The system is broken if it doesn’t leave people whole – Part 5

Previous: Part 1: I maunder on about my experiences as a doula
Part 2: Statistics
Part 3: Illustrative Non-Fiction
Part 4: The more things don’t change

But then, I’m kind of an optimist. Or perhaps the better word would be idealist, although I think we are wrong as a society to say “idealist” with the kind of sneer. If we do not ask for and strive for the ideal then we’ll never come close. Asking for a compromised position right off the bat means that the eventual product will inevitably be even more compromised (just look at the current American health care debate for a prime example of that).

As I said before, I don’t believe that all or even most doctors and registered midwives are evil people looking for the quickest and most painful way to hurt people. That’s ridiculous. Of course most of them are caring and well-meaning people. I say that even though I’ve witnessed quite a few fairly ignorant or arrogant people in the field, one or two exceptionally abusive and manipulative individuals, and rather a lot of folks who exhibit that passive “just following orders/my protocols/our customs” well-intentioned uselessnes.

But the problem is this. The system is broken. It did not and does not have women’s best interests or the best interests of their babies at heart. It is a fraud.

A 30% c-section rate (and a 19% primary c-section rate) is not a bug, it is a feature of the broken system.

That some women would choose to give birth unassisted because they fear what they will experience otherwise at the hands of the medical system, this is also a feature. Unassisted birthers can be used by the mainstream model to make homebirth seem extreme and outlandish, something that only those crazy hippies or religious fundamentalists would do.

I say that as someone who chose to give birth unassisted, and who feels that this can be an awesome valid choice for some folks, but that it should never feel like the only choice available.

When I say that I believe people are well-intentioned, I should also say that it’s time for folks to face the fact that intentions really don’t matter. Or at best they matter only a little bit. What matters is not what you intend, it is what you do. It is the real results of your actions in real people’s lives. If you as a provider through your action or inaction facilitate 20% of of your clients right into unnecessary surgery with very real and significant impacts on their life, health, future fertility and reproduction and on their future children’s life, health and births, but you meant well, it doesn’t reverse the effects. It doesn’t change the real effects that a cesearean scar on her uterus and belly produce.

It seems to me that with a system as broken as this there are only two ethical choices. The first is the actively try to fix the system from the inside. The second is to work outside the system to provide another option for women. I suppose, now I think of it, that there’s a third ethical choice, which is get out of this business entirely. Passively continuing within the system, acting in such a way that you perpetuate the harm that it does, this is not an ethical choice.

I’ll be honest, I’m not sure if it is possible to fix the broken system from the inside, but if you are a care provider within the medical model, there’s a lot you can do to try. Here’s a few suggestions:

  • Practice research-based care.
  • Accept that women are individuals, their bodies are individual, and there is a wide range of normal.
  • If a rule is a bad rule, don’t follow it.
  • Don’t induce women at 38 weeks, at 39 weeks, at 40 weeks, at 41 weeks, at 42 weeks because you’re pretty sure she should deliver by now.
  • Actually, don’t induce them at all if you can help it. Women will, for the most part, go into labour spontaneously when they and their baby/ies are ready.
  • Don’t hold the threat of induction over their head, ever. “If you don’t go into labour by 42 weeks, we’re not allowed to do a homebirth.”
  • Don’t encourage women to induce “naturally”. We do not know exactly causes labour to start spontaneously, but we know that it seems to be a combination of factors regarding readiness for both mother and child. Knowing that, it seems foolish to think that a “natural” induction would be any less dangerous than an “unnatural” one. I would suggest that there is no such thing as a “natural” induction.
  • Actively encourage home birth for all women, low and high risk, since this is actually supported by research. Don’t force it, of course, but assume as a matter of course that this is where birth occurs. Research has shown repeatedly that hospital birth is not as safe as home birth.
  • If a woman prefers a hospital birth, do not admit her to the hospital before she is in active labour (4 cms).
  • Do very few cervical checks. Do none if you can manage it. Learn to gauge the progress of her labour using other less interventive signs.
  • Intermittently monitor the fetal heartrate with a stethoscope instead of using continuous electronic fetal monitoring.
  • Accept that it is not uncommon and not pathological for labour to proceed in a less than straight ahead fashion. Pauses and breaks in labour are actually quite common and don’t mean the process is broken and needs fixing.
  • Learn about non-narcotic comfort measures for women in labour.
  • Accept that there is a difference between pain and suffering, so that just because a woman is experiencing pain, that doesn’t mean she is suffering.
  • Accept that you don’t need to rescue women from their birthing process.
  • Learn to sit on your hands. A lot. Birth needs very little “doing”. If sitting on your hands isn’t a good option for you, learn to knit. Embroidery is probably another good option. Machine quilting might be a bit much.
  • Buy a good quality labour and birthing pool and make it available for your client’s births.
  • Don’t transfer women to the hospital or start otherwise intervening because of arbitrary timelines that have nothing to do with what is actually happening for her in her body. This includes long early labour, long active labour, long pushing stages, long periods with membranes released before the birth of the baby.
  • Use antibiotics responsively, not automatically.
  • Practice informed consent. Be able to articulate the benefits and problems inherent in the interventions you do offer or that clients request, so that nobody ever says, “if only someone had told me what this could do”.
  • If a woman has PROM (premature rupture of membranes), do no cervical checks at all. Be watchful for signs of infection and encourage good hydration and nutrition, but otherwise just be patient.
  • Talk a lot more about nutrition with your clients, since this is one of the only things actually shown by research to make a difference in the health of women and their babies.
  • Study methods to safely facilitate vaginal breech birth.
  • Keep mother and baby together in the period immediately following birth (out to a half an hour or more). They need each other.
  • Practice expectant management of the third stage of labour (delivery of the placenta).
  • Leave the cord intact until the placenta is delivered.
  • Foster friendships with likeminded individuals in your field. Have someone you can call when you think things aren’t going as they should.
  • If a cesarean is necessary, be as humane as possible. Don’t let a hospital’s rules get in the way.
  • Don’t be a martyr. Take good vacations. Get sleep at night. Spend time with your family. Birth work is unpredictable, but try to just live your life.
  • Take good naps at homebirths and eat good food. Nobody needs your attention 100% of the time, and it can be reassuring for women if her care providers remain relaxed and low key.
  • Get help to deal with stress. Foster positive relationships in your personal life.

Perhaps you already do some of these things. Perhaps these do not seem like workable suggestions to you. But if not, ask yourself why and own your answers. And feel free to add your own in the comments section.

5 Comments »

  1. JudyC said,

    February 24, 2010 @ 2:47 am

    An excellent series of articles. Australia is slightly less interventive but we still have the 30% CS rate. Our system also needs fixing.

  2. Carolyn Hastie said,

    February 24, 2010 @ 3:43 am

    Yes. Agreed. Thanks for your posting, warmly, Carolyn

  3. Catina Adams said,

    February 24, 2010 @ 5:15 pm

    A truly excellent decription of the situation that we also face in Australia. I would also add my suggestion – Act local, Think global. Do not underestimate the impact of caring human contact on an individual basis.
    kind regards, Catina

  4. Katherine said,

    February 25, 2010 @ 2:50 pm

    When you say “Research has shown repeatedly that hospital birth is not as safe as home birth.” – has this research accounted for the possibility that hospital birth appears more dangerous than home birth because high-risk births and (actual) problematic births are highly encouraged to occur at the hospital?

    I totally agree with the rest of your message about how hospital births have more intervention than is necessary, which has real effects on the mothers that have them, and that the lack of consent (screw informed consent, doesn’t even look like they get uninformed consent) is both worrying and wrong.

  5. Kenzie said,

    February 26, 2010 @ 2:08 am

    Hi Katherine,

    The most recent study that I know of can be found here: http://www.cmaj.ca/cgi/content/short/cmaj.081869v1 You can click to get the full text in the top right of the page.

    If you read through it you’ll note that they were careful to match homebirthing women to two other groups, first a matched group who planned hospital births with the same group of midwives and second with a matched group who planned hospital births with a physician/OB. By definition, in order for the women to be “allowed” to plan a homebirth with Registered Midwives in BC they would have had to meet the criteria for “low risk” and therefore the matched groups would have had to also. The groups were matched for age, parity, general income levels, etc. Looking at matched groups in this way would seem to be the only way to actually tease out the risks of both birth places.

    The results of this study were that home birth was safer than hospital birth, although as usual it was reported in the media as “home birth is as safe as hospital birth”. That’s the media for you.

    The rate of neonatal death was .35% in planned homebirths with midwives and .65% in planned hospital births with doctors. This is a difference of three babies per thousand births, and I’m not sure how statistically significant it is. But you can bet yer boots that if the difference had been the exact opposite, with the higher death rate in the homebirth category it would have been reported that giving birth at home would NEARLY DOUBLE the risk of your baby DYING! OMGeleventy!

    The risk of c-section was also significantly higher in the hospital birth group, so comparing two groups where one has a higher rate of major abdominal surgery than the other and declaring that they are both “as safe” is sort of like saying that walking on the sidewalk is as safe as walking on the road, with the hidden bias that getting hit by cars occasionally is no big deal as long as you don’t die.

    Keep in mind that “High Risk” and “Low Risk” are moving targets in the obstetric world, and may not even be meaningful categories.

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