tag:theconversation.com,2011:/us/topics/midwifery-2969/articlesMidwifery – The Conversation2024-02-20T05:26:29Ztag:theconversation.com,2011:article/2238522024-02-20T05:26:29Z2024-02-20T05:26:29Z‘Free birthing’ and planned home births might sound similar but the risks are very different<figure><img src="https://images.theconversation.com/files/576666/original/file-20240220-28-49adlz.jpg?ixlib=rb-1.1.0&rect=22%2C143%2C2973%2C1850&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/couple-prays-together-wife-labors-birthing-477573283">In The Light Photography/Shutterstock</a></span></figcaption></figure><p>The death of <a href="https://protect-au.mimecast.com/s/mdtqCvl1EwSp8GrOUQvN9o?domain=dailymail.co.uk">premature twins</a> in Byron Bay in an apparent “<a href="https://www.naturalbirthandbabycare.com/wild-pregnancy/">wild birth</a>”, or free birth, last week has prompted fresh concerns about giving birth without a midwife or medical assistance.</p>
<p>This follows another case from <a href="https://www.theguardian.com/australia-news/2024/jan/06/baby-in-critical-condition-in-victoria-after-being-delivered-in-freebirth">Victoria</a> this year, where a baby was born in a critical condition following a reported free birth. </p>
<p>It’s unclear how common free birthing is, as data is not collected, but there is some evidence <a href="https://theconversation.com/during-covid-19-women-are-opting-for-freebirthing-if-homebirths-arent-available-and-thats-a-worry-142261">free births</a> increased during the COVID pandemic. </p>
<p>Planned <a href="https://pubmed.ncbi.nlm.nih.gov/32994144/">home births</a> also became more popular during the pandemic, as women preferred to stay away from hospitals and wanted their support people with them.</p>
<p>But while free births and home births might sound similar, they are a very different practice, with free births much riskier. So what’s the difference, and why might people opt for a free birth? </p>
<h2>What are home births?</h2>
<p><a href="https://raisingchildren.net.au/pregnancy/labour-birth/birth-environment/homebirth-pregnancy-care-birth">Planned home births</a> involve care from <a href="https://midwives.org.au/Web/Web/About-ACM/Whats_a_midwife.aspx">midwives</a>, who are <a href="https://www.health.gov.au/topics/nurses-and-midwives/in-australia#:%7E:text=The%20Australian%20Health%20Practitioner%20Regulation,(NMBA)%20regulates%20nursing%20registrations.">registered</a> experts in childbirth, in a woman’s home. </p>
<p>These registered midwives work privately, or are part of around 20 <a href="https://www.uts.edu.au/about/faculty-health/school-nursing-and-midwifery/collective-midwifery-child-and-family-health/research/key-research-areas/publicly-funded-homebirth/national-publicly-funded-homebirth-consortium#:%7E:text=The%20National%20Publicly%2Dfunded%20Homebirth,and%20help%20sustain%20these%20models">publicly funded home birth programs</a> nationally that are attached to hospitals. </p>
<p>They provide care during the pregnancy, labour and birth, and in the first six weeks following the birth.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">Explainer: what are women's options for giving birth?</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/29727829/">The research</a> shows that for women with low risk pregnancies, <a href="https://pubmed.ncbi.nlm.nih.gov/31709403/">planned home births</a> attended by competent midwives (with links to a responsive mainstream maternity system) are <a href="https://www.thelancet.com/pdfs/journals/eclinm/PIIS2589-5370(19)30142-7.pdf">safe</a>. </p>
<p>Home births result in <a href="https://pubmed.ncbi.nlm.nih.gov/32280941/">less intervention</a> than hospital births and women perceive their experience <a href="https://pubmed.ncbi.nlm.nih.gov/32636161/">more positively</a>.</p>
<h2>What are free births?</h2>
<p>A <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">free birth</a> is when a woman chooses to have a baby, usually at home, without a registered health professional such as a midwife or doctor in attendance. </p>
<p>Different terms such as <a href="https://aucontemplativelife.wixsite.com/unassistedhomebirtha">unassisted</a> birth or <a href="https://www.naturalbirthandbabycare.com/wild-pregnancy/">wild pregnancy or birth</a> are also used to refer to free birth.</p>
<p>The parents may hire an <a href="https://pubmed.ncbi.nlm.nih.gov/29803611/">unregulated birth worker or doula</a> to be a support at the birth but they do not have the training or medical equipment needed to manage emergencies.</p>
<p>Women may have limited or no health care antenatally, meaning risk factors such as twins and breech presentations (the baby coming bottom first) are not detected beforehand and given the right kind of specialist care. </p>
<h2>Why do some people choose to free birth?</h2>
<p>We have been studying the reasons women and their partners choose to free birth for <a href="https://www.routledge.com/Birthing-Outside-the-System-The-Canary-in-the-Coal-Mine/Dahlen-Kumar-Hazard-Schmied/p/book/9780367506605">more than a decade</a>. We found a previous <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-02944-6">traumatic birth</a> and/or feeling coerced into choices that are not what the woman wants were the main drivers for avoiding mainstream maternity care. </p>
<p>Australia’s childbirth <a href="https://theconversation.com/too-many-healthy-women-are-having-their-labour-induced-for-no-identified-medical-reason-our-study-shows-161281">intervention rates</a> – for induction or augmentation of labour, episiotomy (cutting the tissue between the vaginal opening and the anus) and caesarean section – are comparatively high.</p>
<p>One in ten women <a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">report disrespectful or abusive care in childbirth</a> and some decide to make different choices for <a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">future births</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">More than 6,000 women told us what they wanted for their next pregnancy and birth. Here's what they said</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/32636161/">Lack of options</a> for a natural birth and birth choices such as home birth or <a href="https://theconversation.com/having-a-baby-at-a-birth-centre-is-as-safe-as-hospital-but-results-in-less-intervention-125732">birth centre</a> birth also played a major role in women’s decision to free birth.</p>
<p><a href="https://www.uts.edu.au/about/faculty-health/school-nursing-and-midwifery/collective-midwifery-child-and-family-health/research/key-research-areas/publicly-funded-homebirth/national-publicly-funded-homebirth-consortium#:%7E:text=The%20National%20Publicly%2Dfunded%20Homebirth,and%20help%20sustain%20these%20models">Publicly funded home birth</a> programs have very strict criteria around who can be accepted into the program, excluding many women.</p>
<p>In other countries such as the <a href="https://www.nhs.uk/pregnancy/labour-and-birth/preparing-for-the-birth/where-to-give-birth-the-options/">United Kingdom</a>, Netherlands and <a href="https://info.health.nz/pregnancy-children/labour-and-birth/where-to-give-birth/">New Zealand</a>, publicly funded home births are easier to access. </p>
<figure class="align-center ">
<img alt="Newborn baby holds their parent's finger" src="https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It can be difficult to access home birth services in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-holds-onto-their-fathers-1519293962">Ink Drop/Shutterstock</a></span>
</figcaption>
</figure>
<p>Only around 200 midwives provide private midwifery services for home births nationally. Private midwives are yet to obtain insurance for home births, which means they are risking their livelihoods if something goes wrong and they are sued.</p>
<p>The cost of a home birth with a private midwife is not covered by Medicare and only some health funds rebate some of the cost. This means women can be out of pocket A$6-8,000. </p>
<p>Access to home birth is an even greater issue in rural and remote Australia.</p>
<h2>How to make mainstream care more inclusive</h2>
<p>Many women feel constrained by their birth choices in Australia. After years of research and listening to thousands of women, it’s clear more can be done to reduce the desire to free birth. </p>
<p>As my co-authors and I outline in our book, <a href="https://researchdirect.westernsydney.edu.au/islandora/object/uws:58756/">Birthing Outside the System: The Canary in the Coal Mine</a>, this can be achieved by:</p>
<ul>
<li><p>making respectful care a reality so women aren’t traumatised and alienated by maternity care and want to engage with it</p></li>
<li><p>supporting midwifery care. Women are seeking more physiological and social ways of birthing, minimising birth interventions, and midwives are the experts in this space </p></li>
<li><p>supporting women’s access to their chosen place of birth and model of care and not limiting choice with high out-of-pocket expenses</p></li>
<li><p>providing more flexible, acceptable options for women experiencing risk factors during pregnancy and/or birth, such as having a previous caesarean birth, having twins or having a baby in breech position. Women experiencing these complications experience pressure to have a caesarean section</p></li>
<li><p>getting the framework right with policies, guidelines, education, research, regulation and professional leadership.</p></li>
</ul>
<p>Ensuring women’s rights and choices are informed and respected means they’re less likely to feel they’re left with no other option.</p><img src="https://counter.theconversation.com/content/223852/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC, ARC and MRFF</span></em></p>A free birth is when a woman chooses to have a baby, usually at home, without a registered midwife or doctor in attendance. It’s much riskier than a planned home birth.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2178032023-12-18T23:18:02Z2023-12-18T23:18:02ZWomen want to see the same health provider during pregnancy, birth and beyond<figure><img src="https://images.theconversation.com/files/566233/original/file-20231218-17-b7lsjp.jpg?ixlib=rb-1.1.0&rect=8%2C146%2C5742%2C3578&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mid-adult-female-nurse-comforting-tensed-228783766">Tyler Olson/Shutterstock</a></span></figcaption></figure><p>In theory, pregnant women in Australia <a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">can choose</a> the type of health provider they see during pregnancy, labour and after they give birth. But this is often dependent on where you live and how much you can afford in out-of-pocket costs. </p>
<p>While standard public hospital care is the <a href="https://www.aihw.gov.au/reports/mothers-babies/maternity-models-of-care/contents/about">most common</a> in Australia, accounting for 40.9% of births, the other main options are: </p>
<ul>
<li>GP shared care, where the woman sees her GP for some appointments (15% of births)</li>
<li>midwifery continuity of care in the public system, often called <a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">midwifery group practice</a> or caseload care, where the woman sees the same midwife of team of midwives (14%)</li>
<li>private obstetrician care (10.6%)</li>
<li>private midwifery care (1.9%). </li>
</ul>
<p>Given the choice, which model would women prefer?</p>
<p>Our <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-023-06130-2">new research</a>, published BMC Pregnancy and Childbirth, found women favoured seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">More than 6,000 women told us what they wanted for their next pregnancy and birth. Here's what they said</a>
</strong>
</em>
</p>
<hr>
<h2>Assessing strengths and limitations</h2>
<p>We surveyed 8,804 Australian women for the Birth Experience Study (BESt) and 2,909 provided additional comments about their model of maternity care. The respondents were representative of state and territory population breakdowns, however fewer respondents were First Nations or from culturally or linguistically diverse backgrounds.</p>
<p>We analysed these comments in six categories – standard maternity care, high-risk maternity care, GP shared care, midwifery group practice, private obstetric care and private midwifery care – based on the perceived strengths and limitations for each model of care.</p>
<p>Overall, we found models of care that were fragmented and didn’t provide continuity through the pregnancy, birth and postnatal period (standard care, high risk care and GP shared care) were more likely to be described negatively, with more comments about limitations than strengths. </p>
<h2>What women thought of standard maternity care in hospitals</h2>
<p>Women who experienced standard maternity care, where they saw many different health care providers, were disappointed about having to retell their story at every appointment and said they would have preferred continuity of midwifery care. </p>
<p>Positive comments about this model of care were often about a midwife or doctor who went above and beyond and gave extra care within the constraints of a fragmented system. </p>
<figure class="align-center ">
<img alt="Baby being cleaned after birth" src="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sometimes midwives and doctors in the public system exceeded expectations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-being-cleaned-assessed-by-paediatrician-1118249573">Inez Carter/Shutterstock</a></span>
</figcaption>
</figure>
<p>The model of care with the highest number of comments about limitations was high-risk maternity care. For women with pregnancy complications who have their baby in the public system, this means seeing different doctors on different days. </p>
<p>Some respondents received conflicting advice from different doctors, and said the focus was on their complications instead of their pregnancy journey. One woman in high-risk care noted:</p>
<blockquote>
<p>The experience was very impersonal, their focus was my cervix, not preparing me for birth.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">1 in 10 women report disrespectful or abusive care in childbirth</a>
</strong>
</em>
</p>
<hr>
<h2>Why women favoured continuity of care</h2>
<p>Overall, there were more positive comments about models of care that provided continuity of care: private midwifery care, private obstetric care and midwifery group practice in public hospitals. </p>
<p>Women recognised the benefits of continuity and how this included informed decision-making and supported their choices.</p>
<p>The model of care with the highest number of positive comments was care from a privately practising midwife. Women felt they received the “gold standard of maternity care” when they had this model. One woman described her care as:</p>
<blockquote>
<p>Extremely personable! Home visits were like having tea with a friend but very professional. Her knowledge and empathy made me feel safe and protected. She respected all of my decisions. She reminded me often that I didn’t need her help when it came to birthing my child, but she was there if I wanted it (or did need it).</p>
</blockquote>
<p>However, this is a private model of care and women need to pay for it. So there are barriers in accessing this model of care due to the <a href="https://doi.org/10.1016/j.wombi.2020.06.001">cost</a> and the small numbers working in Australia, particularly in <a href="https://www.ruralhealth.org.au/sites/default/files/publications/fact-sheet-midwives.pdf">regional, rural and remote areas</a>, among other barriers.</p>
<p>Women who had private obstetricians were also positive about their care, especially among women with medical or pregnancy complications – this type of care had the second-highest number of positive comments. </p>
<p>This was followed by women who had continuity of care from midwives in the public system, which was described as respectful and supportive. </p>
<p><iframe id="iRWBu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/iRWBu/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>However, one of the limitations about continuity models of care is when the woman doesn’t feel connected to her midwife or doctor. Some women who experienced this wished they had the opportunity to choose a different midwife or doctor. </p>
<h2>What about shared care with a GP?</h2>
<p>While shared care between the <a href="https://raisingchildren.net.au/pregnancy/health-wellbeing/tests-appointments/gps-shared-care-pregnancy">GP</a> and hospital model of care is widely promoted in the public maternity care system as providing continuity, it had a similar number of negative comments to those who had fragmented standard hospital care. </p>
<p>Considering there is strong evidence about the <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub5/full">benefits of midwifery continuity of care</a>, and this model of care appears to be most acceptable to women, it’s time to expand access so all Australian women can access continuity of care, regardless of their location or ability to pay. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birthing-on-country-services-centre-first-nations-cultures-and-empower-women-in-pregnancy-and-childbirth-170641">Birthing on Country services centre First Nations cultures and empower women in pregnancy and childbirth</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/217803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazel Keedle is affiliated with the Australian College of Midwives. Funding for this study was from a School of Nursing and Midwifery Partnership Grant through Western Sydney University, The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen has received funding from the National Health and Medical Research Commission, the Australian Research Council, the Medical Research Future Fund (funding and for this study and funding from a School of Nursing and Midwifery Partnership Grant through Western Sydney University), The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p>Women favour seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician.Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney UniversityHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114352023-09-05T02:39:09Z2023-09-05T02:39:09ZMore than 6,000 women told us what they wanted for their next pregnancy and birth. Here’s what they said<figure><img src="https://images.theconversation.com/files/545717/original/file-20230831-29-n7bhi3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-newborn-child-birth-maternity-hospital-1938100312">Shutterstock</a></span></figcaption></figure><p>Many women want a different kind of pregnancy and birth the next time around. Many want to see the same one or two midwives throughout, and want to choose where they give birth. And when the time comes, they want a vaginal birth, with less intervention. </p>
<p>This is what thousands of Australian women told us when we asked if they would do anything differently if they had another baby.</p>
<p>We publish our findings today in <a href="http://dx.doi.org/10.1136/bmjopen-2023-071582">British Medical Journal Open</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-why-do-babies-cry-when-they-come-out-of-their-mum-205477">Curious Kids: why do babies cry when they come out of their mum?</a>
</strong>
</em>
</p>
<hr>
<h2>What we did</h2>
<p>In 2021, we undertook Australia’s largest national study of birth experiences. As part of that, we asked women, “Would you do anything different if you were to have another baby?”</p>
<p>A total of 6,101 women left comments. More than 85% of comments were from women who said they’d do things differently the next time around.</p>
<p>Several themes emerged.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mondays-medical-myth-women-forget-the-pain-of-childbirth-12271">Monday’s medical myth: women forget the pain of childbirth</a>
</strong>
</em>
</p>
<hr>
<h2>‘Next time I’ll be ready’</h2>
<p>The largest group of comments (39.2%) were from women who wanted to avoid a repeat of their previous pregnancy and birth experience. They wanted to better advocate for themselves, get more informed about their choices, and avoid certain birth interventions. </p>
<p>For example, there were more than 500 comments from women who would try to avoid having their next labour started manually, known as an <a href="https://theconversation.com/too-many-healthy-women-are-having-their-labour-induced-for-no-identified-medical-reason-our-study-shows-161281">induction of labour</a>. </p>
<p>A woman from Western Australia, who ended up having a caesarean, said:</p>
<blockquote>
<p>I would 100% opt for no induction. I believe it’s the reason that led me to a c-section.</p>
</blockquote>
<p>Australia has a high rate of induction, especially for women having their first babies <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/onset-of-labour">(41% induced labour rate for women having their first baby)</a>. Women feel they are <a href="https://pubmed.ncbi.nlm.nih.gov/32146087/">inadequately informed</a> about the process of induction and not given a choice or alternative options.</p>
<p>We have also shown an induction of labour in Australia can lead to <a href="https://bmjopen.bmj.com/content/11/6/e047040">further medical interventions</a>. High rates of medical intervention, such as induction, can lead to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31472-6/fulltext">poorer</a> maternal and neonatal outcomes when used excessively. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/too-many-healthy-women-are-having-their-labour-induced-for-no-identified-medical-reason-our-study-shows-161281">Too many healthy women are having their labour induced for no identified medical reason, our study shows</a>
</strong>
</em>
</p>
<hr>
<h2>‘I want a specific birth experience’</h2>
<p>This was the second largest category (28.5% of comments). Here, most women said they wanted their next birth to be a vaginal birth (1,735 comments) and some would opt for a caesarean (438 comments). </p>
<p>Of the women wanting a vaginal birth, 1,021 comments related to wanting the next birth at home.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Newborn baby wrapped in towel, with mum holding wrinkly tiny fingers" src="https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545718/original/file-20230831-21-19g87w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many women wanted their next birth at home.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-holds-onto-their-fathers-1519293962">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">Explainer: what are women's options for giving birth?</a>
</strong>
</em>
</p>
<hr>
<h2>‘I want a specific model of care’</h2>
<p>Women also said they wanted to be better prepared by getting better support. This ranged from a more supportive partner, hiring a <a href="https://theconversation.com/what-is-a-doula-and-how-do-they-help-women-giving-birth-113562">doula</a> and choosing their care provider.</p>
<p>Some 17.8% of all comments, the next-largest group, identified a specific <a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">model of maternity care</a>. Women wanted to access a more supportive model that would respect their choices and wishes.</p>
<p>Most women in this group wanted “<a href="https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early">midwifery continuity of care</a>”. This is where women are cared for by one or two midwives throughout their pregnancy, labour and birth, and into the post-birth period.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Midwife or doctor measuring pregnant woman with tape measure" src="https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545862/original/file-20230901-16-laxk62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many women prefer to see the same one or two midwives throughout.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kind-obstetrician-examining-pregnant-belly-clinic-538015297">Shutterstock</a></span>
</figcaption>
</figure>
<p>A woman from Victoria, who told us she wanted continuity of care next time around, said:</p>
<blockquote>
<p>It is very important to me that next time I have a care provider who I fully trust, who has a good understanding of my birth preferences and who I know will be a strong advocate for me and who will encourage, empower, support and believe in me and my ability to birth my baby.</p>
</blockquote>
<p>Midwifery continuity of care is <a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">available</a> now in many public hospitals and is commonly called midwifery group practice or caseload midwifery. Some women access this type of care through private midwives. These charge a fee (there are some Medicare rebates) and can support women to have births at home.</p>
<p>But access to midwifery continuity of care <a href="https://www.aihw.gov.au/reports/mothers-babies/maternity-models-of-care/contents/about">is still limited</a> and booked out early, meaning many women miss out, especially if they live in regional or remote regions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">Call the Midwife: playing catch up with Australia's maternity care </a>
</strong>
</em>
</p>
<hr>
<h2>‘I want better access’</h2>
<p>This group of comments (2.9%) included ones from women in regional and remote parts of Australia.</p>
<p>They said they wished they had access to more local maternity services and equitable access to models that offer continuity of care and homebirth, such as private midwives. </p>
<p>A woman from a remote town in New South Wales said:</p>
<blockquote>
<p>If I ever fell pregnant again. I would move to a bigger town. Obstetric care in the bush is very much lacking. Rural women like myself are lucky to even be alive after our experiences.</p>
</blockquote>
<p>With many maternity units in rural and remote areas <a href="https://www.abc.net.au/news/2023-02-27/rural-remote-maternity-services-in-crisis-experts-have-solutions/102020056">shutting down</a>, women are forced to travel big distances and have fewer maternity care options than women who give birth in cities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pregnant woman driving, holding belly" src="https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545863/original/file-20230901-28-8sz7ov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pregnant women can end up driving long distances to access care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-driving-car-buttoned-belt-633963140">Shutterstock</a></span>
</figcaption>
</figure>
<h2>‘I don’t want to change anything’</h2>
<p>Some 10.2% of comments were from women who didn’t want to change anything the next time around.</p>
<p>Of these, just under half (47%) were from women who received midwifery continuity of care.</p>
<p>This is significant as midwifery continuity of care only represent <a href="https://www.aihw.gov.au/reports/mothers-babies/maternity-models-of-care/contents/what-do-maternity-models-of-care-look-like/major-model-category">15%</a> of maternity models in Australia.</p>
<h2>Why are birth experiences important?</h2>
<p>We’ve shown that many women who reflect on their experience of pregnancy and birth wish they had made <a href="https://www.sciencedirect.com/science/article/pii/S1877575622000854">different decisions</a> and wish they had a more positive experience to look back on. </p>
<p>A <a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">negative birth</a> experience can lead to <a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">birth trauma</a> and post-traumatic stress disorder. </p>
<p>Some of this may be unavoidable, such as when emergency situations arise during the labour. But trauma can also be related to the way women are <a href="https://journals.sagepub.com/doi/10.1177/10778012221140138">respected</a>, informed and cared for.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">So your birth didn't go according to plan? Don't blame yourself</a>
</strong>
</em>
</p>
<hr>
<h2>What happens next?</h2>
<p>What women are asking for is humanised, evidence-based maternity care. So it’s time to act if we are to avoid the type of experiences highlighted during the current <a href="https://www.parliament.nsw.gov.au/committees/listofcommittees/Pages/committee-details.aspx?pk=318">NSW Select Committee on Birth Trauma</a>.</p>
<p>With evidence from more than 4,000 submissions, this reminds us we often fail women during one of the most vulnerable, yet potentially transforming experiences in their life. We hope women’s voices are finally heard.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">1 in 10 women report disrespectful or abusive care in childbirth</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/211435/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazel Keedle is affiliated with the Australian College of Midwives. </span></em></p><p class="fine-print"><em><span>Daniella Susic is affiliated with UNSW Sydney, RANZCOG and MothersBabies. Funding for research has been received via RANZCOG.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC, ARC and MRFF. She is affiliated with the Australian College of Midwives </span></em></p>Many women want to see the same one or two midwives throughout, and want to chose where they give birth. And when the time comes, they want a vaginal birth, with less intervention.Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney UniversityDaniella Susic, Clinical Academic Obstetrician, UNSW SydneyHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2077532023-08-22T14:52:07Z2023-08-22T14:52:07ZSix pregnancy terms you probably won’t hear again, including ‘high risk’ and ‘failed’<figure><img src="https://images.theconversation.com/files/542983/original/file-20230816-17-towf59.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5152%2C3435&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The language midwives use is an important part of the care they provide.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-pregnant-woman-visit-gynecologist-doctor-1404770729">Blue Planet Studio/Shutterstock</a></span></figcaption></figure><p>Medical terminology evolves alongside our understanding of medicine. As time goes by, new terms are adopted while others are abandoned. In midwifery, there should always be a strong emphasis on the language we use, particularly in pregnancy.</p>
<p>In 2020, the Royal College of Midwives launched an initiative to discover the impact language has on women. The aim of the <a href="https://www.rcm.org.uk/rebirth-hub/">Re:Birth</a> project was to find language around pregnancy that could be understood both by people delivering maternity care and those receiving it. </p>
<p>It was the first project of its kind to consult the maternity community (including new mothers and healthcare professionals) directly on their preferred language to describe labour and birth. The findings of the project supported the fact that many women were less concerned about the way their baby was born but with whether they had a positive experience and felt safe and listened to.</p>
<p>Last year, the Royal College of Midwives published a <a href="https://www.rcm.org.uk/media/6234/re_birth_summary_.pdf">report</a> outlining their findings and a new pocket guide is being issued to midwives this year. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/spain-is-the-egg-donation-capital-of-europe-heres-what-its-like-to-be-a-donor-205780">Spain is the egg donation capital of Europe – here’s what it’s like to be a donor</a></em></p>
<p><em><a href="https://theconversation.com/dirty-red-how-periods-have-been-stigmatised-through-history-to-the-modern-day-206967">‘Dirty red’: how periods have been stigmatised through history to the modern day</a></em></p>
<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
<hr>
<p>Here are six maternity terms you are now unlikely to hear:</p>
<h2>1. Delivery</h2>
<p>The term “birth” has now been accepted, rather than the term “delivery”, which has commonly been used in the past. Women and health professionals also wanted accurate, specific descriptions as far as possible to describe what had happened in the labour and birth. For example, “birth with forceps” or “birth with ventouse”. This also includes “caesarean birth”.</p>
<h2>2. Low risk / high risk</h2>
<p>“Universal care needs” is being used rather than “low risk”. While “additional care needs” is now the preferred term for “high risk”. The word “risk” is associated with uncertainty and it is vital that women feel comfortable and confident during their pregnancy.</p>
<h2>3. Normal</h2>
<p>“Normal birth” is a term that has long been used by midwives and other healthcare professionals to describe a spontaneous, physiological vaginal delivery. But what counts as “normal”? Does this label someone as “abnormal” if they did not experience what we classify as “normal” birth?</p>
<p>The new preferred term, “spontaneous vaginal birth”, covers spontaneous labour without significant medical interventions such as induction and oxytocin. It also covers spontaneous vaginal birth without the need for instruments, such as forceps. </p>
<h2>4. Emergency caesarean</h2>
<p>The new overarching term for an operative caesarean section is “caesarean birth”. This replaces the word “emergency”, which is a term that may cause alarm. The term “unplanned caesarean birth” is now preferred over “emergency caesarean”. </p>
<h2>5. Incompetent cervix</h2>
<p>“Incompetent cervix” has connotations of personal failure. So, the preferred term is now “cervical insufficiency”. </p>
<h2>6. Failure / failed</h2>
<p>During the Re:Birth project, women were keen to share how terms such as “failure to progress” can contribute to feelings of failure and trauma. “Delayed progress in labour” or “slow labour” are now preferred terms.</p>
<p>We can apply the same logic to terms such as “failed induction” or “failed homebirth”. “Induction of labour, with delay and followed by operative birth” and “transfer in during planned homebirth” are favoured, respectively. </p>
<figure class="align-center ">
<img alt="A pregnant woman wearing a yellow top clutches her belly." src="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Language matters.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-african-american-woman-doing-morning-1842709132">Prostock-studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>Language which infantalises pregnant women, such as “good girl” or “you are allowed/not allowed to” should also be avoided, as should language which has connotations of blame. Examples of this include “poor maternal effort” and “refused”. </p>
<p>During pregnancy and birth, which is a vulnerable time for many, the role of the midwife is to empower women and to value their autonomy over their care decisions. </p>
<p>The Nursing and Midwifery Council’s <a href="https://www.nmc.org.uk/globalassets/sitedocuments/standards/standards-of-proficiency-for-midwives.pdf">standards of proficiency for midwives</a> document states that midwives provide universal care for all women and new-born infants. Midwives support physical, psychological, social, cultural and spiritual safety. The emphasis on psychological care is clear, therefore, with language having a profound impact on wellbeing.</p>
<p>Healthcare professionals must acknowledge that the language we use is an important part of the care we provide. Improved psychological safety and wellbeing is closely linked to improved safety, positive outcomes and future experiences. Language matters.</p><img src="https://counter.theconversation.com/content/207753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Aubrey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Several familiar maternity terms have been abandoned after a consultation with pregnant women and healthcare professionals.Sarah Aubrey, Lead Midwife for Education, University of South WalesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1868272022-12-06T00:28:07Z2022-12-06T00:28:07Z1 in 10 women report disrespectful or abusive care in childbirth<figure><img src="https://images.theconversation.com/files/492044/original/file-20221027-29153-d7sx1j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5701%2C3795&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-giving-birth-baby-pregnant-patient-2128065755">Shutterstock</a></span></figcaption></figure><p>Having a baby can be an empowering experience when women are treated with kindness and respect. </p>
<p>However, some women are left feeling traumatised by how they were treated. When women receive disrespectful and abusive care from health providers during pregnancy, labour and birth, or after the baby is born, it’s called <a href="https://birthmonopoly.com/obstetric-violence/">obstetric violence</a>. This includes verbal, physical and emotional abuse, threats or coercion by health providers. </p>
<p>Our <a href="https://journals.sagepub.com/doi/10.1177/10778012221140138">study</a>, published today in journal Violence Against Women, is the first to look at Australian women’s experiences of obstetric violence. Of the 8,804 women we surveyed, more than one in ten (11.6%) indicated they had, or may have, experienced obstetric violence. </p>
<p>Respondents who elaborated told us this ranged from disrespectful, abusive and coercive comments (42%) to physical abuse (7%) and vaginal examinations without consent (17%).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">So your birth didn't go according to plan? Don't blame yourself</a>
</strong>
</em>
</p>
<hr>
<h2>‘Dehumanised’, ‘powerless’ and ‘violated’</h2>
<p>Our <a href="https://journals.sagepub.com/doi/10.1177/10778012221140138">data</a> comes from the <a href="https://www.facebook.com/BirthExperienceStudy">Birth Experience Study</a>, a survey asking Australian women about their birth experiences over the past five years. </p>
<p>We asked participants if they experienced obstetric violence and they were able to leave comments if they wanted to. </p>
<p>Like all surveys, women who are more educated and have English as their first language tend to respond the most. To reduce this bias, we translated the survey into seven other languages.</p>
<p>Some 626 women left comments describing feeling dehumanised, powerless and violated. Some experienced psychological and emotional abuse, while others were threatened and yelled at. </p>
<p>More alarming were the experiences of physical assault, such as forcible restraint or being held down. </p>
<figure class="align-center ">
<img alt="Woman grimaces while in labour" src="https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Experiences ranged from emotional abuse to physical violence.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/R5yoJSYDDfI">Jimmy Conover/Unsplash</a></span>
</figcaption>
</figure>
<p>Some women felt the experience was like a sexual assault. This was mainly associated with rough vaginal examinations or procedures the women didn’t consent to. </p>
<p>As one woman from New South Wales explained: </p>
<blockquote>
<p>I was told by the doctor who just appeared in the room that he would need to do a <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">vacuum delivery</a> and an <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">episiotomy</a>, and I felt him cut me as he was speaking before [using] a numbing needle, it wasn’t during a contraction and I hadn’t had a chance to consent yet. </p>
</blockquote>
<p>Another woman from Queensland told us:</p>
<blockquote>
<p>I felt dehumanised because A) nobody told me the procedure was optional or gave me choice to opt out. B) I was very clearly highly distressed and they didn’t pause or stop the procedure to check my consent. C) there were three people I didn’t know standing and looking at my exposed naked body. D) the midwife had joked about the procedure. </p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-new-national-plan-aims-to-end-violence-against-women-and-children-in-one-generation-can-it-succeed-192497">A new national plan aims to end violence against women and children 'in one generation'. Can it succeed?</a>
</strong>
</em>
</p>
<hr>
<h2>What is the law in Australia?</h2>
<p>Australia doesn’t have a <a href="https://www.humanrights.unsw.edu.au/news/human-rights-acts-around-australia">National Human Rights Act</a> or legislation addressing obstetric violence. </p>
<p>The <a href="http://www7.austlii.edu.au/cgi-bin/viewdb/au/legis/act/consol_act/hra2004148/">Australian Capital Territory</a>, <a href="https://www.legislation.vic.gov.au/in-force/acts/charter-human-rights-and-responsibilities-act-2006/015">Victoria</a> and <a href="https://www.qhrc.qld.gov.au/your-rights/human-rights-law">Queensland</a> have their own state/territory human rights acts. This protects against “cruel, inhuman or degrading treatment” and requires clinicians get the “person’s full, free and informed consent” before performing any medical treatment. </p>
<p>However, across Australia, consent is <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-09/sq20-030_-_fact_sheet_-_informed_consent_-_nsqhs-8.9a.pdf">always required</a> before any medical treatment or examination, except where the woman is incapacitated or unconscious. The provider must explain the proposed treatment in a way that is balanced, truthful, timely, and free of harassment and coercion. And she can change her mind at any time.</p>
<p>Clinical guidelines don’t trump the right to bodily integrity. If guidelines suggest a vaginal examination, they need to be explained, including the reasons for the treatment and the alternatives. Then the woman has to be given an opportunity to accept or decline. </p>
<p>Yet our study detailed many instances of treatments or examinations with either no consent, no informed consent, or despite their refusal.</p>
<p>Midwives and obstetric doctors are expected to practise ethically and respect their patients’ right to refuse consent or withdraw consent. </p>
<p>Patients can make complaints about doctors or midwives, however there are a variety of different methods <a href="https://www.ahpra.gov.au/Notifications/Concerned-about-a-health-practitioner.aspx">dependent on state/territory</a> which can make the process confusing and overwhelming. </p>
<figure class="align-center ">
<img alt="Mother holder her newborn close" src="https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The process of making a complaint can be difficult and overwhelming.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/ZTSiID1W7-o">Alexander Grey</a></span>
</figcaption>
</figure>
<h2>How do we eliminate obstetric violence?</h2>
<p>All women deserve respectful maternity care, free from harm and abuse. To prevent obstetric violence, we first need to recognise it exists. </p>
<p>The next steps need to involve getting the main professional colleges for <a href="https://ranzcog.edu.au/">obstetricians</a> and <a href="https://www.midwives.org.au/">midwives</a>, consumer organisations, universities that train health providers, health departments and governments to work together to change policies and improve education.</p>
<p>The International Confederation of Midwives and UN Population Fund created a <a href="https://www.internationalmidwives.org/our-work/other-resources/respect-toolkit.html">RESPECT toolkit</a> to facilitate workshops for health care providers on respectful maternity care to support their strategy to create zero tolerance for disrespect and abuse. Programs such as this could be implemented across Australia.</p>
<p>In Queensland, <a href="http://www.humanrightsinchildbirth.org/">Human Rights in Childbirth</a> and <a href="https://www.maternityconsumernetwork.org.au/">Maternity Consumer Network</a> have just commenced <a href="https://www.maternityconsumernetwork.org.au/about-6">consent training</a> for maternity health professionals. Again, similar programs could be rolled out nationally.</p>
<p>Alongside education, we need legislation recognising obstetric violence as a human rights violation. This would mean women are aware of their rights and have access to legal support if needed. It would also prompt governments and health services to develop <a href="https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/clinical-governance-and-quality-improvement-support-effective-communication/action-602">quality improvement systems</a>, including repercussions for clinicians who commit obstetric violence. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-one-womans-traumatic-experience-drove-her-investigation-into-pregnancy-and-mental-health-177152">How one woman's traumatic experience drove her investigation into pregnancy and mental health</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/186827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bashi Hazard is the Chair of the Human Rights in Childbirth, a US s501(c)(3) NGO.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen and Hazel Keedle do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women described feeling dehumanised, powerless and violated. Some experienced psychological and emotional abuse, while others were threatened and yelled at.Hazel Keedle, Lecturer of Midwifery, Western Sydney UniversityBashi Hazard, Lawyer, PhD Candidate, University of SydneyHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1687622021-09-28T12:37:30Z2021-09-28T12:37:30ZHMP Bronzefield stillbirth proves prison is not safe for pregnant women<figure><img src="https://images.theconversation.com/files/423535/original/file-20210928-22-w9y8x8.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5590%2C3741&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-prisoner-hands-jail-background-1031018551">Sakhorn/Shutterstock</a></span></figcaption></figure><p>“Ms A”, an 18-year-old woman held on remand in HMP Bronzefield women’s prison in Middlesex, England, gave birth to her first child alone in her cell after her calls for help were ignored.</p>
<p>A <a href="https://www.ppo.gov.uk/news/ppo-ombudsman-sue-mcallister-publishes-independent-investigation-into-the-tragic-death-of-a-baby-at-hmp-bronzefield/">new report</a> from the prisons and probation ombudsman provides details on Ms A’s case and the tragic death of her newborn baby.</p>
<p>The report reinforces what <a href="https://www.welevelup.org/prison-campaign#:%7E:text=Prison%20Campaign%20%E2%80%94%20Level%20Up%20Prison%20will%20never,years%2C%20two%20babies%20born%20inside%20prison%20have%20died">campaigners</a>, charities and <a href="https://publications.parliament.uk/pa/jt201719/jtselect/jtrights/1610/report-files/161009.htm">researchers</a> have been saying for years – and what the prison ombudsman herself <a href="https://www.bbc.co.uk/programmes/p09wrwqp">admitted</a> – prison is not a safe place for pregnant women. </p>
<p>The details of this case are hard to comprehend and truly harrowing. Ms A described how she became unconscious, and when she awoke, she found she had given birth to a baby who was not breathing. She bit through the umbilical cord, tying it in a loose knot, in an attempt to revive the baby. Ms A was found the next morning in her blood-covered cell, with her bed covers pulled up to her chin and her dead baby daughter tucked in bed with her.</p>
<h2>One of many</h2>
<p>My <a href="https://researchprofiles.herts.ac.uk/portal/en/publications/im-in-labour-im-telling-you-i-am-in-labour--what-is-the-experience-of-being-a-pregnant-woman-in-prison-findings-of-an-ethnographic-study(af0e3496-831f-490d-b9f2-51e2f4d4f3f4).html">2018 doctoral research</a> highlighted the dangers to pregnant women and new babies in prisons, through interviews with 28 women and ten staff members.</p>
<p><a href="https://www.theguardian.com/society/2018/nov/13/female-prisoners-in-england-left-to-give-birth-alone-in-their-cells-report-reveals">I found</a> that women were often left in a similar situation to Ms A where call bells were not answered, especially at night. The staff I spoke with for my report described babies who survived birth in prisons as “lucky”.</p>
<p>According to the ombudsman report, Ms A was regarded as “difficult” and fearful of authority, which staff perceived as challenging behaviour. The report blames maternity services for being “unimaginative and inflexible” in providing her care. <a href="https://researchprofiles.herts.ac.uk/portal/en/persons/laura-abbott(00a63dc4-0672-49e1-83c1-3e23c8230811).html">My research</a> found that the more pleasant a prisoner was, the more likely she would be to receive appropriate healthcare and entitlements, such as an additional pillow. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ydrISNYoECk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>How Ms A was subsequently treated was also criticised. Unlike the prison staff, she wasn’t offered <a href="https://www.insider.com/mother-lost-baby-jail-not-given-counselling-but-guards-did-2021-9">bereavement counselling</a>. This lack of emotional support to what was clearly a traumatic event was recounted by a woman in my study:</p>
<blockquote>
<p>To have to deal with [a cell birth] is such a trauma, then to come back [to prison] and somebody tell me that, “Oh, we could have lost both of you”, but not explain that, was awful, absolutely traumatic. I’m surprised actually I didn’t go into some form of depression, because all I kept thinking was, well, what do they mean? … I even asked if somebody would contact the midwives, or if they would contact the hospital and just find out what he meant, and nobody was willing to do that. Nobody was willing to find out anything. I still don’t know exactly what happened that night.</p>
</blockquote>
<p>The report found that in the case of Ms A “there was no paediatric or neonatal emergency equipment in the prison and no staff were trained in neonatal resuscitation”. The ombudsman recommended stocking prisons with this equipment, but the proposal was rejected.</p>
<p>Newborns often need basic resuscitation as they adapt to life outside the mother. It is indefensible not to attempt to resuscitate a baby because of a lack of equipment or training.</p>
<p>Basic, inexpensive equipment would consist of a bag, neonatal valve and mask, warm clothing and a hat. <a href="https://unlockedgrads.org.uk/">Some organisations</a> already provide some training for prison officers that would be straightforward to roll out in women’s prisons. </p>
<h2>Fixing the wider problem</h2>
<p>Health research centre <a href="https://www.nuffieldtrust.org.uk/public/news-item/pregnancy-and-childbirth-in-prison-what-do-we-know">the Nuffield Trust</a> found that around one in ten women prisoners give birth in cells or on the way to hospital. In 2017, a baby was stillborn on the way to hospital from Bronzefield – the same prison where Ms A gave birth in her cell.</p>
<p>If the government continues to insist on <a href="https://www.theguardian.com/society/2021/sep/23/fear-of-more-baby-deaths-as-ministers-stand-firm-on-jailing-pregnant-women">imprisoning pregnant women</a>, many problems will need to be addressed to improve safety.</p>
<p>My research made several recommendations including specialist prison midwives leadership, 24-hour access to maternity care for all pregnant women and midwifery representation on the prison inspectorate. </p>
<p>In May 2016, <a href="https://www.birthcompanions.org.uk/resources/5-birth-charter-for-women-in-prison-in-england-and-wales#:%7E:text=Birth%20Charter%20for%20Women%20in%20Prison%20in%20England,Policy%2C%20Trauma-informed%20working%2C%20Understanding%20disadvantage%2C%20Women%20in%20prison">the Birth Charter</a> was distributed to all prisons in England. This document outlined recommendations for the care of pregnant women and new mothers in prison, and was written by charity Birth Companions with the Royal College of Midwives, with guidance from Unicef.</p>
<p>The Royal College of Midwives put out another report highlighting <a href="https://www.rcm.org.uk/media/3640/perinatal-women-in-the-criminal-justice-system_7.pdf">best practices</a> for maternity care in prisons. While these documents made similar recommendations, they have never been widely put into practice. </p>
<p>Prison systems are impenetrable for those on the outside. This includes midwives, who may be unfamiliar with the complex and rigid prison system, and who have to rely on staff to take them into prisons with their strict timetables. Yet even with the best midwifery services, if a call bell from a woman in labour is not answered and she is not swiftly transferred to the local maternity unit -– the outcomes are likely to be devastating.</p>
<p>Ms A had nobody to advocate for her. Having peer support may have helped to break down barriers for Ms A who, understandably, had concerns with authority. Midwives are not in prison at nighttime, but peer supporters may offer a supportive conduit between the woman and maternity services. The charity Birth Companions trains and supports prisoners to be maternity volunteers, so they are available through the night, similar to “listeners” trained by the Samaritans. </p>
<p>New <a href="https://www.gov.uk/government/publications/pregnancy-mbus-and-maternal-separation-in-womens-prisons-policy-framework">mandatory guidance</a> was published this month, separate from the ombudsman report. It lays out requirements for how prisons should support pregnant women and new mothers in prison, including those who are incarcerated in mother and baby units, and those who are separated from their young children (up to age two).</p>
<p>The guidance calls for more emotionally sensitive care, specialist midwifery roles, dedicated pregnancy liaison officers and more training for staff in prisons.</p>
<p>But if these instructions are not applied in practice, all this new guidance does is improve what we see on paper, especially if very basic responses to cries for help are left unheard.</p><img src="https://counter.theconversation.com/content/168762/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Abbott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The details of Ms A’s case reinforce what campaigners and midwives have been saying for years.Laura Abbott, Senior Lecturer in Midwifery, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1338662020-03-22T12:21:18Z2020-03-22T12:21:18ZDuring coronavirus hospital surge, a midwife recommends home birth<figure><img src="https://images.theconversation.com/files/321067/original/file-20200317-60879-d01hck.jpg?ixlib=rb-1.1.0&rect=77%2C46%2C5078%2C3385&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman holds her newborn son right after giving birth; they are still in the birthing pool after labour at home.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>For many health-care providers who worked through the 2003 SARS epidemic, especially in epicentres, like Toronto, the COVID-19 pandemic is a reminder of the many lessons health-care providers <a href="https://www.ncbi.nlm.nih.gov/pubmed/12925421">learned at that time.</a> Social distancing measures are the most effective way to “<a href="https://www.nytimes.com/2020/03/11/science/coronavirus-curve-mitigation-infection.html">flatten the curve</a>” and minimize the spread of the epidemic. </p>
<p>However, as a midwife working in Toronto for over 20 years, I can also speak about another important lesson learned during SARS that is often forgotten or overlooked: <a href="http://doi.org/10.1624/105812410X482329">the importance of home birth and the role of midwives during an epidemic</a>. </p>
<p>There is ample evidence from high-income countries like Canada, the United States and the United Kingdom <a href="https://doi.org/10.1016/j.midw.2018.03.024">to demonstrate the safety of home births for healthy people who have a trained midwife</a>. In fact, research shows that <a href="https://doi.org/10.1111/j.1523-536X.2009.00322.x">home birth may even be beneficial in terms of rates of unnecessary interventions, complications and associated cost to the system</a>. </p>
<p>The evidence is so compelling that in 2014, U.K.’s NICE, the National Institute for Health and Care Excellence — the main body responsible for setting guidelines for health care in the U.K. — <a href="https://www.nice.org.uk/guidance/cg190">recommended home births for all low-risk healthy pregnant people</a>. Since the selection criteria for home birth is <a href="https://doi.org/10.1016/j.jogc.2018.08.008">vitally important to safety</a>, being a low-risk pregnant person is an important factor. For people with <a href="https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/Choice%20of%20birthplace.pdf">high blood pressure, diabetes, preterm labour and other health issues</a>, home birth would not be the safest option.</p>
<p>However, despite these recommendations, mainstream perception has not greatly changed regarding hospital as the preferred place of birth for the large majority. The reasons for this are numerous and complicated, and highly related to <a href="https://doi.org/10.17615/4yqp-tc63">social norms, preferences and perceptions of risk</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A husband and a midwife both congratulate a new mother, moments after birth, placing their hands on her shoulder and the back of the newborn’s head.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>I have seen many news articles, targeted campaigns, TV shows and even movies supporting home births. But in all my 20 years as a regulated midwife, nothing in my recollection came close to changing people’s minds about place of birth than SARS. </p>
<p>For midwives, this was not necessarily surprising, as we know the safety of a home birth. But it was one of the first times mainstream public perception was greatly altered.</p>
<h2>Home births during a pandemic</h2>
<p>During a pandemic, people quickly remember that hospitals are, and should be, for sick people; that is, those needing medical care. Ironically, however, in Canada and the U.S., health-care systems the <a href="https://www.cihi.ca/en/hospital-stays-in-canada">No. 1 reason people are admitted to hospital is for childbirth</a>. </p>
<p>During a pandemic it soon becomes apparent what a bad idea it is to have healthy women and newborns in the same places and spaces as those who are unwell, and increasingly so as more get infected.</p>
<p>Suddenly — our high tech, bells and whistles “for the normal” starts to seem like a really poor idea. In fact, research shows all those bells and whistles lead to more intervention — more episiotomies, more use of forceps and vacuum, and more severe vaginal tearing — <a href="https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/Choice%20of%20birthplace.pdf">with no better outcomes for either the pregnant woman or newborn</a>.</p>
<p>As soon as that babe is here, it becomes even more apparent what a bad idea it is to have a vulnerable new human in a place with lots of sick people.</p>
<p>Home birth starts looking better every second.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman being examined at home by her midwife.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>I fully appreciate all the bells and whistles — when they are needed. But, like many of my colleagues, I personally prefer a home birth for low-risk births with a healthy uncomplicated pregnancy and normal labour. Not just because it can be very beautiful — <a href="https://www.ontariomidwives.ca/home-birth">quiet, intimate, family oriented</a> — but also because it is actually safer for healthy people — at least during a pandemic. </p>
<p>Although I could talk about the great benefits of home births in general, I’m specifically advocating for home births, or out-of-hospital births, during a pandemic. So, as our health resources and hospital beds become more scarce, I hope we remember the importance of home birth.</p>
<h2>Lessons from SARS</h2>
<p>SARS was one of the rare times in my career that I had both obstetrical and pediatric colleagues openly supporting the idea of home births and encouraging people to stay out of hospital. At that time, we understood hospital care should be saved for those who were high risk. This was even more clear as the situation worsened during the SARS epidemic.</p>
<p>There were many other important lessons learned during SARS, particularly for Canadian midwifery — although there is almost no academic literature on this subject. However, I do have some anecdotal experience to share as a front-line care provider during that time.</p>
<p>If there is one essential service that we know must continue during a pandemic, it is the business of birthing.</p>
<p>Midwives are an important part of the health force that is often overlooked. Our speciality is low-risk normal birth: this is where we have the most expertise and where we can be most effective. </p>
<p>This is a time when other birth attendants — mainly obstetricians — will be called on for their clinical and surgical speciality skills to manage those pregnant people who have complications, have COVID-19 or are unwell for other reasons.</p>
<p>Midwives can be divided into those who work within the hospital setting and those that work outside within the community. This would help prevent movement in and out of people’s homes and health-care settings. </p>
<p>Midwives have a lot of crossover skills between nurses and physicians. We can stitch and prescribe, like a physician, but also start an IV and take blood, like a nurse. There are many things we can use our skills for beyond birthing.</p>
<p>Some midwives have more advanced skills such as being able to assist during surgery, perform bedside ultrasounds and conduct vacuum deliveries. These skills could be important as the health force declines.</p>
<p>Birth centres, or other out-of-hospital birth locations, should be considered and opened as places for low-risk people to give birth and for healthy newborns to stay.</p>
<p>Finally, the needs of those who are pregnant are often overlooked. Home birth has many potential benefits, but most importantly in a pandemic, we need healthy people to give birth with the best chances of staying healthy — which doesn’t always mean hospital.</p><img src="https://counter.theconversation.com/content/133866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Manavi Handa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>During a pandemic, a home birth starts looking better every second. Midwives with their specialized skills in low-risk normal birth can be of great service.Manavi Handa, Associate Professor, Midwifery Education Program, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1257012019-10-24T11:49:43Z2019-10-24T11:49:43ZHow forceps permanently changed the way humans are born<figure><img src="https://images.theconversation.com/files/298364/original/file-20191023-119414-620ytz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">James Young Simpson's Caesarian forceps, Hunterian Museum, Glasgow</span> <span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/3/3b/James_Young_Simpson%27s_Caesarian_forceps%2C_Hunterian_Museum%2C_Glasgow.jpg">Stephencdickson/Wikipedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Obstetric forceps look like ninja weapons. They come as a pair: 16 inches of solid steel for each hand with curved “blades” that taper into a set of molded grips. Designed for emergencies that require a quick delivery, they have a heftiness that conveys the weight of wielding them. </p>
<p>The first time I saw forceps used was also when <a href="https://scholar.harvard.edu/shah">I learned how to use them</a>. An experienced senior obstetrician and I did the emergency delivery in tandem. She showed me how to orient myself to the bony parts of the mother’s pelvis and guide each blade into the birth canal with my fingers while ensuring the curvature safely cradled the baby’s head. She clinked the shanks together so that both parts of the forceps locked definitively in place. As the frightened mother pushed, we pulled together so I could get a feel for the proper angles and necessary force. </p>
<p>We pulled so hard that I cringed. I saw the mother’s partner cringe as well. I could hear the depressed heart rate of the baby on the monitor. I could hear my own pulse pounding in my ears. But it worked. A baby girl was born and took her first breath of oxygen-rich air. Aside from matching bruises where the forceps pressed the baby’s cheeks, both she and her mother emerged from the delivery healthy. I was in awe of that power, the ability to step into a delivery room, avert a potential tragedy and preserve a moment of joy. </p>
<p>Once ubiquitous, the skill to use forceps is now rare. As cesarean deliveries and easier-to-perform “vacuum” deliveries became more common, the inclination of obstetricians to use forceps <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=22787679">waned</a>. Still, their introduction into birthing rooms permanently changed the way humans are born.</p>
<h2>The role of lived experience</h2>
<p>For most of human existence the risks of procreation were severe and terrifying. Everybody knew someone who died from a complicated pregnancy. Everybody knew someone whose baby was born dead. Not only did women face the prospect of birth and death simultaneously, in the absence of contraception, they did so again and again. Until the early 20th century, the probability of <a href="https://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780198229971.001.0001/acprof-9780198229971">dying</a> from childbirth was similar to the probability of a woman dying of breast cancer or a heart attack today.</p>
<p>Women managed their understandable fear by drawing on the support of their community. They gave birth at home under the care of other women – family members, friends and neighbors who were also mothers. Families may have called upon a midwife, though back then there were no specific qualifications that distinguished the midwife’s professional skills beyond having attended a lot of births. For most of human existence, the most important form of expertise in childbirth was lived experience. </p>
<p>The capability to intervene in childbirth began to shift the balance of preferred expertise toward those who could wield surgical instruments. At first, the available options were limited and gruesome. Intervention only occurred under dire straits. If the baby appeared stuck in the birth canal, a physician could make more room by fracturing the mother’s pubic bone or by performing a vivisection – a cesarean without anesthesia, good lighting or the ability to stop bleeding. Or he could remove an obstructed fetus by whatever means necessary, potentially saving the life of the mother, but almost guaranteeing the mutilation and death of the baby. </p>
<p>Forceps were a game changer that made saving both possible. Sure, they resembled weaponry. But under the circumstances, the promise of delivering the baby alive and intact was widely welcomed. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=332&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=332&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=332&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=417&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=417&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298366/original/file-20191023-119423-n9v0bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=417&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A late 18th-century illustration of forceps cradling the baby’s head.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/e/ee/Forceps.Smellie.jpg">http://en.wikipedia.org/wiki/User:Ekem</a></span>
</figcaption>
</figure>
<h2>The costs of technology and the need for balance</h2>
<p>Yet, this capability also came at a cost. </p>
<p>In the 19th century, as more women accepted medical intervention in childbirth, the composition of the birthing room began to change. The professionals who originally wielded forceps – both midwives and physicians – were men. They lacked lived experience in giving birth themselves. Gender roles and modesty standards also prevented practical opportunities to learn: men were discouraged from performing direct visual examinations of the female pelvis.</p>
<p>Most importantly, everyone – laboring mothers, their female caregivers and the male midwives themselves – recognized that what the male midwives had to offer was intervention with forceps. This led to a skewed perspective on when intervention was truly necessary. Rather than being performed during emergencies only, the ever-present specter of death made it compelling and common to use forceps preemptively. And as these professional male attendants grew in popularity in the later half of the 19th century, the role of family and community in providing support became increasingly marginalized. By the mid-20th century, intervention in childbirth was routine and nearly all women had their babies in hospitals under the care of male obstetricians.</p>
<p>Many of our modern norms resulted from the way these shifts propagated into the present. Today forceps deliveries are rare but intervention in childbirth is not. Today, 1 in 3 American mothers gets major surgery to give birth, despite <a href="https://www.ajog.org/article/S0002-9378(14)00055-6/fulltext">evidence</a> that this rate of intervention is excessive – and not only unhelpful but harmful. Today, the type of continuous labor support once provided by a mother’s community has largely fallen away, despite <a href="https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth">evidence</a> that it improves both birth experiences and outcomes. </p>
<p>The irony is that in our sharp focus on using technology to prevent harm, we appear to have lost sight of lived experience as its own complementary form of expertise. Valuing lived experience – what a mother is feeling, and what other mothers with similar experiences have felt – might not only make childbirth safer but also more dignified. It might provide better insight into when intervention in childbirth is truly helpful (and when it is not). It might help us support each other better when we are trying to start or grow our families. And it might help us adjust our collective goals to <a href="https://www.expectingmore.org/">expect more</a> from childbirth than simply emerging from the process unscathed. </p>
<p>[ <em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/125701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neel Shah receives funding from the Peterson Center on Healthcare, the Yellow Chair Foundation, the Rx Foundation, the Boston Foundation and the Harvard Risk Management Foundation. </span></em></p>Childbirth used to be a terrifying ordeal. But women were surrounded by others – mothers, aunts, sisters – who brought love and experience. But midway through the 19th century, this changed.Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1172232019-10-08T11:04:11Z2019-10-08T11:04:11ZHow pregnancy can be made more difficult by maternity care’s notions of ‘normal’<figure><img src="https://images.theconversation.com/files/289694/original/file-20190827-184196-1o2h01y.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C2034&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Rawpixel.com/Shutterstock</span></span></figcaption></figure><p>Maternity records in the UK have spaces only for the expectant mother and the baby’s father. This inflexibility can cause difficulties for the pregnant person, their partner, and their unborn baby if they do not fit into these boxes. </p>
<p>Over the last decade there has been a significant increase in the number of people conceiving outside of the traditional model of a heterosexual couple, so this affects an increasing number of parents. It’s not known exactly how many lesbian women give birth, but fertility treatment in UK clinics for lesbian couples <a href="https://www.hfea.gov.uk/media/2894/fertility-treatment-2017-trends-and-figures-may-2019.pdf">has increased 15-20% year-on-year</a> for the past decade. In 2016 there were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthsbyparentscharacteristicsinenglandandwales/2016">1,404 live births registered to same-sex female couples</a>. </p>
<p>No data is available for the numbers of trans men (that is, female-to-male transgender people) who give birth in the UK. But some trans men choose to do so, and the <a href="https://www.gires.org.uk/wp-content/uploads/2014/10/Prevalence2011.pdf">number of referrals</a> to gender identity clinics is rising each year.</p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S026661380190261X?via%3Dihub#bRF8">Research shows</a> that problems occur when heteronormativity – the perception that heterosexuality is the normal, default, or preferred sexual orientation – is communicated either overtly or subtly in the way healthcare staff treat patients, the way leaflets are worded, or the assumptions made in the way administration systems are designed. </p>
<p>This means that co-mothers (the non-birth mothers in lesbian families) may <a href="https://www.aims.org.uk/journal/item/hes-not-the-mother">not be recognised as parents</a>, and so miss out on support such as <a href="https://wearefamilymagazine.co.uk/shared-breast-feeding-induced-lactation/">breastfeeding advice</a> for example, and it can leave both pregnant trans men and lesbian co-mothers <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2648.2012.06115.x">feeling excluded</a>.</p>
<p>Poor experiences in the run-up to, during and after birth can negatively affect expecting couples emotionally and psychologically in ways that lead to problems for the whole family, including the baby. For example, postnatal depression is common and <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2670692">associated with adverse outcomes for both mother and child</a>. A number of studies, while small scale and qualitative in nature, point to higher incidence of symptoms of postnatal depression <a href="https://www.ncbi.nlm.nih.gov/pubmed/17262172">among lesbian birth mothers</a>. There are also similarly small scale and qualitative studies that suggest similarly heightened feelings of anxiety and depression among <a href="https://www.academia.edu/4639049/Celebrating_the_Other_Parent_Mental_Health_and_Wellness_of_Expecting_Lesbian_Bisexual_and_Queer_Non-Birth_Parents">lesbian co-mothers</a>.</p>
<p>For co-mothers in particular, this seems linked to their sense of connection with the baby, and from the extent to which they feel <a href="https://www.academia.edu/4639049/Celebrating_the_Other_Parent_Mental_Health_and_Wellness_of_Expecting_Lesbian_Bisexual_and_Queer_Non-Birth_Parents">recognised as a parent</a> or not by maternity services, family and friends and wider society. The combined stress of identifying oneself as lesbian or bisexual to healthcare staff, and the attitudes of wider society, alongside the stress of pregnancy generally are greater than that experienced by heterosexual pregnant women, and represent a plausible reason for higher symptoms of postnatal depression among lesbians.</p>
<p>This wider issue of difficulties experienced due to heteronormativity in maternity services is something research suggests exists <a href="https://www.sciencedirect.com/science/article/pii/S1751485117303331?via%3Dihub#!">worldwide</a>.</p>
<h2>Discrimination and danger</h2>
<p>For a decade I have worked as a <a href="https://doula.org.uk/about-doulas/">doula</a>, offering non-clinical care and support to women during their pregnancy, through labour and birth and in the days and weeks afterwards. In my experience <a href="https://www.aims.org.uk/journal/item/hes-not-the-mother">issues have often arisen</a> among those who do not fit the configuration of a heterosexual couple. </p>
<p>Earlier this year, I cared for a pregnant trans man whose unborn baby had a 50:50 chance of having a life-threatening medical condition, and might have needed blood transfusions while still in the womb. The condition can be tested for through a maternal blood sample, which his midwives requested. But the laboratory repeatedly failed to do the right test on the blood sample, assuming that the forms had been mixed up because a maternal test was requested for a patient whose records stated was male. This caused weeks of delay, at a time when, for the baby’s health, every day counted.</p>
<p>In a case from the US, a pregnant trans man who attended hospital with severe stomach pain was not treated urgently, after it was initially assumed he was obese rather than pregnant. As a result, doctors missed that his baby’s umbilical cord had slipped through the cervix before the baby – a rare but serious birth complication that requires an immediate birth by caesarean – and <a href="https://eu.usatoday.com/story/news/health/2019/05/16/pregnant-transgender-man-births-stillborn-baby-hospital-missed-labor-signs/3692201002/">the baby subsequently died</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/289638/original/file-20190827-184196-1ubw1fx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lesbian mothers or pregnant trans men may find themselves denied hospital procedures offered to women in heterosexual couples.</span>
<span class="attribution"><span class="source">Africa Studio/Shutterstock</span></span>
</figcaption>
</figure>
<p>It is sometimes not patient records or administration systems but individual staff whose heterosexist assumptions mean birth partners are treated differently. For example, it is common for partners to be allowed longer visiting hours on postnatal wards, and encouraged to fetch food from the canteen for their partners. But lesbian partners may be denied access to wards or not allowed to assist their partners <a href="https://readingmedievalbooks.wordpress.com/2017/03/30/my-daughters-birth">because staff assume all partners are male</a>, and that women trying to come into a postnatal ward are merely other visitors.</p>
<p>They may also encounter blatant homophobia or transphobia from those caring for them, such as the midwife who told a new mum that it was “<a href="https://www.pinknews.co.uk/2017/09/21/lesbian-mum-homophobically-abused-by-midwife-after-17-hour-labour/">disgusting</a>” that her baby had two mums. Discrimination may be illegal, but there is evidence that covert, harder-to-prove prejudicial treatment continues, including the doctor who found inventive ways <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2007.04439.x">not to offer fertility treatment to a lesbian</a> by trying to frighten her, and then by not responding to her queries or passing on her test results. Or the midwife who showed her disapproval of lesbian mums by <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2007.04439.x">performing rough vaginal examinations</a> on a woman in labour.</p>
<p>It is more common however that healthcare staff are well-intentioned but lack the skills, confidence and training to provide good care to pregnant lesbians and trans men. The <a href="https://www.ilga-europe.org/sites/default/files/visitation_rights_best_practices_unison.pdf">Royal College of Nursing</a> and <a href="https://www.nct.org.uk/sites/default/files/related_documents/Fisher%20Meeting%20the%20needs%20of%20lesbian%20mothers_0.pdf">birth support charity NCT</a> have highlighted the issue, but midwives say that while treating lesbian birth mothers is part of their job, they don’t always know how to treat the co-mother. Some say colleagues struggle to care for pregnant lesbians <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2011.05780.x">due to their religious beliefs</a>.</p>
<h2>Better data will reveal the reality</h2>
<p>In the UK, NHS Trusts do not yet collect data on the gender or sexual orientation of pregnant people and their partners. Because we don’t have this data, we don’t have much information about the statistics for lesbian and trans men’s pregnancy outcomes or birth experiences. Most <a href="https://www.tandfonline.com/doi/full/10.1080/02646838.2019.1649919">pregnancy and birth research</a> and <a href="https://journals.sagepub.com/doi/full/10.1177/0964663912474862?journalCode=slsa">most laws and regulations</a> assume babies are created in a heterosexual relationship.</p>
<p>There is no simple solution – substituting “pregnant people” for “pregnant women”, or “partners” for “fathers” on documents may lead to invisibility (especially of women), confusion about whether genetic or social information is required, and is a sticking plaster that doesn’t solve the difficulties they face. We need to understand the problem better: the physical and mental health needs of pregnant lesbians and trans men are <a href="https://www.tandfonline.com/doi/full/10.1080/02646838.2019.1649919">hugely under-studied</a>, and so poorly understood. </p>
<p>A good start would be for NHS maternity records to properly record the gender and sexual orientation of pregnant people and their partners in order that we can more accurately know the number of lesbians and trans men giving birth in Britain, and begin to understand how their experiences may be similar or different to heterosexual women’s birth experiences.</p><img src="https://counter.theconversation.com/content/117223/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mari Greenfield does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For lesbian couples or trans men, the ‘unexpected’ gender of one parent causes difficulties for maternity services where notions of ‘normal’ are increasingly out of step with the times.Mari Greenfield, Honorary Research Associate, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1202102019-08-07T22:36:01Z2019-08-07T22:36:01Z25 years on: What midwifery in Canada has achieved and what it still needs<figure><img src="https://images.theconversation.com/files/285756/original/file-20190725-136759-p6acls.jpg?ixlib=rb-1.1.0&rect=215%2C5%2C3778%2C2586&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demand for midwifery services across Canada is now much greater than midwives can currently provide.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>On Jan. 1, 1994, <a href="https://www.ontario.ca/laws/statute/91m31">The Midwifery Act in Ontario</a> was implemented. This was a historic event as Canada was, at that time, the only developed nation in the world without a system of regulated midwifery. </p>
<p>Over the past 25 years, all the other Canadian provinces and territories have followed Ontario by legalizing and funding midwifery — except <a href="https://www.whitehorsestar.com/News/midwifery-rules-on-track-for-year-s-end">Yukon</a> and <a href="https://www.cbc.ca/news/canada/prince-edward-island/pei-midwives-regulation-application-1.4976724">Prince Edward Island</a>, which are planning to do so. </p>
<p>The number of midwives practising across the country has grown remarkably — from 60 in 1994 <a href="https://canadianmidwives.org/category/maps/">to around 1,700 in 2019</a>. They attend nearly 11 per cent of births in the country.</p>
<p>I am a registered midwife in Ontario, as well as an assistant professor in the midwifery education program at McMaster University. I also used midwifery services in the era before legislation and lobbied the Ontario government in the 1980s to include midwifery in the health-care system. And I was accepted into the first class of midwifery students at McMaster in 1993. </p>
<p>I have been a witness to the changes and advances in midwifery over the past 25 years. During this time, there has been great progress in the profession. At the same time, midwives have been on the sidelines of policy decisions. This has made midwives more vulnerable to the whims of governments than those in older, more established health professions, like nurses and physicians. </p>
<h2>From home to hospital births</h2>
<p>Of course, in 1994, we had no way of knowing how much midwifery would grow and how the practice would change. Midwives at that time attended many births at home, while also working to integrate into the hospital setting. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1011389978113388544"}"></div></p>
<p>Each midwife was on-call 24 hours a day, seven days a week, providing care under the principles of continuity of care, informed choice and choice of birth place. Many had to transfer care to an obstetrician if their client needed an induction of labour or wanted an epidural for pain relief.</p>
<p>Now, in the 21st century, midwives manage both inductions and epidurals, and most of the births they attend take place in the hospital. </p>
<p>Many have moved to “shared care” models of care so that midwives can have more time off-call to spend with their families. Some are participating in “collaborative care” projects to serve diverse populations, such as the longstanding <a href="https://www.scbp.ca/">South Community Birth Program</a> in Vancouver.</p>
<h2>Renewal of Indigenous midwifery</h2>
<p>Midwives in Markham Stouffville Hospital in Ontario have developed the <a href="https://www.msh.on.ca/clinics-departments/stollery-family-centre-childbirth-children/alongside-midwifery-unit-amu">new and exciting Alongside Midwifery Unit</a> — the first space of its kind in Canada, offering specially designed birthing rooms for women expecting a normal birth with a midwife. </p>
<p>Other midwives work in freestanding birth centres <a href="http://www.torontobirthcentre.ca/">such as the Toronto Birth Centre</a>. </p>
<p>In Hamilton, a <a href="https://www.thespec.com/living-story/9277470-new-programs-sees-hamilton-midwives-offer-set-it-and-forget-it-birth-control-method/">group of midwives is providing expanded services</a> that include medical abortion and contraception. </p>
<p>Across the country, there has been <a href="https://indigenousmidwifery.ca/">a renewal of Indigenous midwifery</a>, with Indigenous midwives providing care <a href="https://indigenousmidwifery.ca/audio/">rooted in their culture and traditions</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5vABSuTTrbg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Spirit of Birth. Produced by MAAIINGAN Productions and Frog Girl Films. Directed by Rebeka Tabobondung.</span></figcaption>
</figure>
<p>Regardless of location, demand for midwifery services is much greater than midwives can currently provide.</p>
<h2>Lack of pay equity</h2>
<p>Although midwifery has made great progress, not all news about midwifery is positive. Midwifery services in many parts of Canada are limited and not adequately funded. </p>
<p>A <a href="https://doi.org/10.1016/j.wombi.2018.10.002">recent study of midwives in Western Canada</a> showed high rates of burnout and mental and physical health problems, causing many to consider leaving the profession. </p>
<p>Many midwives, especially those who are aging or who have young families, struggle with the on-call demands of providing care in a continuity of care, or caseload, model. Evidence suggests that <a href="https://doi.org/10.1016/S0140-6736(13)61406-3">this model results in better outcomes for clients</a> — creating a dilemma for midwives who want to provide the best care but also desire better work-life balance.</p>
<p>In Ontario, lack of increases in pay over the past decade led midwives <a href="https://www.tvo.org/article/the-uncertain-future-of-midwifery-in-ontario">to take the government to the Ontario Human Rights Tribunal</a>, arguing that lack of pay equity had led the almost exclusively female profession to fall behind.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1149770161127219200"}"></div></p>
<p>Although the tribunal ruled in favour of the midwives, the <a href="https://www.nationalobserver.com/2019/07/11/news/new-human-rights-challenge-ford-government-says-workload-not-gender-justifies?utm_source=National+Observer&utm_campaign=d20290dad2-EMAIL_CAMPAIGN_2019_07_12_12_22&utm_medium=email&utm_term=0_cacd0f141f-d20290dad2-276861289">current government is seeking to quash the decision</a>. </p>
<p><a href="https://www.cbc.ca/news/canada/windsor/college-of-midwives-ontario-funding-cut-1.4946081">Funding cuts to the College of Midwives</a>, to which midwives must belong, mean that membership fees have increased, further reducing compensation and morale.</p>
<h2>More investment in midwifery needed</h2>
<p>Evidence worldwide shows the <a href="https://www.who.int/workforcealliance/media/news/2013/midwifecochrane/en/">benefits of midwifery-led care for women and babies</a>. </p>
<p>Although midwives in Canada have accomplished many things since 1994, much more needs to be done to make midwifery a sustainable profession that offers the care women wish to receive.</p>
<p>Integrating midwives into decision making and planning for reproductive care, adequately compensating those who do this work and developing flexibility in models of care and scope of practice: these are all paths to building a strong midwifery profession in the years to come.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/120210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathi Wilson is an assistant professor in the midwifery education program at McMaster University, Hamilton ON. She has previously received research funding from CIHR and is a member of the New Democratic Party of Canada.</span></em></p>The benefits of midwifery for women and babies globally are clear. In Canada, innovations in midwifery centres and services are tempered by low pay and high rates of burnout.Kathi Wilson, Assistant Professor, Department of Midwifery, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1190452019-07-18T11:20:27Z2019-07-18T11:20:27ZHome birth may start babies off with health-promoting microbes<figure><img src="https://images.theconversation.com/files/281472/original/file-20190626-76738-16veuf2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What are the differences between planned assisted childbirth with midwife at home versus delivery with obstetrician at a hospital?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-home-birth-traffic-sign-two-471601175?src=jaaoc93ZxlMSXNoDAVr2ow-1-2&studio=1">M-SUR/Shutterstock.com</a></span></figcaption></figure><p>For all of human history, babies have been born where their mothers lived – whether in a house, hut or cave. Only in the last century has birth moved out of the home and into the hospital. How has that changed the types of microbes that live in and on our bodies – collectively known as the microbiome – which we know are vital to human health?</p>
<p>To find out, our group of researchers from New York University, University of California San Francisco and Sejong University in Seoul, South Korea compared different kinds of fecal bacteria from babies born at home to babies born in the hospital. Our results suggest that <a href="https://doi.org/10.1038/s41598-018-33995-7">hospital births can change the gut microbiome of newborns</a>, perhaps placing these babies at higher risk for certain immune or metabolic disorders. So how do we respond? And why do I, as a hospital-based midwife, care? </p>
<p>Starting with the midwife part: There is a bas relief at Angkor Wat in Cambodia that depicts a woman giving birth. She is supported from behind, a midwife kneels in front and a newborn lies across her chest. It looks just like many midwife-attended births today, despite the fact it comes from halfway around the world and is 800 years old. </p>
<p>I like to think about what it means to do the same work that midwives did centuries ago. Whether by necessity (then) or by choice (now), the midwives’ philosophy of care is pretty much the same. Namely, to support an undisturbed birth – where interventions are used only when absolutely necessary. Increasingly, <a href="https://doi.org/10.1038/d41586-018-02480-6">research suggests this is a good approach to care</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A bas relief on a temple at Angkor Wat shows a woman giving birth with the help of a midwife.</span>
<span class="attribution"><span class="source">Robin Hayes</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Babies’ first inheritance</h2>
<p>In the last decade, researchers have discovered many ways <a href="http://dx.doi.org/10.1136/gutjnl-2018-317503">our health depends on the trillions of bacteria</a> and other microorganisms that reside in and on our bodies. Exposure to vaginal bacteria at birth starts an important colonization process in the newborn. In the beginning, bacterial colonies on different parts of babies’ bodies are similar and tend to match their mothers. Over time, different body habitats, like the skin, mouth and gut, develop their own distinct microbial communities. </p>
<p>The baby’s intestinal microbiome plays a key role in initiating immune and metabolic function. That is why we wanted to investigate how hospital factors might shape the early gut microbiome. We compared feces from healthy, breastfed babies who were born vaginally at home to similar babies born in the hospital. Then we determined which microbes were most likely to flourish in which babies during the first month of life. </p>
<p>Here is what we found: Babies born at home were more likely to <a href="https://doi.org/10.1038/s41598-018-33995-7">be colonized with “beneficial” microbes</a>, the kinds associated with normal immune, metabolic and digestive functioning. Babies born in the hospital were more likely to be colonized with microbes associated with interventions like cesarean section, antibiotic treatment and formula feeding even though none of those things happened to the babies in our study.</p>
<p>Then we wanted to see if these differences in the microbiome made epithelial cells – which line the colon – behave differently. </p>
<p>So we exposed these epithelial cells to fecal material – which contains a sample of the baby’s microbiome. We found that cells exposed to material from hospital-born babies were more likely to show an inflammatory response when the baby was one month old. While inflammation is an important defense mechanism, chronic inflammation at the cellular level can also contribute to inflammatory diseases later in life.</p>
<p>To be clear, we observed this only in the lab, not in a living baby, so we can’t speculate on the significance of this finding for the long-term health and well-being of babies. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A midwife examines her patient preparing for a home birth.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-being-examined-home-by-432161725?src=VQ_E5NDVZPJntx_jor88cw-2-2&studio=1">Monkey Business Images/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Undisturbed birth</h2>
<p><a href="https://doi.org/10.1038/d41586-018-02480-6">Research suggests that babies benefit</a> from undisturbed exposure to their mother’s bacteria, including vaginal and fecal bacteria at birth, then ongoing exposure to the mother’s milk and skin bacteria while breastfeeding during the first year. Disruptions in early mother-to-baby transmission are associated with changes in the infant microbiome which, in turn, have been <a href="http://doi.org/10.1016/j.molmed.2014.12.002">associated with health problems later in life.</a> Thus, supporting an undisturbed birth process makes sense. </p>
<p>But, undisturbed birth isn’t always possible. Complications arise, and microbiome-altering interventions – like antibiotics or cesarean section – can save a mother or baby from life-threatening emergencies. These interventions may impact the baby’s microbiome, but no one would recommend any other course of care. </p>
<p>However, what about interventions performed without medical necessity? For example, one in three babies in the U.S. is delivered by cesarean section. That’s around <a href="http://doi.org/10.1186/s12978-015-0043-6">double the rate we would expect</a> if responding to medical need alone. Women in the U.S. frequently experience many <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">interventions while giving birth</a>. <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">Too much intervention used too soon</a> doesn’t help, and in many cases <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">may harm, mothers, babies and their microbiomes</a>.</p>
<p>The mothers of the babies in our study did not experience overt interventions at birth. All mothers who had antibiotics, a cesarean delivery or a water birth were left out. That meant our study was small, only 10 babies in the hospital and 10 babies at home. Yet a large study of over 1,000 babies came to the same conclusion: full-term, breast-fed babies born vaginally at home had the most “beneficial” microbiomes. That is, they were colonized with microbes that have been <a href="https://doi.org/10.1542/peds.2005-2824">associated with normal health and development</a>. Further research is needed to understand the implications, but thinking through a typical hospital birth may suggest areas to study further.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Are hospital births too sterile?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-child-hospital-516260941?src=Ix8Km2-pMoruh5WE5t0ERQ-1-17&studio=1">Lolostock/Shutterstock.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Birth in the hospital: Too clean?</h2>
<p>One reason hospital births differ from those at home is that hospitals prioritize cleanliness. Hand washing, bactericidal scrub and frequent cleaning limit the spread of germs. As the baby nears delivery, a sterile drape may be placed underneath the woman and sometimes over her legs and abdomen to create a “sterile field” around the baby. </p>
<p>In some hospitals a bactericidal soap may be used to wash the vagina before delivery, destroying almost all the bacteria. This practice reflects just how little we value the robust microbial habitat of the mother’s vagina which, interestingly enough, <a href="http://doi.org/10.3389/fmed.2018.00181">changes during pregnancy to promote an abundance of healthy flora</a>. There may also be frequent vaginal exams performed during labor that carry small amounts of antiseptic lubricant into the vagina. </p>
<p>After birth, the baby may be taken to a semi-sterile warmer instead of having contact with the mother’s skin. Antibiotic ointment is usually applied to the baby’s eyes. A full-body bath to “clean” the baby is also common, constituting another source of potential damage to microbial colonies on the newborn’s body. </p>
<p>But even for babies who “room in,” contact with the outside world is limited compared to home where a baby might get licked by the family dog or passed around to an array of visitors. The “hygiene hypothesis” suggests that we, as humans, <a href="https://doi.org/10.2147/ITT.S61528">need early and frequent exposure to diverse organisms</a>. We tend to restrict this in the first few days of life in the hospital. Is that the right approach? </p>
<p>In the U.S. only 1% of births occur at home. Our research suggests a previously unrecognized benefit of home birth. Might this information also lead to a redesign of hospital care? When we start to value the power of babies’ first inheritance – bacteria from their moms – we may end up with a different view of what “best practice” really is. </p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/119045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Combellick received funding from the Gerber Foundation.</span></em></p>Evidence suggests that microbes play a vital role in health. But what microbes we get depends whether we were born in a hospital versus at home. That could impact our health decades later.Joan Combellick, Assistant Clinical Professor of Midwifery, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1160562019-05-02T21:54:14Z2019-05-02T21:54:14ZRoyal baby: Did Meghan Markle have a home birth?<figure><img src="https://images.theconversation.com/files/272103/original/file-20190501-113855-cw2e0y.jpg?ixlib=rb-1.1.0&rect=23%2C29%2C3957%2C2620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Meghan, Duchess of Sussex, arrives for her baby shower at the Mark Hotel on Feb. 19, 2019, in New York. She was rumoured to want to deliver her baby at home rather than in hospital. </span> <span class="attribution"><span class="source">(AP Photo/Kevin Hagen)</span></span></figcaption></figure><p>The Duke and Duchess of Sussex — Prince Harry and Meghan Markle — have <a href="https://nationalpost.com/news/world/buckingham-palace-says-prince-harrys-wife-meghan-has-gone-into-labour-with-their-first-child">announced the birth of their first child</a>, a baby boy. </p>
<p>While the world has waited anxiously for <a href="https://www.nytimes.com/2019/05/06/world/europe/meghan-markle-baby-boy.html">news of this British royal birth</a>, there has been intense speculation about where Meghan Markle, the Duchess of Sussex, would deliver her baby. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1125396713777156097"}"></div></p>
<p>Reports that she wished <a href="https://www.elle.com/culture/celebrities/a27097980/meghan-markle-home-birth-report/">to deliver her baby at home</a> for reasons of <a href="https://www.dailymail.co.uk/news/article-6904657/Meghans-home-birth-plan-Duchess-Sussex-wants-baby-home.html">privacy and comfort</a> have renewed debates about the safety of home birth. </p>
<p>While some media reports were positive about the idea, <a href="https://www.theguardian.com/commentisfree/2019/apr/13/meghan-markle-home-birth-should-not-blind-us-to-risks-for-most-women">others warned about the risks</a> of childbirth in general and, in particular, when it takes place at home.</p>
<h2>A home birth is a safe choice</h2>
<p>In the United Kingdom, <a href="http://www.historyandpolicy.org/policy-papers/papers/choice-policy-and-practice-in-maternity-care-since-1948">most women gave birth at home until the 1960s</a>. After the National Health Service was established, <a href="https://www.ncbi.nlm.nih.gov/books/NBK328267/">the Peel Report</a> of 1970 recommended universal hospital birth. By 1975, only five per cent of women still gave birth outside of hospital. </p>
<p>The <a href="https://vanierinstitute.ca/context-understanding-maternity-care-canada/">story in Canada is similar</a>, with a sharp move away from home birth occurring in the middle of the 20th century. Safety for both mother and child has been declared the reason for this shift. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research in Canada shows that women who planned a home birth had lower rates of obstetrical intervention, such as pain medication and fetal monitoring, and lower rates of caesarean section.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>However, there is little evidence that hospitals have made birth safer for women who are experiencing normal, healthy pregnancies.</p>
<p>I am a registered midwife in Ontario and an assistant professor in the midwifery education program at McMaster University. My colleagues and I take great pride in providing evidence-based care to the pregnant women who choose midwifery care. We know that good evidence supporting the safety of home birth has been lacking in the past. </p>
<p>Recent research from several countries, however, has shown that for those with low-risk pregnancies, giving birth at home is a safe choice.</p>
<h2>Lower rates of caesarean section</h2>
<p>In Canada, three studies — one from <a href="https://doi.org/10.1503/cmaj.081869">British Columbia</a> and <a href="https://doi.org/10.1503/cmaj.150564">two</a> from <a href="https://doi.org/10.1111/j.1523-536X.2009.00322.x">Ontario</a> — have looked at the outcomes of more than 21,000 planned home births. </p>
<p>The planned home birth group included women who were transferred to hospital. They were compared to the outcomes for low-risk women having hospital births attended by midwives or family physicians. </p>
<p>These studies all showed that the outcome for newborns was the same. But the women who planned a home birth had lower rates of obstetrical intervention, such as pain medication and fetal monitoring, and lower rates of caesarean section.</p>
<p>Similarly, in England, a <a href="https://europepmc.org/articles/pmc3223531">study of place of birth</a>, including home birth, concluded that, overall, outcomes for the newborn did not differ by place of birth. </p>
<p>The newborns of first-time mothers, however, did have a slightly higher chance of a poor outcome. On the other hand, in the Netherlands, where home birth is more common, <a href="https://doi.org/10.1111/j.1471-0528.2009.02175.x">a study of 529,688 births</a> showed no differences in newborn outcomes between home and hospital births, even though more than 40 per cent of women in the study had planned a home birth.</p>
<h2>Publicly funded midwifery is essential</h2>
<p>A key component that promotes the safety of a planned home birth is the existence of regulated and well-trained midwives who are integrated into the health-care system. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Society of Obstetricians and Gynaecologists of Canada recently released a statement supporting home birth for healthy, low-risk women.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In Canada, the U.K. and the Netherlands, midwives receive university-level education. Midwifery care, regardless of birthplace, is publicly funded, and access to emergency services and hospital birth is readily available. Smooth transfer to hospital, when needed, is an important part of safe home birth services.</p>
<p>In Canada, <a href="https://doi.org/10.1111/jmwh.12896">approximately 20 to 25 per cent of planned home births</a> are transferred to hospital. Most of these transfers are for non-emergency reasons such as prolonged labour or need for pain relief. In many cases, midwives continue their care for the woman in the hospital.</p>
<p>Currently <a href="https://www.ontariomidwives.ca/home-birth">in Ontario</a>, about 4,000 or three per cent of the 140,000 births that occur per year are planned to take place at home. </p>
<h2>A long tradition of royal home births</h2>
<p>Over the past few years, planned home birth has increasingly gained acceptance by obstetricians. The Society of Obstetricians and Gynaecologists of Canada recently released <a href="https://doi.org/10.1016/j.jogc.2018.08.008">a statement that supports the choice of home birth for healthy, low-risk women</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Britain’s Meghan, the Duchess of Sussex, leaves King’s College, London, after joining a panel discussion to mark International Women’s Day on March 8, 2019.</span>
<span class="attribution"><span class="source">(AP Photo/Frank Augstein)</span></span>
</figcaption>
</figure>
<p>In the United Kingdom, the National Institute for Health and Care Excellence <a href="https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#place-of-birth">recommends that healthy women with uncomplicated pregnancies consider out-of-hospital birth, including home birth</a>, to reduce rates of intervention, especially caesarean section.</p>
<p>If the birth of Baby Sussex did, indeed, take place at Frogmore Cottage, it will become part of <a href="https://www.goodhousekeeping.com/life/a27113224/meghan-markle-home-birth/">a long tradition of royal babies born at home</a>. </p>
<p>And, no doubt, a royal home birth would spark an increase in this choice of birth place in the United Kingdom and elsewhere.</p><img src="https://counter.theconversation.com/content/116056/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathi Wilson has previously received funding from the Canadian Institutes of Health Research.</span></em></p>A professor of midwifery education reviews the research evaluating the safety of home versus hospital births.Kathi Wilson, Assistant Professor, Department of Midwifery, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1159282019-04-26T10:03:56Z2019-04-26T10:03:56ZMeghan Markle reportedly seeks a private childbirth – medieval women really did have one<figure><img src="https://images.theconversation.com/files/270961/original/file-20190425-121241-9hmupd.jpg?ixlib=rb-1.1.0&rect=0%2C146%2C3733%2C2667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Privacy, please. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-march-11-meghan-markle-1335905381?src=VZoR9y4qQcKwk378Z0fvmg-1-4">Mr Pics/Shutterstock.</a></span></figcaption></figure><p>The British royal family <a href="https://twitter.com/victoriaarbiter/status/1116273837082075136">has released a statement saying</a> that the Duke and Duchess of Sussex will keep plans for the arrival of their baby private. Other royal births have been announced almost immediately, with the new family posing for photographs soon afterwards on the steps of the Lindo Wing of St. Mary’s Hospital in London. Meghan and Harry, however, have chosen to “celebrate privately as a new family”, before placing their baby in the public eye. </p>
<p>As the London <a href="https://www.independent.co.uk/life-style/health-and-families/royal-baby-meghan-markle-prince-harry-pregnancy-birth-when-due-title-a8840136.html">media speculates</a> about when and where the birth will take place, the modern craving for instant information and “access-all-areas” insights has never been more apparent. Despite established <a href="https://www.gov.uk/data-protection">privacy laws</a>, information continues to spread, leak and diffuse – often without the subject’s consent. The fact that the Duchess had to make the request at all is, in itself, a telling sign. </p>
<p>Indeed, Meghan’s desire to retain privacy surrounding her impending birth has a historical precedent. The intimate – and largely lost – realm of the medieval “lying-in” room is a reminder that the modern predilection for publicising the deeply personal was not always the norm. </p>
<h2>A long lie-in</h2>
<p>Most pregnant women in the middle ages were tended to by other women, during an extended lying-in period of around two months, before and after childbirth. This private zone gave expectant women the time and space to prepare for, and recover from, childbirth, while awaiting the moment they were permitted to re-enter the church, in the ceremony of purification after childbirth. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=562&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=562&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=562&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=706&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=706&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270699/original/file-20190424-19297-ulbfbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=706&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The birth of St Edmund, from Lydgate’s Lives of SS Edmund and Fremund, England, 1434–1439.</span>
<span class="attribution"><span class="source">British Library</span></span>
</figcaption>
</figure>
<p>A 15th century manuscript miniature of the birth of St Edmund depicts the birthing chamber, midwives and female companions. The new mother rests in her bed as she is fed, made comfortable and soothed with aromatics by the women who care for her, while the baby is warmed before the fire.</p>
<p>The lying-in room was a womb-like space, adorned with tapestries for privacy and warmth, with daylight limited often to a single window, and herbs scattered across the floor to create a pleasant scent with therapeutic benefits. Women of higher social status were often bestowed with brooches, pendants and books depicting icons of healing saints, as well as jewelled girdles and statues of female saints. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=587&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=587&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=587&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=738&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=738&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270705/original/file-20190424-121237-1n4yton.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=738&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A painted birth tray, depicting a mother lying-in, by Francesco di Michele c.1410.</span>
<span class="attribution"><span class="source">Harvard Art Museum</span></span>
</figcaption>
</figure>
<p>Painted birthing trays, or salvers – such as this <em>desco da parto</em> from Florence – were given to wealthy women after childbirth, to serve mulled wine and clean linens: a sign of the value bestowed on noble births. Though present in this depiction, men were rarely permitted to enter the lying-in room – entrance was by invite only, through the monitored doors. </p>
<h2>Wandering wombs</h2>
<p>Childbirth was a dangerous business for mother and child in medieval times, regardless of their social station. Of course, royal births in the middle ages were different to those of peasant women, whose return to the hard labour of everyday life would demand a less luxuriant recovery period. But while aristocratic households could afford the services of university-trained male physicians, hands-on care remained the job of the midwife. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=797&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=797&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=797&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1002&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1002&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270843/original/file-20190424-121258-1is3oua.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1002&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disembodied wombs with foetal positions and a pregnant female in Wellcome Apocalypse (MS 49), f. 38r, c.1420.</span>
<span class="attribution"><span class="source">Wellcome Library</span></span>
</figcaption>
</figure>
<p>The medieval gynaecological and obstetrical handbook known as <a href="http://www.upenn.edu/pennpress/book/13753.html">The Trotula ensemble</a> contains instructions for midwives on how to deliver a baby safely. Medieval understandings of the female body included the <a href="http://exhibits.hsl.virginia.edu/antiqua/gynecology/">ancient Hippocratic belief</a> that a woman’s womb was like a living creature that “wandered” around her body – a stereotype of “unruly” women which <a href="https://www.vogue.com/article/trump-women-hysteria-and-history">still lingers today</a>. The postpartum uterus was seen to be particularly disordered. The Trotula author notes: </p>
<blockquote>
<p>The womb, as though it were a wild beast of the forest, because of the sudden evacuation falls this way and that, as if it were wandering. Whence vehement pain is caused.</p>
</blockquote>
<p>Such notions of the “wandering womb” are manifest in images from medical manuscripts that show the uterus “floating” around the words on the page. These disembodied wombs show common foetal presentations, and a reasonably accurate knowledge of anatomy – surprising, in an age when human dissection was taboo and male physicians had limited access to women’s bodies. </p>
<h2>Dragons and divination</h2>
<p>The story of <a href="https://en.wikipedia.org/wiki/Margaret_the_Virgin">St Margaret</a>, the patron saint of childbirth, was well-known to women in the middle ages. Margaret was swallowed by a dragon but, after making the sign of the cross, was expelled quickly. Her popularity reveals how an uncomplicated birth was desired just as much throughout history.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=579&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=579&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=579&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=727&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=727&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270713/original/file-20190424-121262-1do5fmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=727&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St. Margaret and the Dragon. From an illuminated medieval Book of Hours. Walters Manuscript.</span>
<span class="attribution"><span class="source">Walters Art Museum</span></span>
</figcaption>
</figure>
<p>Just as our modern fascination at guessing the sex of newborn babies remains, various medieval techniques for predicting the sex of a baby abounded. This one from The Trotula requires some careful orchestration: </p>
<blockquote>
<p>In order to know whether a woman is carrying a male or a female, take water from a spring and let the woman extract two or three drops of blood or milk from her right side and let these be dropped in the water. And if they fall to the bottom, she is carrying a male; if they float on top, a female.</p>
</blockquote>
<p>It’s safe to say that Meghan and Harry are unlikely to try this at home. But these medieval practices show that – unlike <a href="http://blog.catherinedelors.com/marie-antoinettes-first-laying-in/">Marie Antoinette’s hugely public birth</a> in the 18th century – watched by a plethora of spectators after her obstetrician called, “the Queen is going to give birth!” – childbirth need not always be a public spectacle.</p><img src="https://counter.theconversation.com/content/115928/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Kalas does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Duke and Duchess of Sussex wish to keep the arrival of their baby private – and it’s caused some consternation. But this was normal for most medieval women.Laura Kalas, Lecturer in Medieval Literature, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082822018-12-10T11:16:03Z2018-12-10T11:16:03ZCould AI take control of human birth?<figure><img src="https://images.theconversation.com/files/249014/original/file-20181205-186052-anz0r8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alexa, shall I proceed with a caesarean section? </span> <span class="attribution"><span class="source">Tomsickova Tatyana/Shutterstock</span></span></figcaption></figure><p>Instead of looking up at the sky to see whether you need an umbrella, people increasingly ask virtual assistants such as Alexa. And they may be wise to do so. AI methods are powerful – capable of anything from <a href="https://www.theverge.com/2017/11/15/16654352/ai-astronomy-space-exploration-data">analysing astrophysical data</a> to detecting tumours or helping to <a href="https://www.jmir.org/2018/5/e10775/">manage diabetes</a>. An algorithm that analyses shopping patterns recently <a href="https://www.dailymail.co.uk/news/article-2102859/How-Target-knows-shoppers-pregnant--figured-teen-father-did.html">detected that a teenage girl was pregnant</a>, earlier than her father did. So could childbirth be next for Al? </p>
<p>The most popular AI subset is “machine learning”, which allows a machine to learn a task <a href="https://theconversation.com/worried-about-ai-taking-over-the-world-you-may-be-making-some-rather-unscientific-assumptions-103561">without being explicitly programmed</a>. This is achieved by algorithms that are designed with the ability to discover relationships within large amounts of data. </p>
<p>Just imagine an AI system that can continuously read maternal and foetal movements, breathing patterns and bio-signals such as heart rate or blood pressure – and reliably identify crucial individual patterns in the physiology, emotions and behaviours of both mothers and foetuses – during childbirth. Through learning day by day, it would get more accurate at determining which combination of patterns would lead to which outcome. Could such a system be used to suggest what to do during labour, minute by minute, with excellent levels of accuracy – including whether to go ahead with a vaginal birth or opt for a caesarean section? </p>
<p>Maybe this could even reduce <a href="http://www.who.int/mediacentre/news/releases/2018/positive-childbirth-experience/en/">unnecessary interventions</a> and <a href="http://www.who.int/news-room/fact-sheets/detail/maternal-mortality">maternal mortality</a>, in line with WHO recommendations. If a simple reduction in interventions is the aim, AI could be very promising, in theory.</p>
<p>Some supporters will say that such a system would save lives and taxpayers’ money. Others will be horrified at the thought, feeling that it will result in a total loss of human companionship in labour – and of midwifery and obstetric skills and practice. </p>
<h2>Fact or fiction?</h2>
<p>But how close are we actually to having AI involved in childbirth – and do we know whether it would be beneficial? </p>
<p>A group of researchers from MIT have already developed an AI robot that can assist in a labour room. In their study involving doctors and nurses, they found that the robot’s recommendations were accepted 90% of the time and that the number of errors were similar whether the robot was there or not. On that basis <a href="http://people.csail.mit.edu/gombolay/Publications/Gombolay_RSS_2016.pdf">they suggested it should be safe and efficient</a> to use AI during childbirth.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/x89r6X-7lIg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>However, this also raises the question – if the technology is no better than human expertise, why would we use it? Especially as humans pick up a range of subtle cues that machines cannot perceive. For example, a clinical trial called INFANT showed that the use of software that was designed to improve the decision making of midwives and obstetricians for women who had continuous electronic foetal monitoring during labour <a href="https://www.sciencedirect.com/science/article/pii/S0140673617305688?via%3Dihub">did not improve clinical outcome</a> when compared to expert judgement.</p>
<p>So, it may be some time before AI is rolled out in maternity units. But we cannot ignore the writing on the wall – the potential for totally AI supported birth is not so very fantastical.</p>
<h2>Emotional support</h2>
<p>But birth, the beginning of life, is not a transactional enterprise that only requires monitoring and measuring to be both safe and fulfilling. It is an interaction story between the woman, her baby, her partner, labour supporters and healthcare providers. For most women around the world, it is a profoundly important experience that has an <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194906">impact on parenting</a> and self-esteem – lasting way beyond the moment of birth.</p>
<p>It was recently recognised that caring companionship and human emotional and psychological support not only <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/support-during-childbirth/en/">improve birth health outcomes</a> for both women and infants, but could have long term effects into newborn’s adult life. And current versions of AI are not actually that good at <a href="https://theconversation.com/will-ai-ever-understand-human-emotions-70960">understanding human emotions</a> or <a href="https://theconversation.com/ai-theres-a-reason-its-so-bad-at-conversation-103249">talking to people</a>.</p>
<p>As we are focusing more and more on the prioritisation of measuring, monitoring, counting and recording in labour over simple human interaction, and as we fall more and more in love with our personal technology devices, there is a risk we could lose sight of what matters for human well-being in a range of areas. In fact, we are making it easier and easier to translate childbirth expertise into an Alexa-style birth assistant interface. </p>
<p>What will happen to women and babies if, as a result, AI one day becomes so smart that it controls us? Maybe, if AI could be used as an aid for skilled and caring birth professionals and childbearing women – rather than as the ultimate decision maker – it could contribute to the best and safest experience for each woman and her baby.</p>
<p>At the moment though, it seems like no matter that prominent thinkers such as the late <a href="https://www.theguardian.com/science/2016/oct/19/stephen-hawking-ai-best-or-worst-thing-for-humanity-cambridge">Stephen Hawking</a> and tech-entrepreneur <a href="https://www.cnbc.com/2018/04/06/elon-musk-warns-ai-could-create-immortal-dictator-in-documentary.html">Elon Musk</a> have repeatedly warned of the potential risks of AI, we are on a headlong rush towards it. While it is impossible to stop a river in spate, it is possible to reroute it, and to use it for benefit rather than just letting it destroy everything in its path.</p><img src="https://counter.theconversation.com/content/108282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anastasia Topalidou receives funding from Innovate UK. She does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond her academic appointment.</span></em></p><p class="fine-print"><em><span>Soo Downe has received funding from a range of government research organisations, including the UK NIHR.Innovate UK, and the EU. She also undertakes funded consultancies for the WHO and NHS hospital Trusts</span></em></p>Some believe that including AI in childbirth could save lives and taxpayers’ money.Anastasia Topalidou, Research Associate (Biomechanics of Pregnancy and Childbirth, Thermal Imaging), University of Central LancashireSoo Downe, Professor of Midwifery Studies, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1053112018-11-23T14:49:52Z2018-11-23T14:49:52ZWeight monitoring during pregnancy could help save lives<figure><img src="https://images.theconversation.com/files/246839/original/file-20181122-182059-1nkjo71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-scales-stomach-feet-weight-round-97858217?src=HUsyiVtt5WC90XThBaLULQ-3-11">Shutterstock</a></span></figcaption></figure><p>There are times in a person’s life when specific events can have long-term implications on their future health. Pregnancy is one of those times – when major and <a href="https://www.researchgate.net/scientific-contributions/2132640934_Emma_Derbyshire">dramatic changes occur</a> within a woman’s body composition in a short period of time.</p>
<p>A key element of a healthy pregnancy is <a href="https://www.nhs.uk/common-health-questions/pregnancy/how-much-weight-will-i-put-on-during-my-pregnancy/">appropriate weight gain</a>. Maternal obesity is thought to be one of the most common factors in high-risk pregnancies. It can cause short and long-term health risks to both mother and child, an increased birth weight and problems with delivery.</p>
<p>It is thought that <a href="https://www.midirs.org/over-20-of-pregnant-women-are-obese-statistics-show/">20% of pregnant women in the UK are obese</a>, and due to the current <a href="https://www.ncbi.nlm.nih.gov/pubmed/28449616">obesogenic environment</a> it is likely that this proportion will increase.</p>
<p><a href="https://www.marchofdimes.org/pregnancy/being-overweight-during-pregnancy.aspx">Obesity in pregnancy</a> can cause infants to be predisposed to develop childhood obesity, metabolic syndrome and diabetes. For the mother there is also the risk of pre-eclampsia, miscarriage and gestational diabetes. </p>
<p>To combat this, there have been calls for <a href="https://www.theguardian.com/commentisfree/2018/sep/19/pregnancy-weigh-ins-healthy-diets-royal-college-midwives?CMP=Share_iOSApp_Other">women’s weight to be monitored</a> throughout the course of their pregnancy. This is something which has not been carried out consistently in the UK since the 1990s (when there was a lack of clinical evidence to suggest it was worthwhile).</p>
<p>But we know now that body composition measurements <a href="https://www.ncbi.nlm.nih.gov/pubmed/25796512"><em>can</em> help</a> predict maternal health and pregnancy outcomes. This monitoring throughout pregnancy may also have an influence on the birth weight of the baby, which in turn is a key determinant of short and long-term health conditions.</p>
<p>Midwives have a unique opportunity to provide advice regarding appropriate nutrition to the women in their care, and health promotion and education are considered among the most important activities they perform. However <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404046/">studies in the UK</a>, <a href="http://journal.stembi.ac.id/medias/journal/Pages_107-112.pdf">Sweden</a> and <a href="http://ro.uow.edu.au/sspapers/792/">Australia</a> conclude that many struggle to provide this advice.</p>
<p>One reason for this is that midwives <a href="https://www.bbc.co.uk/news/health-45558294">do not have clear guidelines</a> regarding what weight a woman should gain throughout her pregnancy. The National Institute of Health and Care Excellence (NICE) <a href="https://www.thetimes.co.uk/article/pregnant-women-face-return-of-the-weigh-in-dtx8qf7hl">are currently considering</a> a target of 16kg for women of a normal weight and 9kg for those who are obese. </p>
<h2>Eating for how many?</h2>
<p>It is important to remember that weight gain during pregnancy is not the sole issue with regard to the future health of the baby. If a baby has low weight gain following birth the risk of chronic disease later in life is increased and the child can also be undernourished and suffer stunted growth.</p>
<p>And while the focus is often on obesity and excessive weight gain, there are also serious issues at the other end of the spectrum. Women who do not gain enough weight and are not consuming enough calories are more at risk of giving birth preterm to children with a low birth weight. Babies born under 2.5kg <a href="https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072759/">are less likely to survive</a>, and those that do also have an increased risk of long-term health conditions. </p>
<p>The current dietary reference value for a pregnant woman is an extra 200 Kcal per day <a href="https://www.nutrition.org.uk/healthyliving/nutritionforpregnancy/pregnancyweight.html?start=1">in the third trimester only</a>. This is all that <a href="https://www.gov.uk/government/publications/sacn-early-life-nutrition-report">should be required</a> in order to maintain the healthy development of the foetus. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/246859/original/file-20181122-182040-v6npdt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Counting 200 calories.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnancy-people-eating-concept-happy-pregnant-766025020?src=f4fDwjXx-S0rb34p8IbvNA-1-24">Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.rcog.org.uk/en/news/eating-for-two-pregnancy-myth-still-risks-harming-mothers-and-their-babies-despite-best-intentions/">The myth</a> that pregnant women are “eating for two” encourages them to feel they can eat whatever they want. The right information about how much and what they should eat during pregnancy is still not reaching many women – potentially putting their health, and that of their unborn babies, at risk. </p>
<p>So who should be providing this information? The weight loss organisation<a href="https://www.slimmingworld.co.uk"> Slimming World</a> has been commended for <a href="https://www.slimmingworld.co.uk/health/evidence-base/pregnancy-and-postnatal.aspx">supporting women</a> to eat healthily and monitor weight increase in pregnancy. </p>
<p>But there also needs to be advice provided to how to increase weight for those who are underweight. Alongside information regarding adequate and appropriate nutritional intake, there is a need for specialist support and education within this area. This could be a <a href="https://www.researchgate.net/publication/318103344_Midwives'_Role_in_Providing_Nutrition_Advice_during_Pregnancy_Meeting_the_Challenges_A_Qualitative_Study">valuable role for a nutritionist</a> as part of the care provided to women during their pregnancy.</p>
<p>Management of a healthy weight and subsequent weight gain in pregnancy is becoming increasingly difficult to maintain within modern society. The <a href="https://www.nice.org.uk/guidance/ph27">current advice</a> from NICE is that weight and height are measured at the pregnant woman’s first appointment – but not regularly throughout the pregnancy. </p>
<p>Yet pregnancy is a time when women often have an increased nutritional awareness and the motivation to do what is right for themselves and their baby. Regular weight monitoring would be an effective way of helping them achieve this – while they are hungry for information on how to be as healthy as they can be.</p><img src="https://counter.theconversation.com/content/105311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazel Flight does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The right advice on nutrition is not always reaching pregnant women.Hazel Flight, Programme Lead Nutrition and Health, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/982942018-10-04T21:38:17Z2018-10-04T21:38:17ZPoor women who use midwives have healthier babies<figure><img src="https://images.theconversation.com/files/239209/original/file-20181003-52666-n9kuap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A study published in the _British Medical Journal Open_ reports that midwifery patients were 41 per cent less likely to have a small-for-gestational-age baby compared to patients of obstetricians.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Women who are marginalized by poverty may be reaping the greatest benefits from midwifery care. This is the finding of <a href="http://dx.doi.org/10.1136/bmjopen-2018-022220">a large study that we published with colleagues this week in the <em>British Medical Journal Open</em></a>.</p>
<p>We found that women who were eligible for government assistance and were seen by a midwife for prenatal care had significantly lower likelihood of preterm birth, small and low birth weight babies. </p>
<p>The study, which drew on evidence from 57,872 pregnancies, made sure that women who were seen by midwives were of comparable health status to women seen by general practitioners and obstetricians during the prenatal period.</p>
<p>A common belief is that midwifery care is only affordable for, and sought after by, wealthy and educated women. This is not always the case. Our research shows that midwifery care is an effective model of prenatal care for women living in lower socioeconomic circumstances.</p>
<p>We hope that this evidence may help pave the way for maternal health policy to address ongoing health disparities experienced by mothers and babies living in poverty in Canada.</p>
<h2>Demand for midwives exceeds supply</h2>
<p>Despite a long history of midwifery practice in Europe and North America, legislated midwifery care has only been available in Canada for the last 24 years. </p>
<p>In British Columbia, where midwifery care has expanded most rapidly, <a href="http://www.perinatalservicesbc.ca/Documents/Data-Surveillance/Reports/SpecialReports/MidwiferyReport2015_16.pdf">22 per cent of births now have a midwife involved in care</a> and <a href="http://bccewh.bc.ca/wp-content/uploads/2012/05/2003_Solving-the-Maternity-Care-Crisis-Policy-Brief.pdf">demand for midwifery care continues to exceed supply</a>.</p>
<p>The study reports that midwifery patients were 41 per cent less likely to have a small-for-gestational-age baby compared to patients of obstetricians (29 per cent compared to patients of general practitioners). </p>
<p>Preterm birth was 26 to 47 per cent less likely and low birth weight was 34 to 57 per cent less likely for patients of midwives, versus those of general practitioners or obstetricians.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239211/original/file-20181003-52695-fsasdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The benefits of midwifery care are not limited to the wealthy and educated.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These are important findings. At least one other report — an international Cochrane review combining the results of eight trials — found <a href="http://dx.doi.org/10.1002/14651858.CD004667.pub5">similar results for preterm birth for women in the general population</a>. </p>
<p>Our study takes the findings reported in the Cochrane review a step further. It shows that women of lower socioeconomic means are not only accessing and using midwifery care provided under a universal health-care system, but are also benefiting remarkably in terms of having healthier birth outcomes than their counterparts seen by medical practitioners.</p>
<h2>A deep clinician-patient relationship</h2>
<p>On average, prenatal midwifery appointments last 30 to 60 minutes, and are designed to promote physical, social, emotional, cultural, spiritual and psychological health. This midwifery model of care may better address the social determinants of health that especially affect birth outcomes for vulnerable women, compared to other models of care.</p>
<p>Study results show patients of midwives to be 2.2 times more likely to have mental health conditions documented in their maternity records, compared to patients of general practitioners, and 3.4 times more likely than those of obstetricians.</p>
<p>The rate of documented depression for midwives’ patients was 18.8 per cent, <a href="https://doi.org/10.1007/s00737-016-0629-1">close to that reported in the wider research literature (17.2 per cent)</a>. In contrast, documented depression was 12.8 per cent for general practitioners’ patients and 7.4 per cent for obstetricians’ patients.</p>
<p>That could be because midwifery patients may be more inclined to disclose sensitive information to their care providers because of the depth of the clinician-patient relationship fostered over time. </p>
<p>Midwifery patients were also more than twice as likely to have an adequate number of prenatal appointments, at the appropriate times, compared to general practitioner or obstetrician patients. Receiving adequate prenatal care has been shown to protect against preterm birth, stillbirth and infant death.</p>
<h2>Health and cost benefits</h2>
<p>An Alberta study measuring the cost-effectiveness of midwifery care reported savings of $1,172 per pregnancy for midwifery patients, compared to <a href="https://doi.org/10.1016/S1701-2163(16)34568-6">patients receiving standard prenatal care</a>.</p>
<p>Mounting evidence suggests that the health and cost benefits of midwifery care are at least equivalent, if not better in some instances, for moms, babies and the health-care system. This debunks any notion of midwifery care being <a href="https://doi.org/10.1016/j.ssmph.2016.01.007">a second-class service</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239216/original/file-20181003-52684-15iougz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Expansion of midwifery care will require more seats in provincial midwifery education programs.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Midwifery care is the fastest growing maternity care service in B.C., increasing in volume <a href="http://www.perinatalservicesbc.ca/Documents/Data-Surveillance/Reports/PHR/2015_16/PHR_BC_2015_16.pdf">year-by-year since 2008</a>. </p>
<p>The widespread adoption of midwifery care not only provides expanded choice in prenatal care options, but is a viable solution to the critical decline in the number of doctors offering maternity services and the continual shortage of rural physicians.</p>
<h2>Provincial governments must step up</h2>
<p>To address the demand for midwifery care, and to move it from the margins to a mainstream option, policy is needed which supports the continued expansion of midwifery care — for example by increasing the number of seats in provincial midwifery education programs. </p>
<p>This needs to include outreach to vulnerable women. And we need to increase public awareness of the availability of midwifery care, its coverage under health-care systems, the full range of services midwives provide and how to access them. </p>
<p>Midwives select where they will practise and their clientele. To encourage outreach to marginalized women, midwives may need to be compensated for the extra time involved in caring for women with higher socioeconomic risk.</p>
<p>The time has come to expand innovative and effective ways of meeting the needs of prenatal women, especially those with high social and economic needs. Access to and use of midwifery care is one such approach. </p>
<p>All provincial governments in Canada should step up and act, in line with the evidence.</p><img src="https://counter.theconversation.com/content/98294/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nazeem Muhajarine receives research funding from the Canadian Institutes of Health Research, Global Affairs Canada, Saskatchewan Health Research Foundation. </span></em></p><p class="fine-print"><em><span>As of May 2018 Daphne McRae has provided part-time consulting services for the Midwives Association of BC. </span></em></p>New research shows that midwifery care is not just for the wealthy – it has health and cost benefits for vulnerable women and provincial governments must act to increase their access.Nazeem Muhajarine, Professor, Department of Community Health and Epidemiology and Director, Saskatchewan Population Health and Evaluation Research Unit, University of SaskatchewanDaphne McRae, Postdoctoral Research Fellow in Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1018382018-08-21T12:43:10Z2018-08-21T12:43:10ZHow the NHS can make maternity care better<figure><img src="https://images.theconversation.com/files/232870/original/file-20180821-149481-187zdbz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-preparing-breast-feeding-baby-family-1093134218">Shutterstock</a></span></figcaption></figure><p>Healthcare in the UK has been a political football for decades. Despite the constant mantra that the NHS is the “envy of the world”, everyone knows there are problems. In my clinical area – maternity care – the <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf">Morecambe Bay scandal</a>, where midwifery was found to be seriously sub-standard, and the fact that the UK has persistently high rates of <a href="http://www.who.int/news-room/fact-sheets/detail/preterm-birth">pre-term birth</a>, reveal that all is not well.</p>
<p>Promises to increase spending on the NHS reached new heights with the infamous (and now <a href="http://uk.businessinsider.com/boris-johnson-says-his-350-million-a-week-brexit-claim-was-an-underestimate-2018-1">discredited</a>) £350m slogan on the side of the Leave campaign’s Brexit tour bus. But even if the promised money was to materialise, would things in the NHS necessarily get better? Smarter organisation may not cost more; perhaps the key is to unlock what smarter care consists of, and learn how to replicate it.</p>
<p>Smarter care involves looking past the “hard outcomes” (the rates of death and illness) to consider the relational aspects – that is, the human factors that are key to making any organisation work effectively.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2pfskj_xbGE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>We know from high-level <a href="https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early">research reviews</a> that certain models of maternity care produce better outcomes. Midwife-led care is key. This includes “caseload midwifery” where a named midwife is responsible for each pregnant woman’s care. In theory, this sense of continuity promotes a trusting relationship, which improves communication – always a significant variable in health outcomes.</p>
<p>However, two problems present themselves. First, the “magic ingredient” – what actually causes the improved outcomes – is not yet proven, although many believe it is the relational, human factor, which consists of more than just good communication.</p>
<p>Though we know these continuity models work well, it’s extending them beyond the research setting that is problematic. Most maternity care struggles to guarantee pregnant women a constant relationship with the same midwife throughout. Defining and measuring this relational human quality is difficult (never mind funding it), but unlocking this quandary may be possible if we can work out how the ingredients that make up good care actually gel in practice.</p>
<h2>A framework for good care</h2>
<p>The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/abstract">Quality Maternal and Newborn Care Framework</a> is a global analysis which looks in detail at the ingredients of good quality care. The framework emphasises the importance of positive values and holistic, respectful relationships, and is well-regarded, informing the World Health Organisation’s <a href="http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/">revised antenatal care guidelines</a>. </p>
<p>It is also proposed as a way to improve <a href="https://www.midwiferyjournal.com/article/S0266-6138(16)00022-X/fulltext">global midwifery education standards</a>, and has been put forward by <a href="https://www.midwiferyjournal.com/article/S0266-6138(18)30186-4/fulltext">senior midwifery academics</a> from Europe, Australia and North America as an effective way to evaluate midwifery care. Anticipating this call, and as a first step in developing a toolkit for this purpose, we used the framework as a topic guide in a series of 12 focus groups with pregnant women, new mothers, midwives and obstetricians.</p>
<p>This work is part of the McTempo research programme, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949880/">Models of Care: The Effects on Maternal and Perinatal Outcomes</a>, hosted at the <a href="https://nursing-health.dundee.ac.uk/research/mother-and-infant-research-unit">Mother and Infant Research Unit</a> at the University of Dundee. Our intention is to unpick what works and what doesn’t, when and for whom.</p>
<p>We analysed the <a href="http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0200640&type=printable">focus group discussions</a>, and when we mapped these findings back to the original framework we found a good match. But crucially, we discovered that the fluidity of the care experience does not fit neatly into descriptive boxes. The framework’s separate components of care, which in <a href="https://www.researchgate.net/publication/266376054_Midwifery_An_Executive_Summary_for_the_Lancet%27s_Series/figures?lo=1">diagram form</a> appear distinct, frequently overlapped.</p>
<h2>Applying women’s experience</h2>
<p>Participants told us not just about when they received good care, but also when it was poor. Analysing both good and poor practice and then drilling down to see how these experiences reflect the relevant care model, may allow us to identify some of the key ingredients which either need to be reinforced, replicating good practice, or addressed, helping to head off potential problems. “Organisational culture” was a recurrent theme which closely reflected the framework component called “Organisation of care”.</p>
<p>We were not surprised to find that “relationships” and “information and support” were strong themes, too. Less predictably, however, we found that the negative aspects of these three themes produced a fourth: “uncertainty”. Positive reactions to uncertainty often revolved around addressing negative root causes, so women would strengthen their own capabilities or obtain information and support, and staff would seek ways to empower women. However, this feedback mechanism was not failsafe: while practitioners sometimes acted remedially to “explain the system” to pregnant women, the negative aspects also included “anxiety and confusion”, and “muddling through”.</p>
<p>Evaluating care also means assessing those factors that predate the pregnancy, including the woman’s preexisting capabilities and whatever family or community knowledge and support she can draw upon. Crucially, we found that women who had experience of caseload midwifery were far more positive in their discussions than women who had experienced “standard” care.</p>
<p>While aware of the limitations of a small-scale study – we cannot yet link experiences and perceptions to “hard” outcomes – we are encouraged by this initial work, and currently testing this approach further in Australia, the Netherlands and Scotland, with another study proposed for Bangladesh. Bringing the human element back into the heart of healthcare is both good in itself and likely to be very cost effective. It’s a win-win for everyone involved.</p><img src="https://counter.theconversation.com/content/101838/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Symon currently has funding from the Scottish Government to assess the implementation of community-based midwifery continuity of carer schemes. </span></em></p>Better ante-natal care may not need more cash, just a smarter, consistent and more relatable way of making things work.Andrew Symon, Senior Lecturer, Midwifery, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/994682018-07-31T10:31:19Z2018-07-31T10:31:19ZClamping the umbilical cord straight after birth is bad for a baby’s health<figure><img src="https://images.theconversation.com/files/227466/original/file-20180712-27027-vjjbeu.jpg?ixlib=rb-1.1.0&rect=0%2C31%2C997%2C634&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Umbilical cord clamps.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/499869328?src=53oLBexvq5cAR9NkZm108w-1-6&size=medium_jpg">KANOWA/Shutterstock.com</a></span></figcaption></figure><p>Clamping and cutting a baby’s umbilical cord as soon as it is born can be bad for its health. The <a href="http://apps.who.int/iris/bitstream/handle/10665/148793/?sequence=1">World Health Organisation</a> advises that clamping should be delayed for two to three minutes after the baby has been born, and the UK watchdog <a href="https://www.nice.org.uk/guidance/qs105/chapter/Quality-statement-6-Delayed-cord-clamping">NICE advices</a> midwives and obstetricians not to clamp the cord earlier than one minute after the birth. But in nearly a third of cases, this doesn’t appear to be happening. </p>
<p>In a <a href="https://mailchi.mp/positivebirthmovement/press-release-40-of-uk-babies-are-having-cords-clamped-too-soon-in-spite-of-guidelines">survey</a> of 3,500 parents whose children were born in the UK between 2015 and 2017, 31% said that their baby’s cord was clamped less than a minute after they were born. One in five said that their baby’s cord was cut immediately following the birth.</p>
<h2>Life support</h2>
<p>The umbilical cord consists of a vein and two arteries, which are surrounded by a gelatinous substance called Wharton’s jelly. A membrane, called the amnion, holds the whole thing together. </p>
<p>During pregnancy, the umbilical cord vein carries oxygen-rich blood and nutrients from the placenta to the baby, and the arteries return deoxygenated blood and waste products, such as carbon dioxide, to the placenta.</p>
<p>A baby’s blood supply is independent of its mother’s, and remains within this closed circuit throughout pregnancy, labour and birth. As the baby is squeezed through the birth canal or an abdominal incision (if it’s a caesarean birth), a lot of the baby’s blood is pushed back into the placenta. But as the baby emerges, the umbilical cord – if left to pulsate – returns all of this blood to its rightful owner in a few minutes. </p>
<p>The cord continues to act as the baby’s only oxygen supply until the baby starts to breathe, before the placenta becomes detached. So, even when a baby needs help to breathe, the cord should ideally remain intact as the baby is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26191414">resuscitated at the bedside</a>. If the umbilical cord is cut too early, the baby <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334141/">can be deprived</a> of oxygen, 20-30% of its blood volume and 50% of its red blood cell volume. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=920&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=920&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=920&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1156&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1156&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227428/original/file-20180712-27045-1d8cxmk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1156&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Baby with a clamped umbilical cord.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=1428596">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>This shortage of blood will leave <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835342/">up to 30%</a> of babies with iron-deficient anaemia. A <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1753-4887.2006.tb00243.x">review of 27 studies</a> involving six to 24-month-old babies found that babies with iron-deficient anaemia have significantly poorer brain, physical, social and emotional functioning. Iron deficiency has also been linked to <a href="https://www.sciencedirect.com/science/article/pii/S1751722207000200">recurring infections</a>, <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/jpc.12483">autism</a> and <a href="https://www.sciencedirect.com/science/article/pii/S1751722207000200">learning difficulties</a>. </p>
<h2>A few minutes makes a big difference</h2>
<p>Aside from reducing the risk of iron-deficiency anaemia, delaying clamping by a few minutes has a range of other health benefits, including: a reduced <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3823451/">lifetime risk</a> of developing chronic lung disease, asthma, diabetes, epilepsy, cerebral palsy, Parkinson’s disease, infection and abnormal tissue growths; a reduced risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/28826265">bowel infections</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29097178">death in premature babies</a>,<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564438/">sepsis and brain haemorrhage</a> in very premature babies; and an <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2296145?utm_medium=facebook&utm_source=peds_fb">increased likelihood</a> of being more sociable and better behaved at age four.</p>
<p>Babies who have delayed cord clamping also enjoy <a href="http://www.cochrane.org/CD004074/PREG_effect-timing-umbilical-cord-clamping-term-infants-mother-and-baby-outcomes">higher birth weights</a>, compared with babies who have their cords clamped immediately. </p>
<p>Ultimately, immediate cord clamping disrupts the natural birth process and may cause harm to some babies by depriving them of essential blood and stem cells. Waiting until the umbilical cord is empty of blood before clamping it is the way to go.</p><img src="https://counter.theconversation.com/content/99468/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Pezaro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Umbilical cord blood is not a waste product.Sally Pezaro, Midwife, Lecturer and Researcher, Coventry UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/950482018-04-26T08:00:22Z2018-04-26T08:00:22ZPregnant women are at increased risk of domestic violence in all cultural groups<figure><img src="https://images.theconversation.com/files/216426/original/file-20180426-175074-q6jr9a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women having a subsequent baby are more likely to disclose domestic violence than first time mothers.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1059281756?src=CyQd4Z4-wdqBDSLlvqiEtA-1-99&size=medium_jpg">Vyshnova/Shutterstock</a></span></figcaption></figure><p>Domestic violence occurs across all age groups and life stages. Rather than reducing during pregnancy, expecting a child is a <a href="https://aifs.gov.au/cfca/publications/domestic-and-family-violence-pregnancy-and-early-parenthood">key risk factor for domestic violence beginning or escalating</a>. </p>
<p>Our research, <a href="http://bmjopen.bmj.com/content/8/4/e019566">published today in the journal BMJ Open</a>, found that 4.3% of pregnant women due to give birth in Western Sydney disclosed domestic violence when asked about it by a midwife at her first hospital visit. The study examined more than 33,000 ethnically diverse women who gave birth between 2006 and 2016, and found that these disclosures spanned all cultural groups. </p>
<p>Domestic violence in pregnancy not only causes distress and trauma for the mother and baby, it increases the risk of the baby having a low birth weight (very small baby) or being born prematurely (before 37 weeks), which is linked to jaundice, anaemia and respiratory distress in infancy, and diabetes and heart disease later in life. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/midwives-can-help-detect-domestic-violence-heres-how-37918">Midwives can help detect domestic violence – here's how</a>
</strong>
</em>
</p>
<hr>
<h2>Abuse and trauma</h2>
<p>Depending on the state or territory, women may receive a <a href="http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2010_004.pdf">“psychosocial” assessment</a> from midwives when they first book into a public hospital during pregnancy. This screens for depression, anxiety, childhood abuse, domestic violence, support and stress.</p>
<p>Using these assessments, we found that 4.3% of women disclosed domestic violence overall, but rates were higher among women having a subsequent baby, compared with first-time mothers. </p>
<p>We’re unsure if this is because violence has escalated for these women with subsequent pregnancies; if they trust health providers more to disclose the violence; or if they seek help because they’re becoming more aware of the impact of domestic violence on their children. </p>
<p>We found a strong link between the disclosure of childhood abuse and the disclosure of domestic violence. Nearly 24% of women disclosing domestic violence had also disclosed childhood abuse. </p>
<p>This doesn’t mean that one causes the other, but women who experience childhood abuse are more vulnerable to re-victimisation (being abused again). They may feel like they’re not worthy and gravitate towards men who abuse them.</p>
<p>Women who disclosed domestic violence in our study were more likely to have a history of anxiety or depression (34%) and have thoughts of harming themselves. </p>
<p>This is concerning, as <a href="https://theconversation.com/we-need-to-protect-new-mothers-from-trauma-and-suicide-17254">maternal suicide</a> during pregnancy or following the birth appears to be rising and has now become one of the <a href="https://theconversation.com/factcheck-is-suicide-one-of-the-leading-causes-of-maternal-death-in-australia-65336">main causes</a> of maternal death in Australia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-to-protect-new-mothers-from-trauma-and-suicide-17254">We need to protect new mothers from trauma and suicide</a>
</strong>
</em>
</p>
<hr>
<p>We also found rising rates of pregnant women disclosing domestic violence and being admitted to hospital for bleeding and signs that labour may be starting early (before 37 weeks). When this happens, women are admitted to hospital to try to stop the labour, or to find the source of the bleeding. Sometimes stress can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179976/">contribute</a> to preterm birth and bleeding in pregnancy.</p>
<h2>Ethnic backgrounds</h2>
<p>We found that domestic violence occurred across all cultural groups, but reported rates were highest among women from New Zealand and Sudan. </p>
<p>Previous research has shown high rates of domestic violence among Maori women in some parts of <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.838.4995&rep=rep1&type=pdf">New Zealand</a>. </p>
<p>There is also evidence of high rates of domestic violence among <a href="https://www.reuters.com/article/us-southsudan-women-violence/south-sudan-war-seeps-into-homes-spurring-domestic-violence-idUSKBN1DT196">Sudanese</a> women prior to migration.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/family-violence-victims-need-support-not-mandatory-reporting-44133">Family violence victims need support, not mandatory reporting</a>
</strong>
</em>
</p>
<hr>
<p>We found that women born in India and China reported very low rates of domestic violence. This may reflect a cultural tendency not to discuss what is considered private family business with outsiders.</p>
<p>It’s important that health professionals know how to ask about domestic violence in a culturally appropriate way so women feel comfortable disclosing abuse and can access appropriate support. </p>
<h2>What needs to be done?</h2>
<p>Midwives need to consider cultural norms and acceptability when asking migrant women questions about domestic violence, and this must always be done in a way that keeps the woman safe. Partners should not be present when the questions are asked – and this may be done at another time in the pregnancy if necessary.</p>
<p>Where English is not the first language, interpreters should be used. But this can also present challenges if the interpreter comes from the same community and is known to the woman.</p>
<p>When women have <a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">continuity of midwifery care</a> and get to know a midwife well throughout the pregnancy, it is easier for midwives to gain women’s trust and to notice when things change. This style of care should be rolled out more widely in Australian public hospitals. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/acting-on-family-violence-how-the-health-system-can-step-up-45592">Acting on family violence: how the health system can step up</a>
</strong>
</em>
</p>
<hr>
<p><em>The National Sexual Assault, Family & Domestic Violence Counselling Line – 1800 RESPECT (1800 737 732) – is available 24 hours a day, seven days a week for any Australian who has experienced, or is at risk of, family and domestic violence and/or sexual assault.</em></p><img src="https://counter.theconversation.com/content/95048/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives</span></em></p><p class="fine-print"><em><span>Virginia Schmied receives funding from NHMRC ARC</span></em></p>Domestic violence in pregnancy not only causes distress and trauma for the mother, it also poses serious risks for the baby’s health and development.Hannah Dahlen, Professor of Midwifery and Higher Degree Director, Western Sydney UniversityVirginia Schmied, Professor, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/920792018-03-08T11:16:00Z2018-03-08T11:16:00ZWomen need more freedom during labour, not a medicalised birth script to follow<figure><img src="https://images.theconversation.com/files/209309/original/file-20180307-146675-rllu6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Everyone is born to someone, so birth is everyone’s business – or so it seems.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/several-hands-touch-belly-pregnant-woman-641032354?src=l87KMBNf79Y6-fc7p9yaLg-1-97">Dariia Pavlova/Shutterstock</a></span></figcaption></figure><p>Countless women around the world give birth to babies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595040/">without medical intervention</a> in this natural process. For them, the most valuable care is the constant presence of a midwife or other skilled attendant who creates an environment which supports their <a href="http://www.nationalpartnership.org/research-library/maternal-health/hormonal-physiology-of-childbearing.pdf">hormonal and physical processes</a>. </p>
<p>Midwives, the experts in physiological, undisturbed birth, have been providing – and arguing for – <a href="https://www.routledge.com/The-Social-Context-of-Birth-3rd-Edition/Squire/p/book/9781785231254">the supportive care</a> of birthing mothers for decades. However, while they want to exercise their professional autonomy in order to give care which centres around the mother’s individual needs – during what can be a risky time – they are increasingly battling with their employers and a professional blame culture <a href="https://midwiferytoday.com/mt-articles/equality-for-midwives/">to do so</a>. Strict time limits on labour progress and so-called “active management of labour” intervenes in the natural process, with the aim of preventing labour delay. </p>
<p>But there is evidence – both <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002492">clinical</a> and experiential – which shows that labour and birth cannot be rigidly regarded as universal, mechanised processes defined by clinical parameters. Now, a new guideline from the World Health Organization (WHO) has definitively stated that medical professionals’ approach to caring for and supporting women in childbirth <a href="http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/">must change</a> to recognise this. </p>
<p>But surprising as this notion may be, a more humanistic model of care is difficult to implement. The WHO acknowledges that the main reason for this is the increasing medicalisation of natural childbirth processes. The “birth script” – which involves repeated use of a particular type of language (such as “failure to progress”) and habitual interventions (for example, routine electronic monitoring) sets doctors and midwives as the experts and holders of the mysterious and specialist knowledge of birth. </p>
<p>The system gives them the control and power over women, and means they may intervene when it is not necessary or indicated by the mother. They control the experience of birth by presenting choices, chances and clinical indicators in ways which do not reinforce or even indicate the fact that the majority of births can happen with little intervention. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209363/original/file-20180307-146666-5h45lw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Care, support and autonomy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mid-adult-female-nurse-comforting-tensed-228783766?src=IQDUJS-BDcrTRq6oNY7HPA-1-41">Tyler Olson/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Freedom to decide</h2>
<p>Research shows that how midwives and doctors communicate with women makes them more likely to make choices which are <a href="http://blogs.bmj.com/bmj/2018/02/08/humanising-birth-does-the-language-we-use-matter/">in line with the professionals’ preferences</a>. The way that things are phrased seems to pressure individuals <a href="http://www.pec-journal.com/article/S0738-3991(16)30454-2/fulltext">towards certain choices</a>. For example, using the phrase “we just need to” makes it harder for a woman to say no to intervention. </p>
<p>These professional preferences are often grounded in a culture of risk which does not seem to support autonomy in childbirth or respect women’s ability to make their own decisions. Simply changing the language used by medical professionals when talking to and about expectant mothers <a href="http://blogs.bmj.com/bmj/2018/02/08/humanising-birth-does-the-language-we-use-matter/">can change all this</a>, however. One glaring example is how women are referred to as “the labourer” or told about “the induction”. They are people and should be referred to as such.</p>
<p>This idea is <a href="https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#care-throughout-labour">supported by NICE guidelines</a>, which advise midwives and doctors to communicate in a way that creates a “culture of respect” for the birthing woman. Under this advice, she is recognised as being the person in control of the situation, not the professionals. </p>
<p>While having this enshrined in a guideline is helpful, it is also a damning indication of the current state of the culture of obstetrics and midwifery. At present, women do not have the freedom to make decisions without being pressured into taking certain options – such as declining invasive examinations in labour, or into giving birth in certain places – because it is believed to be in their best interests. </p>
<h2>Informed choices</h2>
<p>Midwives and obstetricians cannot avoid the fact that they need to look closely at their own practices and change the ways that they communicate. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26407981">Research has shown</a> that changing the “birth script” enables the birthing woman to understand their innate ability to birth without intervention, and make informed choices that are in line with their own needs and preferences. It can also help mothers to adapt to changing circumstances during birth, and cope better on the rare occasions that valuable medical intervention is needed, so that they still have a positive birth experience. </p>
<p>During pregnancy and birth, women <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2016.24.10.682?journalCode=bjom">are being disempowered</a> during their encounters with medical professionals. The new WHO guidelines are a welcome change, but we need to make sure they are followed. Professionals must become aware of the power of their behaviour and communication during birth, and give childbearing women the opportunity and right to become more knowledgeable about what they are going through. Women must be able to make appropriate, informed decisions for themselves while accessing the safety net of expert knowledge and care. </p>
<p>It may be a potentially radical shift for some healthcare providers – away from a medicalised model of viewing birth in terms of risk – but the recommended practice of respectful care will give women the care and support they want as well as need.</p><img src="https://counter.theconversation.com/content/92079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Alys Bethan Einion is a member of the Editorial Board of The Practising Midwife Journal. </span></em></p>New WHO guidelines warn that medicalisation of birth is creating a lack of choice for birthing women.Alys Bethan Einion, Associate Professor of Midwifery and Women's Health, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/863062017-11-14T23:50:09Z2017-11-14T23:50:09ZCanada’s impending refugee crisis and how midwives can save the day<figure><img src="https://images.theconversation.com/files/194403/original/file-20171113-27585-1jko624.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clinics in Toronto serving refugees and the uninsured indicate that 20 per cent of all visits are for pregnancy-related issues.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>There is no question there is a worldwide refugee crisis, with global border crossings at an all-time high. According to the UN, <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwicwoWYgLvXAhUG0YMKHfG5AOAQFggmMAA&url=http%3A%2F%2Fwww.cnn.com%2F2016%2F06%2F20%2Fworld%2Funhcr-displaced-peoples-report%2Findex.html&usg=AOvVaw3_Xoy4l_K-13LQRJDAT4BQ">we currently have more displaced people than during and after the Second World World War</a>. With recent natural disasters in the Caribbean, this number will only increase: <a href="http://www.cbc.ca/news/canada/montreal/rcmp-says-it-has-intercepted-3-800-asylum-seekers-crossing-illegally-into-quebec-since-aug-1-1.4250806">More and more people are entering Canada</a>. </p>
<p>As a midwife working in Toronto for almost 18 years, I have dedicated most of my career to the care of newcomers, refugees and the medically uninsured. As a health-care provider on the ground, I can see the changes on a micro level before they are seen at a macro level. I can see the groundswell of newer immigrants — and I think I can fairly accurately say a storm is coming.</p>
<p>Many believe everyone in Canada has health insurance. But since the advent of medicare, Canada has always had populations that lack health insurance. Historically, this has included a few religious sects, such as Amish and Mennonite, as well as marginalized people dealing with issues like homelessness, drug addiction or mental health challenges.</p>
<p>However, in the past two decades, the categories of people without health insurance has dramatically increased to include more newcomers, immigrants and refugees. <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=18&cad=rja&uact=8&ved=0ahUKEwiDup_BhLvXAhXpxYMKHcRGDZk4ChAWCE0wBw&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC3395500%2F&usg=AOvVaw2H0wr0vNrssnVdBAICF9kR">The reasons for this are complex and related both to changes in Canada’s immigration policies as well as increasing global migration</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=491&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=491&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=491&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=618&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=618&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194405/original/file-20171113-27607-qi2l5o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=618&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A group of refugee claimants from Eritrea cross the border from New York into Canada in March 2017 in Hemmingford, Que.</span>
<span class="attribution"><span class="source">(THE CANADIAN PRESS/Ryan Remiorz)</span></span>
</figcaption>
</figure>
<p>Care for pregnant people involves particular challenges. Without health insurance, people need to pay for physician care, hospital fees and diagnostic tests. In a low-risk pregnancy, this can mean costs close to $10,000; with a higher risk pregnancy these costs can double, triple or more. For most pregnant people, these costs are untenable. </p>
<p>As a result, care is minimal, delayed or even refused. Many women choose to give birth alone, show up late in pregnancy or only seek care at the time of labour. This potentially results in higher risk situations — putting a demand on a health-care system that’s already strained for resources. </p>
<p>Even during war, famine and fear, people have sex and get pregnant. In fact, some people argue that refugee populations have more <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&ved=0ahUKEwiosdDxhbvXAhUB1oMKHbosCZoQFgg6MAM&url=http%3A%2F%2Fwww.who.int%2Fbulletin%2Fvolumes%2F95%2F9%2F17-193664%2Fen%2F&usg=AOvVaw17XgNvvG1xHjB1Q82L4MHP">complex needs in pregnancy</a> than the standard population. This is for a variety of reasons. <a href="https://theconversation.com/quebecs-niqab-ban-uses-womens-bodies-to-bolster-right-wing-extremism-86055">Rape is used as a tool of war </a>and women are particularly targeted during war and genocide. Access to contraception is difficult during war and disaster. And generally, increased life stresses make people less attentive to reproductive health-care needs. </p>
<p>About 20 per cent of all people seeking health care in refugee camps and disaster zones do so for pregnancy-related concerns. As well, <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&ved=0ahUKEwiy0au8hrvXAhUM5YMKHcAXAoIQFgg6MAM&url=http%3A%2F%2Fwww.wellesleyinstitute.com%2Fwp-content%2Fuploads%2F2014%2F12%2FUD-resources-Apr27.pdf&usg=AOvVaw05q5LGMCZ3o7g9slOJ42Q3">clinics in Toronto serving refugees and the uninsured indicate that 20 per cent of all visits are for pregnancy-related issues</a>. </p>
<h2>Now add the unanticipated Trump effect</h2>
<p>Canada already welcomes a high number of immigrants. But <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwiPnoSBh7vXAhWEx4MKHcTUARoQFggtMAE&url=http%3A%2F%2Fwww.metronews.ca%2Fnews%2Ftoronto%2F2017%2F02%2F09%2Ftoronto-sees-increase-in-numbers-of-refugees-from-the-us.html&usg=AOvVaw0pSEUOwvcZds0zYbBHu1xf">with every anti-immigrant declaration by U.S. President Donald Trump, Canada receives new waves of unanticipated, vulnerable migrants</a>. In the past year, Canada has seen waves of Haitian refugees, Nigerians and others crossing a small-town borders, mostly in Québec.</p>
<p>Anecdotal evidence from my clinic visits tells me that people of colour in the U.S. are terrified of deportation and increased race-related violence. For those fleeing war, economic and political instability, there are few options. Instead of risking being sent back home, many are choosing to enter Canada. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193468/original/file-20171106-1041-1vwk0z5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">About 20 per cent of all people seeking health care in refugee camps and disaster zones do so for pregnancy-related concerns.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>While those entering the country are claiming refugee status, the number of accepted refugees in Canada is minimal compared to the number of claimants. Those whose refugee claim is refused face being sent home or living in Canada illegally. For many, there is no choice — going home would mean facing poverty, incarceration, torture or worse.</p>
<p>Recently, I was sitting in my midwifery clinic and doing a first midwifery visit with a newly arrived Nigerian couple from the United States who had entered Canada through Québec. I asked: “I’m seeing a lot more Nigerians in your situation recently, what’s going on in your community?”</p>
<p>They told me everyone was afraid of their immigration status because of Trump. Also, as racialized people, they are increasingly afraid. They had lived in the American Midwest for more than six years and, up until recently, had never experienced the kind of daily, racially motivated violent threats they have since Trump came into office. </p>
<p>The couple had heard of a Nigerian man in a neighbouring state who had been brutally beaten for no apparent reason. They started thinking about fleeing. Getting pregnant was actually the precipitating factor for them to leave.</p>
<p>Two months earlier, I had a Pakistani couple in my clinic who were previously in the U.S. on legal student visas, both attending a southern state university in a small town. They fled because the woman, who wore a hijab, was literally being stoned by people on her way to campus and they were worried about the safety of their two small children. Pregnant with their third child, their fears increased. </p>
<p>After hiding for two weeks in their apartment and running out of food, they fled out of fear for their lives. They travelled along a now well-established line of acquaintances, contacts and safe houses from the southern U.S. to Canada — a makeshift refugee underground railroad for the modern era. </p>
<p>The U.S. has traditionally been seen as a designated “safe country” by Canada — meaning people cannot apply for refugee status while living in the U.S. — but if you are being stoned on the way to school and <a href="https://www.theatlantic.com/politics/archive/2017/08/trump-defends-white-nationalist-protesters-some-very-fine-people-on-both-sides/537012/">your president openly supports white supremacist demonstrators</a>, how can we still consider the U.S. a safe country? </p>
<h2>Babies still come</h2>
<p>A lot of the people crossing the border will be pregnant, and those who choose to stay may get pregnant. Many will be denied a valid refugee claim; many will chose to stay here illegally, without valid immigration status and as a result, without health-care insurance.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=474&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=474&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=474&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194406/original/file-20171113-27595-16fkmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Asylum seekers leave Olympic Stadium in August 2017 in Montréal. The stadium is being used as temporary housing to deal with the influx of asylum seekers arriving from the United States.</span>
<span class="attribution"><span class="source">(THE CANADIAN PRESS/Ryan Remiorz)</span></span>
</figcaption>
</figure>
<p>Keeping people out of the health care system creates more problems than it solves. Pregnancy is a perfect example. Unlike many other health-care issues, most pregnancy outcomes can only be put off for so long — for the most part the babies eventually come. </p>
<p>Unfortunately, research shows that women without health insurance in Ontario don’t get adequate prenatal care. Adequate prenatal care dramatically decreases low birth weight and premature infants. </p>
<p>This lack of care for refugees and the uninsured will cost us all. One of the top five expenditures in all of health care is for the care of babies born too early and too small. We are likely to have more pregnant people without insurance, having little or no access to care and as a result, babies who are less healthy.</p>
<p>The majority of people fleeing poverty, war and violence don’t have the kind of money that health care requires. Some may argue that this is a global problem and not Canada’s problem. </p>
<p>However, whether we like it or not, people are still going to enter our country and stay because of a lack of options. And whether we like it or not, we are paying for it. Regardless, like it or not, resist it or not, people are coming and our health-care system is not ready.</p>
<p>In Ontario, midwives have always been funded to care for any resident of the province, regardless of health care or insurance status. This is similar to Ontario’s Community Health Centres. In 2015, the province increased funding so that any physician who needed to get involved in higher risk pregnancies
would also be paid. </p>
<p>As a result, midwives in Ontario are able to provide relatively seamless care to pregnant people without health-care insurance. Research has shown that <a href="https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=20&cad=rja&uact=8&ved=0ahUKEwjmjuLdi7vXAhVJxoMKHX-DCr04ChAWCFswCQ&url=http%3A%2F%2Fpubmedcentralcanada.ca%2Fpmcc%2Farticles%2FPMC4786402%2Fpdf%2F1880e80.pdf&usg=AOvVaw2LIC_yK6fZzJhZabtRHbDb">women under midwifery care have improved outcomes and as a result cost the system less money</a>. However, this isn’t the case in the rest of the country. </p>
<p>Given the wave of refugees coming, and previous experience showing that many of the newcomers will end up lacking health insurance, it only makes sense for other provinces to follow Ontario’s lead and provide the funding for midwives to care for this population.</p>
<p>This will take a substantial burden off the health care system, improve outcomes and ultimately cost less.</p><img src="https://counter.theconversation.com/content/86306/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Manavi Handa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>About 20 per cent of refugees to Canada are pregnant. Many of them are medically uninsured. It’s not only morally correct to provide prenatal care, but also cheaper for Canada’s system to do so.Manavi Handa, Associate Professor, Midwifery Education Program, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/827792017-08-31T11:53:08Z2017-08-31T11:53:08ZWhy UK midwives stopped the campaign for ‘normal birth’<figure><img src="https://images.theconversation.com/files/184186/original/file-20170831-22597-1ixxr40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many midwives still want to reduce the number of unnecessary interventions during childbirth.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-midwife-assistant-538015270?src=aHA0V4H2p6jsk7_t2NrJ-g-1-39">COLLATERAL/Shutterstock</a></span></figcaption></figure><p>There has been much interest in the fact that the Royal College of Midwives (RCM) is no longer running its <a href="https://www.rcm.org.uk/tags/campaign-for-normal-birth">Campaign for Normal Birth</a>. After 12 years of focusing on “normal birth”, the end of the campaign is not a kneejerk reaction to a specific event, but rather a natural progression. In any organisation – commercial or public – campaigns need to be revitalised and adjusted to serve a changing social and cultural environment. </p>
<p>It is also not a recent change as the <a href="https://www.rcm.org.uk/better-births-initiative">Better Births Initiative</a> had already succeeded the Campaign for Normal Birth in 2014. However, the RCM did not remove all references to the campaign from the website until May this year.</p>
<p>One key question is why the campaign was necessary in the first place. While appropriate interventions save lives, there is considerable evidence that too many women are having unnecessary interventions in childbirth. The consequence is disparities in care, with very high rates of intervention in some countries while in others women cannot get the interventions they need. For example, the caesarean section rate in urban Brazil exceeds <a href="http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf?ua=1">WHO recommendations</a>, but in others, such as rural Nepal, too few women can access this life-saving procedure. </p>
<p>Achieving a balance is clearly important, as too much intervention can also be harmful. A caesarean section is a major operation that <a href="https://www.nice.org.uk/guidance/cg132/chapter/guidance#planning-mode-of-birth">comes with serious risks</a>.</p>
<p>So what do we mean by a “normal” birth and who gets to decide what normal is? Normal is a socially constructed concept and therefore will be interpreted differently depending on the context. Normal can be seen as cultural – how a specific culture expects a person to behave. But normal can also be seen as statistical – something that is close to the average and within a normal range. </p>
<h2>Paradoxical views</h2>
<p>A sociological perspective may help here. Society holds paradoxical views of childbirth, where most people agree that pregnancy is not an illness. But at the same time we have come to expect health surveillance and a hospital birth. The “social model” maintains that pregnancy and childbirth are largely physiological events that occur in most women’s lives. Those following <a href="http://www.socresonline.org.uk/10/2/teijlingen.html">this model</a> argue that pregnancy and childbirth do not normally need medical interventions. </p>
<p>The “<a href="http://www.socresonline.org.uk/10/2/teijlingen.html">medical model</a>” portrays a very different view, namely that childbirth is potentially pathological, and therefore every woman is at risk when she is pregnant or in labour. A frequently heard expression is: “birth is only safe in retrospect”. If you believe this, it makes sense to argue that every woman should “deliver” in high-tech hospitals supervised by experts. </p>
<p>Everybody’s views will sit somewhere on a continuum between the medical and the social model. The challenge is to find a balance that is workable in society, but also in a particular maternity unit. It should be clear that an obstetric hospital is operating on the more medical model of the spectrum than the freestanding midwifery-led unit 20 miles away.</p>
<p>We live in rather a risk-adverse society. At a time in history where childbirth in the UK is at its safest (compared to 100 or 1,000 years ago) we intervene more than ever before, and <a href="http://bmjopen.bmj.com/content/4/5/e004551">often unnecessarily</a>. Changing this perception of childbirth being risky, and our response to this, requires that birth is seen in society as a normal life event.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182936/original/file-20170822-31963-v1aqi6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Our view of birth changes over time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/midwife-preparing-bath-newborn-baby-694302625?src=aHA0V4H2p6jsk7_t2NrJ-g-2-42">Vyntage Visuals/Shutterstock</a></span>
</figcaption>
</figure>
<p>The Campaign for Normal Birth was one way of addressing the imbalance in maternity care, which in the UK had swung towards a more medical model of childbirth. However, the media also has an important role to play in this regard. For many women, the only opportunity they have to witness birth is on television, through programmes such as Channel 4’s One Born Every Minute. These programmes often feature dramatic stories that <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0827-x">might make childbirth appear inherently risky</a> and always requiring medical intervention.</p>
<h2>Appropriate decision</h2>
<p>One of the challenges with changing societal narratives is how any health message is conveyed. The term “normal birth” carries with it a value judgement. It follows that if you do not conform then you are not normal, and for many women (and partners) this could translate into a sense of failure. Hardworking midwives in the UK and across the globe aim to help women to have the best, evidence-based maternity care, which meets women’s needs and wishes. Therefore it is entirely appropriate that the RCM changed its terminology to “better births” to recognise the sensitivity around the word “normal”. </p>
<p>One could be mistaken for thinking that such a change would universally be regarded as good news – unfortunately, this is not the case. Although there are plenty of examples of high quality NHS maternity care where normal birth is encouraged, it is the problematic cases that often get a lot of attention. That’s what happened following an inquiry into the deaths of 11 babies and one mother at <a href="https://www.gov.uk/government/news/morecambe-bay-report-publication">University Hospitals of Morecambe Bay NHS Foundation Trust</a>, which claimed midwives’ desire for “normal births” had been a factor in unsafe practices. </p>
<p>It not surprising to see people making the link between the end of the RCM campaign with the Morecambe Bay Report and portraying this as a battle between medical staff and midwives. In fact, this could not be further from the truth, as both professional groups are working collaboratively to reduce unnecessary intervention. The challenge is how we change the current maternity system so that it enables midwives and doctors to provide the evidence-based, woman-centred care that supports women to give birth without unnecessary intervention.</p>
<p>Also, there are political advantages to be gained from talking about the end of the campaign. The Secretary of State for Health, Jeremy Hunt, recently linked the end of the RCM campaign with the government’s “ambition” to reduce neonatal deaths. Tweets like these, linking childbirth and pregnancy to risk and death are very damaging in that they can influence the views and expectations of pregnant women, their families, midwives and the media.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"896243800296882176"}"></div></p>
<p>The focus on single cases that are unrepresentative of wider practices in the NHS is extremely unhelpful. The lack of political support for midwives and other undervalued health workers in the NHS undermines trust. Furthermore, it detracts from where our focus should be – on ensuring that all women have the best birth possible, according to their needs and wishes.</p><img src="https://counter.theconversation.com/content/82779/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vanora Hundley is a member of the Royal College of Midwives. She has in the past received funding from Wellbeing of Women/RCM for an International Fellowship in Nepal with colleagues at Bournemouth University and The University of Sheffield. </span></em></p><p class="fine-print"><em><span>Edwin van Teijlingen has in the past received funding from Wellbeing of Women/RCM for an International Fellowship in Nepal with colleagues at Bournemouth University and The University of Sheffield.
Edwin van Teijlingen is member of the NMC (Nursing-Midwifery Council) Midwifery Thought Leadership Group, London (2017-2018).
</span></em></p>Society holds paradoxical views of childbirth, which can make the debate around it confusing.Vanora Hundley, Professor of Midwifery, Bournemouth UniversityEdwin van Teijlingen, Professor of Reproductive Health Research, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/771282017-05-19T11:17:43Z2017-05-19T11:17:43ZOh baby: seven things you probably didn’t know about midwives<figure><img src="https://images.theconversation.com/files/170105/original/file-20170519-12217-a9levo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/470594660?src=tIyBgtOF09va7zfu67hrwQ-1-0&size=medium_jpg">Vasiuk Iryna/Shutterstock</a></span></figcaption></figure><p>The term “midwife” can conjure up images of a stern matron, iron pressed and ready for some no-nonsense birthing, or, in the more modern era, a back-rubbing, hand-holding, motivational cheerleader who can make or break the birthing experience. Midwives are so much more than those two stereotypes. Here are a few things you may not know about the profession.</p>
<p><strong>1.</strong> The word “midwife” means “with woman”, although in France, where the midwife is a “sage femme”, it means “wise woman”.</p>
<p><strong>2.</strong> Some people think that midwifery is simply another branch of nursing. Midwifery is, in fact, one of the oldest professions in the world, one that is thought to have arrived prior to the nursing and medical professions. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170158/original/file-20170519-12231-fox3m6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Midwifery is not a branch of nursing.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/387771343?src=wg1k54RscC85L-h2TJNIWA-1-0&size=medium_jpg">Kzenon/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>3.</strong> Midwives make up <a href="http://www.unfpa.org/sites/default/files/pub-pdf/EN_SoWMy2014_complete.pdf">36% of the midwifery-service workforce</a>, according to a survey of 73 countries. Other professional members of the team may include auxiliaries, nurse-midwives, nurses, associate clinicians, general physicians, obstetricians and gynaecologists. Yet, as midwives can perform most essential maternal and newborn care, future investment in midwives could free up these other professionals to focus on other health needs around the world.</p>
<p><strong>4.</strong> Midwives are among the few healthcare professionals that don’t generally care for the sick. Although they are trained to manage emergency situations, midwives are the experts in normal childbearing. </p>
<p><strong>5.</strong> Midwives don’t just catch babies. There are a number of specialist roles that a midwife can fulfill. Such specialist roles may include sonography (ultrasound scanning) during pregnancy as well as safeguarding – where a midwife works to protect vulnerable families. Midwives can also work in management, commissioning, education, policy, quality assurance, inspection, <a href="https://www.facebook.com/TheAcademicMidwife/">and research</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=547&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=547&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170116/original/file-20170519-12221-3f0yqd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=547&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Midwives also do ultrasound scanning.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/546641992?src=w0AB0NQOj6Hm8OPokQYKPw-1-0&size=medium_jpg">GagliardiImages/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>6.</strong> Along with the decline of women’s social status during the middle ages, midwives (almost always female) were <a href="http://drbeardmoose.com/sitebuildercontent/sitebuilderfiles/witchesmidwivesandnurses.pdf">denounced as witches</a> by doctors (always male) who felt threatened professionally. Yet, while doctors were trying to catch up to midwives in learning about physiology in childbirth, women were unable to train as doctors. So, despite their wealth of professional experience, midwives were pushed out as the less desirable choice in childbearing. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=434&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=434&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=434&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170114/original/file-20170519-12257-1m5dybr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In medieval times, midwives were denounced as witches.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=14533045">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p><strong>7.</strong> During the 19th and early 20th centuries, <a href="https://library.tulane.edu/journals/index.php/NAJ/article/viewFile/199/142">doctors ran campaigns</a> to socially stigmatise midwifery and make the ancient practice <a href="http://samples.jbpub.com/9781284025415/9781284025415_CH02_Pass2.pdf">illegal in some places</a>. This was largely done for economic reasons, but also to increase the status of the predominantly male medical profession. </p>
<p>It worked, as the care of physicians in childbirth during this time became the popular choice for upper-class women. Now, in the 21st century, midwives continue to reclaim their position as respected experts in childbirth, working in partnership with doctors, multidisciplinary teams, mothers and families to achieve the best outcomes in childbirth around the world.</p><img src="https://counter.theconversation.com/content/77128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Pezaro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Clearing up some of the misconceptions about midwives.Sally Pezaro, Midwife, Lecturer and Researcher, Coventry UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/731632017-03-08T03:08:07Z2017-03-08T03:08:07ZDespite differences in culture, US and India fall short in childbirth in similar ways<figure><img src="https://images.theconversation.com/files/159691/original/image-20170307-20739-1fsg95m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Woman in labor, shown with monitors. Via Shutterstock.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/285782207?src=ZhDnqj5_lDvFvjgIL0p5eA-1-3&size=huge_jpg">From www.shutterstock,com</a></span></figcaption></figure><p>After eight years of practicing obstetrics and researching childbirth in the United States, I know as well as anyone that the American maternal health system could be better. Our way of childbirth is the <a href="http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html">costliest in the world</a>. Our health outcomes, from mortality rates to birth weights, <a href="http://www.mappinghealth.com/maternitycare">are far, far from the best</a>. </p>
<p>The reasons we fall short are not obvious. In medicine, providing more care is often mistaken for providing better care. In childbirth the relationship between <em>more</em> and <em>better</em> is complicated. Texan obstetricians, when compared to their counterparts in neighboring New Mexico, are <a href="http://www.mappinghealth.com/maternitycare">50% more likely to intervene</a> on the baby’s behalf by performing a cesarean section. Nonetheless, Texas babies still have a lower survival rate than New Mexican babies.</p>
<p>I long assumed that our most puzzling American health care failures were idiosyncrasies–unique consequences of American culture, geography, and politics. But a trip to India for the 2017 <a href="http://www.humanrightsinchildbirth.org/">Human Rights in Childbirth</a> meeting led me to a humbling realization: when it comes to childbirth, both countries fall short in surprisingly similar ways.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/157987/original/image-20170222-6422-vo4cbn.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Neel Shah, center, pictured with Jishnu Das, a Lead Economist at the World Bank and Leslie Page, President of the Royal College of Midwives.</span>
<span class="attribution"><span class="source">Neel Shah</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Human rights in childbirth</h2>
<p>I take care of patients in at a well-funded teaching hospital in Boston, where pregnant women seem well-respected and have clear, inviolable rights.</p>
<p>I’ve read about the <a href="http://eprints.lse.ac.uk/46132/1/Gender%20based%20violence%20and%20reproductive%20health%20in%20five%20Indian%20states%20(lsero).pdf">gender-based violence</a>, the profoundly disturbing cases of disrespect and abuse that too many women in India and around the world experience. But these are not things I have deep experience with. </p>
<p>I initially hesitated when I received an invitation to speak at a human rights meeting. Still, the opportunity to scrutinize my profession alongside international experts from a broad range of disciplines was compelling. Over 200 activists and scientists, midwives and physicians, journalists and attorneys planned to discuss strategies to advance justice, dignity, and respect for pregnant women. So I got on the long flight from Boston to Mumbai.</p>
<p>The meeting began with Indian women describing their experiences of care gone wrong. Many were heartbreaking stories of women receiving <em>too little care too late</em> – failures to provide antibiotics, blood and other forms of resuscitation in a timely way. Others were equally heartbreaking examples of women receiving <em>too much care too soon</em> – unnecessary inductions of labor, <a href="http://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/episiotomy/art-20047282">episiotomies</a> and C-sections. Beyond instances of clinically measurable harm, the stories illustrated routine misappropriations of care that these women felt deprived them of basic dignity.</p>
<p>Throughout, I was conscious of the fact that Indian clinicians have different training and face different constraints than I do. Indian women often have less agency to advocate for themselves compared to American women. <a href="http://unicef.in/Whatwedo/30/Child-Marriage">Nearly half</a> of Indian women are married before the age of 18 and have limited capacity to make independent decisions regarding reproduction. Indian women also have less access to basic social services than American women, though they are far more likely to require them. Higher rates of chronic and infectious diseases, higher rates of illiteracy, higher rates of abject poverty are all factors <a href="https://www.hrw.org/news/2009/10/07/india-too-many-women-dying-childbirth">contributing to avoidable suffering in childbirth</a>.</p>
<p>But as I sat there, listening to case after case, aware of the differences between the American and Indian context, much of what I was hearing also sounded uncomfortably familiar. Fundamentally, providing too little care too late or too much care too soon are challenges that all maternal health systems are confronting, including the American system. And in America, India, and many other countries, the standard approach to address these challenges is similarly limited.</p>
<p>The principal way my profession aims to improve care is by issuing guidelines that spell out the things we should be doing more of. But simply advocating that we start to do more things may be inadequate. In <a href="http://www.choosingwisely.org/clinician-lists/#topic-area=Obstetrics">many cases</a> doing more can actually be harmful. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159466/original/image-20170306-29012-1sr3mx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A security device is shown on the right ankle of a newborn in the maternity ward at Medical City Hospital in Dallas, March 15, 2007.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/AP-A-TX-USA-Maternity-Ward-Safety/7fbac93780b644e5ab3b53be2aa6ffdf/2/0">AP/Matt Slocum</a></span>
</figcaption>
</figure>
<h2>The balance between too much care and too little</h2>
<p>In a recent <a href="http://www.thelancet.com/series/maternal-health-2016">Lancet commission on maternal health</a>, 77 researchers from around the world, including me, concluded that our primary struggle in maternal health care is to find the appropriate balance – to provide the right patient with the right care at the right time.</p>
<p>The testimonies during the conference revealed a startling set of facts. In <a href="http://www.livemint.com/Politics/z3S7GLR5mayCDE9QokRzsI/The-alarming-increase-in-caesarean-births-in-India.html">India</a>, as in the <a href="http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/">United States</a>, the biggest risk factor for getting an avoidable and potentially harmful c-section appears to be which facility a woman goes to for care, not her personal preferences or medical risks. </p>
<p>In India, as in the United States, those facilities that are better at achieving the right balance of interventions rarely share best practices with others. And in <a href="https://www.cambridge.org/core/journals/journal-of-biosocial-science/article/div-classtitlebirth-rights-and-rituals-in-rural-south-india-care-seeking-in-the-intrapartum-perioddiv/813A6A1F3A683418BB1DD8426BCE44EF">India</a>, as in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20337205">United States</a>, efforts to elicit and attend to the legitimate preferences women may have during childbirth are the exception rather than the rule.</p>
<p>These parallels have their limits. On average, health outcomes in the United States are significantly better than those in India. But this mode of comparison misses a critical point. Dignity is a consequence of appropriate care, and appropriateness cannot be easily determined by population statistics. In our intense focus on mortality rates, we often overlook the obvious fact that childbearing women have goals other than emerging from birth alive and unscathed. </p>
<p>Childbirth is a moment of identify formation as a mother. It is a moment of profound self-agency (or lack thereof). It is a moment that nearly all my patients tell me has long-lasting and nuanced effects on their lives, though we do not have good ways of measuring such things. </p>
<h2>Appropriate care is about more than safety</h2>
<p>The stories of care gone wrong in India gave me an uncomfortable feeling that even the routine, seemingly respectful and safe care I provide in Boston may occur in a system that may not be designed to prioritize the dignity of my patients. </p>
<p>A large part of the challenge is that <a href="http://onlinelibrary.wiley.com/doi/10.1111/birt.12273/full">many women may not know what they deserve</a> when it comes to the experience of having a baby. </p>
<p>An impoverished Indian woman who treks to civil hospital, only to give birth through an avoidable episiotomy, with minimal labor support, on a dirty metal cot, in a room crowded with other patients, may see that as normal. She may even expect it. </p>
<p>Of course, an American woman who labors in a clean, private room, within a state of the art hospital, only to receive an avoidable c-section will often see that as normal as well. In both cases, as long as the baby is healthy, women are almost always grateful.</p>
<p>Those of us in the birth community could do better in helping women understand what they deserve, and in developing systems of care that deliver on this promise. But first we have to be willing to link the ideas of appropriateness and justice, of patient experience and dignity. In other words we have to be willing to see childbirth through the lens of human rights.</p>
<p>As an obstetrician, I understand the hesitation. There’s a part of me that still bristles at this framing. In practice, knowing when to intervene in the course of an otherwise healthy woman’s labor can be incredibly difficult. Perfect accuracy may actually be impossible. </p>
<p>Yet there are certainly broad ways that the American maternal health system can do better. About <a href="http://www.nytimes.com/2014/12/15/opinion/are-midwives-safer-than-doctors.html">50 percent of U.S. counties lack any qualified childbirth provider</a>, limiting access to necessary care. Paradoxically, when we do provide access to care, we tend to provide too much. In the case of unnecessary c-sections, <a href="http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/">the error margin is again about 50 percent</a>.</p>
<p>While perfection may not be a reasonable goal, delivering appropriate care with the same success rate as a coin flip is not reasonable either. In fact, it is unjust.</p><img src="https://counter.theconversation.com/content/73163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neel Shah is an advisor to Square Roots and a board member of March for Moms. He receives grant funding from the Robert Wood Johnson Foundation, Peterson Center on Healthcare, Rx Foundation, and Square Roots.</span></em></p>Childbirth in the U.S. can be dangerous and dehumanizing. An ob/gyn who traveled recently to India to review childbirth there says the U.S. and India fall short in similar ways.Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/724262017-02-12T10:03:19Z2017-02-12T10:03:19ZMidwives and the right of women to give birth the way they want to<figure><img src="https://images.theconversation.com/files/156326/original/image-20170210-8651-ier8xz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Midwives play a crucial role in enabling women to make choices about how they give birth.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/wra_gs/31828541694/in/photolist-QuzAyf-RrT3ft-RwGXXz-RAgaGF-QxgDWV-QxgNUV-RHtozo-QuzAk9-RM3RGp-Rxxxcm-QxgyEx-QxgP8R">The White Ribbon Alliance/Flickr</a></span></figcaption></figure><p><em>Giving birth is a significant life event that should aim for a healthy baby and mother. There are growing calls for women to give birth in their preferred birth positions. But this requires midwives to be trained in a way that enables them to respect the choices that women make. The Conversation Africa’s health editor Joy Wanja Muraya asked Lydia Mwanzia to explain why women have the right to make choices, and the important role played by midwives.</em></p>
<p><strong>What do international guidelines say about the rights of pregnant women during delivery?</strong></p>
<p>According to the <a href="http://imbco.weebly.com/">International Mother Baby Childbirth Initiative</a>, women have a right to be treated with respect and dignity during labour and child birth by partnering with her in the decision making.</p>
<p>Giving birth can either be a wonderful experience or a traumatic one, depending on how women are handled by health professionals, particularly midwives.</p>
<p>If mothers are excluded from the <a href="http://www.literallydarling.com/blog/2015/05/08/violation-of-womens-rights-during-labor-and-delivery/">decision making process</a> during delivery – even when things don’t go as planned – their rights are being <a href="http://www.literallydarling.com/blog/2015/05/08/violation-of-womens-rights-during-labor-and-delivery/">violated</a>.</p>
<p>When care is not collaborative, an unhealthy conflict arises that may harm the mother or baby.</p>
<p>There are <a href="https://www.mindtools.com/pages/article/professionalism.htm">strategies</a> that defend both the mother and baby from abuse, neglect and mistreatment. Examples of <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001847">lack of respect</a> include slapping or pinching during delivery, verbal abuse and the use of harsh or rude language.</p>
<p><a href="https://www.nice.org.uk/guidance/sg1/chapter/patient-centred-care">Patient centred partnerships</a> deliver the best outcome although it’s true that <a href="http://nursingexercise.com/roles-responsibilities-midwives/">midwifery</a> can be a tedious and psychologically draining profession that requires giving women a lot of emotional support. </p>
<p><strong>What motivated your research on the rights of pregnant women during delivery?</strong></p>
<p>One morning while at the entrance of a maternity unit in a referral hospital in Kenya I came across a pregnant woman who was on the floor and in pain. She was struggling to talk to a security guard. </p>
<p>She was in labour and I helped her to the delivery room where a quick assessment established that she was ready to give birth.</p>
<p>The midwife on duty advised her to follow procedure by lying on her back but the client insisted that her four previous births had been successful in the <a href="http://www.jpma.org.pk/full_article_text.php?article_id=1040">squatting position</a>. </p>
<p>As the stand off continued, the baby was born in the squatting position and the midwife rushed to safely deliver the baby. Despite the conflict, it ended well with no complications and within minutes she was recovering in the postnatal ward with her newborn daughter. </p>
<p>But the mother was disappointed that her request was disrespected despite informing the midwife of her preferred birth position.</p>
<p>This incident triggered a <a href="https://www.researchgate.net/publication/272527056_An_investigation_into_the_perceptions_and_preferences_of_birth_positions_in_a_Kenyan_referral_hospital">study</a> on women’s and midwives perceptions and preferences of birth positions at the hospital. It also interrogated what influences a woman’s view of the hospital birth experience or choice of birth place.</p>
<p>The study found that there were no significant differences between midwives and women’s preferences giving birth on their backs as encouraged in some cultures in Africa.</p>
<p>But research has shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/15376403">lying on the back</a> for prolonged periods during labour and birth, may result in complications for both the mother and the newborn.</p>
<p><strong>How can midwives influence a woman’s choices during birth?</strong></p>
<p>Midwives have an obligation to routinely apply their knowledge and skill to ensure a normal progression from pregnancy to delivery and eventual breastfeeding.</p>
<p>Midwives should provide continuous support during labour and birth and they should respect women’s choices when it is within safe practice to do so. </p>
<p>Midwives have an obligation to provide women with drug free comfort and pain relief and to protect them from harmful procedures and practices. These are their <a href="https://www.babble.com/pregnancy/understanding-rights-labor-delivery/">rights</a>. Midwives also have an obligation to give women the right information so that they can make informed collaborative choices. </p>
<p>Midwives play a very important role because they can greatly influence the choices women make about where they give birth as well as their preferred birth position. </p>
<p><strong>How can midwifery contribute to better maternal and infant health?</strong></p>
<p>About 65% to 75% of births globally are handled by <a href="http://newbirthmidwifery.com/midwifery-home-birth/little-known-facts/">midwives</a> and happen <a href="http://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery">without use of drugs</a> or other techniques to trigger labour. </p>
<p>About 20-25% of deliveries are performed by specialist doctors who use instruments and often drugs during delivery procedures like Cesarean sections.</p>
<p>Midwives provide lifesaving interventions like providing emergency treatment during deliveries.</p>
<p>Midwives have offered safe maternal and infant care in situations where there are no doctors in <a href="http://www.sciencedirect.com/science/article/pii/S0020729215001356">countries</a> across Africa. By increasing the number of trained midwives, healthier babies were born and less mothers died from pregnancy and birth related complications. </p>
<p>The World Health Organisation reports show that <a href="http://www.who.int/whr/2005/en/">developed countries</a> reduced maternal deaths by half in the early 20th century by providing professional midwifery care at childbirth.</p>
<p><a href="https://www.webmedcentral.com/article_view/2599">Malaysia</a>, <a href="http://documents.worldbank.org/curated/en/367761468760748311/Investing-in-maternal-health-learning-from-Malaysia-and-Sri-Lanka">Sri Lanka</a> and Thailand halved their maternal mortality ratios within 10 years by <a href="http://journals.lww.com/jbisrir/Abstract/2013/11040/Maternal_mortality_in_Cambodia,_Thailand,_Malaysia.3.aspx">increasing</a> the number of midwives in the 1950s and 1960s. Over a further 15 year period, Thailand reduced its maternal mortality ratio from 200 to 50 maternal deaths per 100 000 live births by deploying even more midwives and by <a href="https://pophealthmetrics.biomedcentral.com/articles/10.1186/s12963-016-0087-z">increasing the capacity</a> of hospitals at the district level. </p>
<p>Between 1983 and 2000, <a href="http://www.prb.org/Publications/Reports/2004/MakingMotherhoodSaferinEgypt.aspx">Egypt</a> doubled the proportion of deliveries assisted by skilled birth attendants and <a href="http://www.tandfonline.com/doi/full/10.1080/01443615.2016.1242559?scroll=top&needAccess=true">reduced</a> its maternal mortality ratio by 50%.</p>
<p>By <a href="https://www.ncbi.nlm.nih.gov/pubmed/24965818">investing</a> in the education, regulation and management of midwives, the quality of health care for both mother and child is continuously improved.</p>
<p>We should all appreciate that women’s rights during pregnancy, labour and after delivery underpins all maternity care.</p><img src="https://counter.theconversation.com/content/72426/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lydia Mwanzia does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Midwives should provide continuous support during labour and birth and they should respect women’s choices when it is within safe practice to do so.Lydia Mwanzia, Lecturer, School of Nursing, Department of Midwifery and Gender, Moi University Licensed as Creative Commons – attribution, no derivatives.