| Musings
Have we lost the plot with physiological birth?
Physiological birth is becoming extinct. The extinction process has been relatively quick, with a rapid loss of knowledge and skills since the wholesale move of birth from the home/community into medical settings in the 1900s. I probably need to clarify what I mean by physiology, so here is an excerpt from my book Reclaiming Childbirth:
"The word 'physiological' describes the 'normal function of an organism'... I use the term 'physiological' to describe a birth that involves a woman labouring and birthing her baby in a healthy and uncomplicated way without interventions that alter the functioning of her body. Physiology also encompasses all the individual variations that are not the 'norm' but are also not pathological."
We now have generations of women and care providers who have no experience of physiological birth. Women, in general, are blamed for this due to being too [insert preferred risk factor] or because they demand intervention. Neither is true (as I write about in my book). In contrast, there is a growing movement to reclaim physiology supported by knowledge of birth hormones, long-term health outcomes and women's experiences and preferences. Unfortunately, we have lost the plot and are attempting to reclaim physiology from within the paradigm that brought it to the brink of extinction.
Indicators and Objectives
We are not measuring what we want to increase and grow, so we have no clear data points for progress. Many countries collect maternity statistics and report key indicators to measure improvements in the quality of maternity services. However, indicators and objectives are about reducing the rates of intervention rather than increasing the rates of spontaneous vaginal births resulting in a healthy (physically and emotionally) mother and baby. If we want to reclaim physiology, we need to know how often (or not) it is happening. In my opinion, if we want to assess how well a service or institution supports physiology, there are two key questions:
- What % of first-time mothers go into spontaneous labour, labour without augmentation, and have an uncomplicated non-instrumental vaginal birth?
- What % of women report having respectful care and adequate information to support their decision-making?
Whilst data for question two is usually not collected, it is very likely that the data for question one has been collected, just not reported in a way that answers the question. You can sometimes read between the lines of the reports, but it is very frustrating trying to isolate statistics about non-intervention. For example, here is what I managed to extract from the Australian government maternity report: Overall, 30% of women went into spontaneous labour and laboured without augmentation, which leaves me with more questions than answers. What proportion of that 30% had a non-instrumental vaginal birth without an episiotomy? What were the stats for first-time mothers, because they are usually much less likely to avoid intervention? I also acknowledge that if we are to include birthing the placenta without intervention as part of physiological birth (which it is), then we are probably talking about less than 1% of women in hospital settings.
Research
We don't have research into physiological undisturbed birth. Maternity research emerged after birth had moved into hospitals, and medical management was the norm. So, we've ended up with studies comparing interventions with other interventions. For example, comparing labour induction at 39 weeks with induction after 40 weeks and/or medicalised spontaneous labour. Or, how one birth position compares to another rather than what positions women instinctively get into if they are undisturbed (because directions and disturbance are the norm). We don't have an evidence-base for physiological birth and are unlikely to get one via research in settings where physiology is rare. Also, scientific research, by its very nature, is 'problem-based' and starts with a problem to solve, such as reducing complications by introducing an intervention. For physiology, we need a different approach. We need to study physiological birth and find out what supports it. Learning from the settings and care providers with high physiological birth rates. What are they doing or not doing that supports physiology?
Education and Practice
Midwifery education and practice have been severed from their foundation of physiology. Midwives in hospital settings seldom see physiology; they may get glimpses of it, but an entirely undisturbed physiological birth is a rarity. Instead, they get to see lots of interventions and complications caused by those interventions. Physiology is also slipping through the fingers of community-based midwives as increasing regulations and medical oversight require them to bring hospital practices into the home. Some midwives also disrupt physiology with 'natural' interventions to get women's bodies to fit medically prescribed labour patterns and 'norms'. Student midwives are caught up in a Catch-22 because they are supposed to become the experts in physiological birth, yet they cannot observe undisturbed physiology on their placements. They are also assessed on their intervention skills rather than their ability to support physiology. Some are even bullied for questioning interventions and/or trying to apply evidence to support physiology.
I'm not sure what the answer is. But I know it is unlikely to come from within the current paradigm. We've had 30 years of trying to reclaim birth and improve the maternity system using research and education. Yet, we are drifting further away from physiological birth as the norm. Is it time for a radical restructuring of birth knowledge and practice for those who want to reclaim physiology? |
