An Intervention in Maternity Care

In the dictionary to intervene is defined as,

“to take a decisive or intrusive role (in) in order to modify or determine events or their outcome”

foll by in or between to come or be (among or between)

 (of an event) to disturb or hinder a course of action”        Collins online 2014

I personally as a modern practicing midwife feel like I am “between others” . I believe current and future mothers might feel the same.

 

These “others” have their own agendas about maternity care. On the one hand there are people who believe that birth is a natural process and therefore requires the minimum of intervention to achieve success. From the blogs, publications and papers it may not be meant but it feels like they gently sneer at anyone needing hospital care or who opt for pain relief.

On the other side are the frightened professionals or parents who see the whole birth process as so riddled with risk that only the most prepared and controlled should attempt it. The writings of these people seek to raise the fear level beyond that which is actually required by the process and they in turn sneer at “earth mother” types as being somewhat unhinged.

The fight between the factions is so vociferous and emotional that the really good things they are offering are getting lost in the fight. The obvious intransigence of the proponents is actually not helping anyone. Women do not know who to believe and are seemingly forced into one camp or the other by the particular professionals they meet and their personal beliefs.

This piece is an attempt to look at this picture a little differently and ask for a ceasefire.

 

Intervention in the care of women in pregnancy and birth has a long history. There have been excellent works written on the topic that paint the picture better than I. For example: Donaldson’s. Midwives and Medical Men (1977).  And Marsden Wagner the Pursuit of the Birth Machine (1994).

By intervention in pregnancy and birth it is accepted we mean things like induction of labour, the breaking of the amniotic sac, the acceleration of labour by medication. Pain relief might also be regarded as an intervention. More recently it is the technical monitoring process of labour that has been added to the intervention list. Even caesarean section can be seen as an intervention in itself rather than a choice but is often a required intervention to save a life or lives.

Many midwives and mothers believe that these interventions in many instances are unnecessary, they have a strong belief in physiological birth and the woman’s ability to do it naturally without medical assistance. These midwives fight really hard for a woman’s right to birth where she likes and with whom she wants.  They fight so hard on this one agenda that they may be seen as ignoring many of the problems that might arise during pregnancy and childbirth.  Not all pregnancies are straightforward.

By doing so they in fact alienate a large proportion of midwives working in maternity care where such interventions are used on a daily basis and seen as trying to assist the woman in birth. The “natural birth is all” campaigners might well be doing more harm than good if they want to influence what happens on these obstetric units throughout the country. It builds up a fear in the women of attending an obstetric unit where in fact they are receiving appropriate care for them.

But whilst it is the unnecessary interventions that form the basis of the “natural birth” campaign, it is the midwives themselves, who are under scrutiny by the “risk” believers,

 

Midwives have always been there in women’s lives during pregnancy and birth. This is a fact.  No, I am not talking about midwives as they are today but the local woman who was brought to be with the pregnant woman when births were imminent.  These women have always been there in communities and they are still there in third world societies today. They were, and are, often viewed suspiciously by men.  Many were suspected of being “witches” as they seemed to have skills beyond human understanding to help mothers at birth. These suspicions may have been related to these women’s involvement with abortion as well as birth. They were often the woman who was sought at the point of death also, to lay out the body. These women were. and are, not well respected by the establishment but they may be all the woman has got.

Fact: It is very rare for a woman to birth her baby totally alone. It may be her mother or grandmother, who is with her, but women are “with” women in these circumstances and it will always be so.

But these local women were not seen by “medical men” (Donaldson 1977) in the 19th century in the UK to be good enough to care for women. This was in the day when people paid for care albeit a few shillings. So if a local woman could help at birth for free or a minimum charge, this was a challenge to the local doctor who would definitely need payment for his services.  Interestingly this debate is currently ongoing in modern countries America and Australia, where women pay for care. Midwives and doctors vie for the woman’s business and often “safety” is used as a lever.

It was accepted that these local women needed some education in birth to ensure they provided safe care, so in the 19^th century they were being trained by doctors and other midwives to gain certification. No midwife could work without a licence to practice. 1902 brought the first Midwives Act so legislation was in place to ensure women received satisfactory care.

Women have received maternity care for free within the NHS since 1948. So in the UK there can be no fight about money between obstetrics and midwifery, so the emphasis has turned to risk. The basic debate is continued, are you better to have a midwife deliver your baby or to be safe should it be a doctor?

Midwives currently work to specific rules and sphere of practice. It is clearly stated that when things cease to be normal the woman should be referred to the appropriate practitioner.

“In an emergency or where a deviation from the norm, which is outside of your current scope of practice, becomes apparent in a woman or baby during childbirth, you must call such health or social care professionals as may reasonably be expected to have the necessary skills and experience to assist you in the provision of care.” (Rule 5 NMC)

 

Midwives in the UK are qualified to degree level standard which is professionally recognised as ensuring she/he is able to care for women safely and competently. This profession is overseen in the UK by the Nursing and Midwifery Council. The Royal College of Midwives and Local Supervisors of Midwives aim to ensure that women receive the best competent care possible whatever their choice of birth setting. We have a strong solid framework to ensure midwives are confident and competent professionals.

 

But I suspect that there is a historical hangover; the idea that the “local midwife” is not competent to care for the women in birth lives on. There is still a lot of ignorance and suspicion about the things that doctors know midwives do for women in birth, such as  massage, aromatherapy, birthing in water etc. ( Mmmm might these not be also regarded as birth “interventions” ?)

There remains in the air, that despite all that education and competency, the midwife will not be trusted to do the right thing if an emergency occurs. The ‘belief in birthing’ approach to care is still regarded by some modern Obstetricians as no better than the “witchcraft” wielded by non-educated midwives in previous centuries.

The fact that there are documented cases where individual midwives have not asked for help in time and babies have died as a consequence means that there will always be a slight suspicion about care provided outside of a hospital where no apparent safety net exists.

But there are more facts, there are also documented incidents of cases in hospital where medical staff are available and in close attendance and the birth has still “gone wrong”.(NHSLA 2012 ) In fact there are actually more of these cases because this is where most births currently take place within the UK. These are births that have all the care apparently necessary on tap and things still go wrong. So hospital obstetric led care cannot be held up as the absolute as there are issues to attend to here also.

In modern maternity services there are systems in place to review what went wrong and to take steps to reduce morbidity and mortality rates. It is my opinion that there is no complacency in the majority of these systems. Everyone wants better safer births.

 

There is evidence that in an effort to control “risk”, we may be using interventions to create problems in pregnancy and birth, rather than preventing them.

The clear example of this is Electronic Fetal Monitoring or Cardiotocograph (CTG).  This technique of being able to monitor the baby’s heart beat continuously during labour and birth. This method of monitoring which has been in use in hospitals for over fifty years, had never been researched before it was introduced. It was just imposed on women as medical staff searched for and delighted in a technological answer to the problem of observing the fetus.  This has saved lives.

The review however, of intrapartum Surveillance (Spencer & Ward 1993) concluded that intermittent monitoring using a hand held dopplar or pinard was “as good” at detecting problems as continuous monitoring even in at risk pregnancies.  But it would be a very brave modern maternity unit that stopped using this evidence machine that provides yards and yards of paper to produce in court.

Good evidence now suggests that if this CTG monitoring is used continuously on pregnancies and labours that have no underlying concerns, that it actually leads to more intervention and a higher chance of caesarean section. (Devane et al 2012).  Maternity units have now stopped using this intervention on such labours.

It should only be used now on pregnancies and labours where there are concerns about fetal wellbeing and pardon me, but of course where the piece of paper would be useful in court.

 

So, in an attempt to keep women away from unnecessary intervention there is strong evidence to support a change in place of care. NICE (2014) are suggesting that if all is well, women should birth elsewhere other than the hospital. This evidence must be difficult for the anxious people to take in, but be a breath of fresh air to the “belief in birth” proponents.

But actually the woman and her pregnancy and her preferences are what should be central, not what either group would prefer. We don’t yet try and match mothers to midwives or medical staff who have similar beliefs to the process of birth. Therefore the professional must adapt.

 

Birth should be regarded as the biological process it is and supported to happen as such. If interventions are needed they should be done as to what is clinically or emotionally required for the mother or her child, not the convenience or protocol of the department. Things can go wrong in birth like any other pursuit in life, but with excellent midwifery and if necessary medical support they can be minimised and responded to quickly to save lives.

In conclusion I am trying by this paper to produce an “intervention” between the two apparently opposing groups. Please stop fighting each other and find ways of working together to recognise what might help the mother and her baby.

There will never be one way or the other, only the way the mother chooses and what is needed during her particular birth process. As individual to her as the new life she will produce.

 

References

Devane D1, Lalor JG, Daly S, McGuire W, Smith V. 2012 Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing Cochrane Database Syst Rev. 2012 Feb 15;2:CD005122. doi: 10.1002/14651858.CD005122.pub4

Donnison J. (1977) Midwives and Medical Men A History of the struggle for control of childbirth Heinemann. London

NICE National Institute of clinical Excellence. 2007 Clinical Guideline 55 Intrapartum care Care of healthy women and their babies during childbirth

NICE 2014 Draft Guidance for Consultation Intrapartum care: care of healthy women and their babies during childbirth LINK

NMC (2012) Midwives rules and standards via www.nmc.org accessed 23/07/2014

NHSLA National Health Service Litigation Authority (2012) Ten Years of Maternity Claims An Analysis of NHS Litigation Authority Data Link

Ed. Spencer JAD  Ward RHT (1994 Edition) Intrapartum Fetal Surveillance  RCOG Press

Wagner M.  Wagner MG (1994) Pursuing the birth machine. The Search for Appropriate Birth Technology, Camperdown, New South Wales: ACE Graphics,