that helps to differentiate between potential for an individual baby and woman and ‘risk’ for all breech babies, as follows:

The ‘evidence’

The Toronto Term Breech Trial, a multinational trial studying outcomes for mother and baby, ended in April of last year. The study compared perinatal and maternal morbidity and mortality differences between planned vaginal deliveries and planned Caesarian sections when the baby was in a flexed or extended legs breech presentation at term. The findings were as follows:  

“Planned Caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.” [10]

Publication of results with a commentary[11] urging quick dissemination of findings will certainly be effective in shutting down women’s options to give birth naturally to their breech babies.

Mandatory Caesarean section

To give a blanket statement that all breech babies should be born by Caesarian section is very problematic. It will result in a great deal of fear for those women (approximately a quarter of all breech presentations[12]) whose babies are not diagnosed as breech presentations until labour, a good proportion of whom will go on to rapidly give birth. Within the study 9.6 percent of babies were born vaginally despite their allocation to the Caesarian section group. This is unlikely to change therefore vaginal breech births will continue to occur – not only accidentally but, as experience shows, because of women’s choice. The skills to assist women giving birth to their breech babies remain essential.

Randomized controlled trials

As with all randomized controlled trials both the study and control groups of the Term Breech Trial did not have a “strong management preference”.[13] The act of giving birth in highly interventionist childbirth cultures will automatically see those women who wish to achieve natural childbirth exclude themselves from randomization. As this self-excluding group was not studied it is unknown whether the results are generalizable to those women who have a strong preference for natural breech birth.

Considering how intervention can cause the problem

It is commonly acknowledged that cord prolapse is a concern specific to the breech baby. Cord prolapse is more specific to pre term babies who are less likely to have a good sized buttocks to cover the cervical opening. It is also these pre term babies who are more likely to present as footling breeches – again a factor that predisposes to cord prolapse.[14] Obstetric interventions can turn a potential risk into an actual complication. A recent study[15] reported in the American Journal of Perinatology examined the circumstances surrounding umbilical cord prolapse for eighty-seven women. It was found that in forty-one cases (forty-seven percent of the study group) obstetric practices – including breaking of waters; application of ‘scalp’ electrodes and intrauterine pressure catheter insertion – preceded umbilical cord prolapse. Rather than pointing to evidence that therefore all breech babies should be born by Caesarian section to avoid cord prolapse, how to avoid the problem becomes highlighted. The most appropriate form of monitoring with a breech baby is the non-invasive Pinard stethoscope or other external forms of monitoring so the membranes are left intact to provide the cushioning pool of waters.

Midwifery practice

A spontaneous onset of labour; upright and woman-led positions; normal healthy muscle tone that has not been decreased by epidural anaesthesia; a baby who is not debilitated by sedation and epidural anaesthesia optimize the likelihood of healthy birthing. These are all strategies to the midwifery model of care. The Term Breech Trial did not embrace the distinct and separate style of care that the midwife provides when facilitating the act of giving birth. Instead this evidence is only cognizant of medical management of vaginal breech birth. Seen in this light of medicalised birth, the study gives a well-rounded overview of the perinatal morbidity and mortality with such management. However, it remains of dubious relevance to woman-centred care and midwives need to consider the relevance of the findings to their practice.

Conclusion

As mentioned previously, medicalised birth has colonized the act of healthy birthing for women and babies who have no additional health care needs. When one is seeing monthly Caesarean section rates of between thirty-one and thirty- three percent at a tertiary obstetric and neonatal facility catering for approximately two hundred and fifty births a month along with a ten to twelve percent instrumental delivery rate, this means just over half of births in that same facility will be experienced as ‘normal’ births.[16] These so-called normal births are vaginal births without the use of forceps or vacuum extraction. The women may still have had inductions or augmentation of labour; narcotics; epidurals; episiotomies; sutured lacerations; post partum haemorrhages; intravenous fluids or blood replacements; manual removals and so on. If the knowledge and practice of supporting well women to give birth to well babies has been lost to such a degree, there is minimal likelihood that the woman or baby needing additional expertise will be able to access it. Women who have extra considerations in their pregnancies can be overwhelmed with the negative view that health professionals have about their pregnancy. Even women who are very knowledgeable and assertive can feel intimidated by the barrage of pathology that is aimed at them and their unborn babies. Our focus on every woman receiving woman- centred care, irrespective of additional heath care needs, must be maintained. It is every childbearing woman’s birthright to be supported as a unique individual throughout the childbirth continuum. The politics of birthing have divided maternity services into those things that a midwife ‘can and cannot’ do. To contemplate where we stand in relation to supporting women in their informed choices in childbirth is to contemplate the very essence of midwifery. We must never forget that midwifery is about being ‘with woman’. Providing woman-centred care is not without its own challenges. It upsets the dominant players (medicalised practitioners) and the way obstetric services are currently ordered, that is, with institutional expedience in mind. It is my experience and that of other midwives who practice the woman-centered way of midwifery that the road is not easy. However, no midwife can afford to take a position of distance and aloofness from the woman, isolating her in her journey. The consequences for the woman of losing her midwife’s knowledgeable companionship are too great and there is too much at stake – a healthy and uninjured mother and baby who are well placed to start mothering and maturing – the next step in the continuum of childbearing.

References

1. New Zealand College of Midwives. (1993) Midwives Handbook For Practice. Author: New Zealand. P. 48.
2. Senate Community Affairs Reference Committee (1999, December) Rocking the Cradle: A Report into Childbirth Procedures. Australia. P. 109.
3. Cited in Banks, M. (2000) Home Birth Bound: Mending the broken weave. Hamilton: Birthspirit Books. Pp. 30-33.
4. National Health Committee. (1999) Review of Maternity Services in New Zealand. Author: Wellington.
5. Guilliland, K. (1998, July) “Midwives and Midwifery – Leaders in Safe Maternity Care.” New Zealand College of Midwives National Newsletter. Pp. 1-3.
6. H.M.S.O. (1993) Changing Childbirth. Part 1: Report of the Expert Maternity Group. London: Author. P. 41.
7. Ibid. P. 10.
8. World Health Organization. (1996) Care in Normal Birth: A practical guide. Maternal & Newborn. Health/Safe Motherhood Unit. Geneva. P.2.
9. “The Canadian Consensus on Breech Management at Term.”, retrieved 8 February 1998.
10. Hannah, M.A.; Hannah, W.J.; Hewson, S.A.; Hodnett, E.D.; Saigal, S.; Willan, A.R. (2000, October 21) “Planned caesarian section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial.” The Lancet. Vol. 356. Issue 9239. Pp. 1375-1383.
11. Lumley, J. (2000, October 21) “Any room left for disagreement about assisting breech births at term?” The Lancet. Vol. 356. Issue 9239. Pp. 1368 -1369.
12. Nwosu, E.C.; Walkinshaw, S.; Chia, P.; Manasse, P.R. & Atlay, R.D. (1993, June) Undiagnosed breech. British Journal of Obstetrics & Gynaecology. Vol. 100. Pp. 531-535.
13. Term Breech Trial Newsletter. Vol. 4. Issue 6. June 30, 1998.
14. Banks, M. (1998) Breech Birth Woman-Wise. Hamilton: Birthspirit Books. Pp. 22-23.
15. Usta IM, Mercer BM & Sibai BM. (1999) “Current obstetrical practice and umbilical cord prolapse.” American Journal of Perinatology. Vol 16. No 9. Pp. 479-484.
16. Macfarlane, M. (2000, 7 November) Child & Women’s Health Maternity Statistics. Health Waikato Ltd PIMS data