The paradox of ‘safer’ childbirth

Even before the first pang of labour, some pregnant women are adamant about seeking an epidural for pain relief, while others are dead set on avoiding it. But the majority, as reflected in new research, are undecided, prepared to “go with the flow” and see how they get on.

They end up going with the flow, agrees midwife academic Dr Elizabeth Newnham, but it's "with the institutional flow rather than the physiological flow". That institutional momentum favours the use of technology and timely interventions, to be on the safe side.

But is that a skewed view of what’s “safe”?

Hospital practices such as induction of labour and epidurals involve medication and monitoring and are quite substantial interventions in the birth process, she says. Yet they have become normalised to the point that they are not really thought about as interventions.

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"The paradox is that in trying to eliminate risk, they create other risks," says Dr Newnham, Ussher assistant professor in midwifery at Trinity College Dublin, and lead author of a new book entitled Towards the Humanisation of Birth: A study of epidural analgesia and hospital birth culture.

One intervention can start a cascade of others. For instance, induction may make contractions more painful, leading to use of an epidural, which can lengthen labour and decrease the efficiency of the woman’s pushing, which increases the need for an instrumental delivery or even an emergency Caesarean.

‘Emergency situations’

The flow of technological practice “works very, very well in emergency situations”, Dr Newnham stresses, but in the majority of cases it would be far better to support the physiology of birth as much as possible and then intervene towards the end only if necessary.

“We know continuous support in labour decreases the length of labour, increases vaginal birth rate, decreases [use of] analgesia.” Immersion in water has also been shown to be a very effective, non-medical way of relieving pain yet this tends to be presented within the conventional system as a “risky” alternative choice and is available in only one maternity hospital in Ireland.

Dr Newnham refers to studies that show hospitals are potentially sites of risk for low-risk pregnant women because “they are not going to get much out of a hospital except for intervention”.

That’s another “paradox”, which is a word Dr Newnham uses a lot when talking about how the book explores the personal, social, cultural and institutional influences on women in deciding whether or not to use medicalised pain relief in labour. It’s much more complex than simply “have pain, need epidural”.

About 70 per cent of women in Ireland opt for an epidural on their first birth and this rate drops to about 30 per cent on second or more births – often because subsequent labours tend to be much faster and there may be no time for an epidural. Fear, lack of support and hospital policies can have greater influence on epidural use than a woman’s level of pain, says Dr Newnham, who is from Adelaide in Australia and took up her Trinity post just over a year ago.

“Women want support and if they don’t get it, they want pain relief. We know fear heightens the perception of pain but one-to-one support is what helps allay it.”

Reduces fear

What also reduces fear is learning about the physiology and knowing the pain comes from the muscles doing the work of birth and “is not some big huge pathological thing. It is a bit like running a marathon – but it’s the uterus, not your legs.” Dr Newnham sees how women who go to gym or are runners can identify with that concept.

From the women interviewed by Dr Newnham and two Australian colleagues for this research, before and after giving birth in a large Australian maternity hospital, it was clear that “pain is not necessarily a negative experience” and that “an epidural doesn’t necessarily increase satisfaction in the process either”, she reports.

She stresses that she is not saying an epidural shouldn’t be available to any woman who wants it but it “should be a reasoned option” and not passed off as a very safe choice that nobody has to think about, with the consequential risks glossed over. It has become a quick fix that suits the hospital system and is popularly regarded as a panacea for modern women.

“It’s kind of tidier and easier. The emotional labour is decreased. Some midwives prefer if the women are tucked in with an epidural and a monitor going – not being loud and noisy and moving around and taking all that emotional work of the midwives.” But piling more technology onto a physiological process doesn’t mean it is going to get safer and safer.

“We know mammals like to give birth in quiet places and hormonal systems work best in that way. Because we have medicalised a physiological process, it can have the opposite effect of the intent.”

Newnham has found when teaching first-year midwifery students, both in her native Australia and in Trinity, “suddenly the penny drops – they read the research, they read the history, they read the sociology and they go ‘oh my God, who is going to tell the women?’. They become quite upset that this stuff goes on and it is not talked about enough.”

She also refers to an article in the Wall Street Journal article last September, in which a US obstetrician neatly sums up the institutional impact by pointing out that the biggest factor in determining whether a woman will have a Caesarean delivery "is the door she walks through" to give birth, rather than her own health profile.

Caesarean rates

It would seem to be similar here, judging by the statistics recently published by Cuidiú, the Irish Childbirth Trust in the new edition of Bump2Babe, its guide to the State's 21 maternity units. Caesarean rates for 2017 range from 26 per cent in Wexford General Hospital to 39 per cent in St Luke's Hospital, Kilkenny. But for another intervention, induction of labour, St Luke's registered the lowest rate among all the hospitals, at 20 per cent, while it was most common at Cork University Maternity Hospital, where 36 per cent of mothers were induced.

The title of Dr Newnham's book, Humanisation of Birth, is taken from the name of a global movement that started in South America. It is really about putting the woman at the centre of everything that happens rather than imposing a medical scientific model or a particularly spiritual, holistic model, which are the two ends of a spectrum, she points out.

Instead, the woman should be put in the middle and everybody else, midwives and obstetricians alike, work around her. “It also means respect and communication.”

If a woman feels listened to, even if she wants a home birth and ends up in hospital with an epidural, labour and then a Caesarean section, “it doesn’t have to be a bad experience”, Dr Newnham contends. The trauma is caused when it all happens without her feeling she had any say in it and being treated disrespectfully.

That can equally apply to home births, she says, “if you have some midwife rolling her eyes and saying you should have done more yoga”.

We know how polarised debate about birth can become, both among women and health professionals. Considering midwives have traditionally been women and, up to recent years at least, obstetricians were predominantly male, does she think gender politics influence hospital birth culture?

“Medicine is a kind of patriarchal and masculinist system,” replies Dr Newnham, but she doesn’t believe the gender of an individual doctor or midwife comes into play now.

‘Lack of respect’

However, she continues, “I think the way that medicine as a system has treated women’s bodies and knowledge of women’s bodies has been appalling. I think that there has been a lack of respect and a lack of trust that women can actually give birth. So, in that sense, gender politics is what the whole thing comes down to – control over the birth process.”

As the mother of three sons aged 24, 20, 18, and a daughter aged 13, she has ample personal as well as professional experience of birth. She anticipates my next question: “I didn’t have any pain relief.”

She didn’t train to become a midwife until after her first two children. “It was having a good birth experience that made me want to be a midwife.”

During her first pregnancy, she just happened upon a book by American midwife Ina May Gaskin, Spiritual Midwifery, and after reading it believed that labour was going to be great.

“And it kind of was – although I thought I was going to die at one point but I think that’s part of it. Then you have a baby,” she says with a laugh. “I think I was lucky really but women shouldn’t have to be lucky to have a good birth. It shouldn’t matter what I knew or what I thought.”

That brings her back to the “humanising” of birth. “All women should have the physiology of birth supported – and have the optimal chance of that experience unless,” she adds, “they decide for some reason they don’t want to and that’s fine.”

- Towards the Humanisation of Birth: A study of epidural analgesia and hospital birth culture, by E Newnham, L McKellar, J Pincombe, is published by Palgrave Macmillan