Midwives, fear, and unassisted childbirth

I’m reading through Dr. Rixa Freeze‘s doctoral thesis on “Free Birth” or “unassisted childbirth” (UC), which is extremely interesting, and well worth reading, regardless of whether you are an extreme supporter of UC, or think it’s the worst thing to happen in the world since the A-bomb. You will certainly learn something, regardless of where on the spectrum you find yourself.

On the 81st page of the pdf (p. 66 of the numbered pages) is this statement: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I understand this; but whether this fear is unfounded or not is another question entirely. The problem is, on one hand there are a whole host of L&D nurses, midwives, OBs and other doctors who have a view of childbirth as a medical problem, attendant with innumerable potential complications (including death or severe disability for mother and/or child), and it is their job to prevent these negative outcomes from happening, or reduce their severity, and to accomplish this through the use of technology. While I and a great many others would argue that their use of technology is not “judicious”, and they should practice evidence-based medicine, and conserve their interventions when they will be beneficial as opposed to introducing unnecessary risk (such as elective inductions), the truth is that sometimes even in the best, “freest” or “purest” circumstances, bad things can and do happen.

Different people have different ideas when it comes to risk and responsibility in childbirth; and that is one thing that I greatly admire about the UC movement, and that is that the parents assume full responsibility for their child in labor and birth, and don’t put any of that responsibility on anyone else, be it doctors, nurses, or midwives. But this weight of total responsibility is too much for many people to bear, so they put (some would probably use the word “shirk”) part of their parental responsibility onto the shoulders of one or many care providers. In this way, when something goes wrong, the parents can always blame the doctors; in a UC, that’s impossible — all blame must rest with the parents, since no one else had anything to do with the birth. Some would argue that the parents still should shoulder all responsibility, since they choose the care provider who may end up being overly interventive. I agree that in this situation, the parents do share some part of the burden of risk and responsibility in what happens in birth due to their choice of care provider; but that the care-provider, in that s/he holds a position of trust, takes on more.

While most births — even among the very high-risk, such as births which occur in countries like Sierra Leone with little or no access to anything like decent medical care, much less clean water, plenty of food, good nutrition, availability of medications and C-sections when needed, etc. — do not end in the death or serious disability of mother and/or child, there is always a possibility that something might go wrong. Because that’s the way the world works; and anyone who says, “Just think happy thoughts, and happiness is guaranteed to follow,” is either trying to deceive you or is seriously deluded himself. I do think we should “think positively,” but that doesn’t mean that it is only “positive thoughts” or “positive energy” that is keeping us from disaster. That’s superstition. There’s no point in being overly negative, of course; but I think there needs to be some sort of middle ground between the “head in the clouds” idea that everything will be just peachy if we just keep negativity away from us, and the “birth is only normal in retrospect” idea of many obstetricians who spend hours attending women in labor and birth all the while sweating and fearing that something somehow somewhere is going to jump out of the middle of nowhere and cause disaster.

Back to the quote: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I agree with this statement, but tend to think it is a “healthy fear” or rather “respect” of the birth process which usually works well, but is not guaranteed to do so.

Some months ago, I read of a woman who died from an amniotic fluid embolism when her placenta suddenly detached at 34 weeks gestation; both she and her baby went from (seemingly) perfectly healthy to dead within hours. Those who are of the hospital bent cannot blame “crazy UCers” or “crazy home-birthers,” because she was under the care of an obstetrician; and those of us who are of the home-birth bent cannot blame any medical intervention at all, because she wasn’t induced or anything. It just happened, with little or no warning.

Friends of mine lost their baby a little over 3 years ago, due to cord strangulation, right around the due date. Up until that point, everything had seemed to be perfectly fine and normal, although I think the mom felt less movement leading up to the death but thought it was normal. It wasn’t. She was under the care of an obstetrician, planning a hospital birth — you can’t blame it on home birth. She noticed the last movements either right before, or in the early stages of, her labor, before going to the hospital — you can’t blame it on hospital birth.

One problem I have with the UC movement is the talk I hear in various quarters that pretty much reaches the level of superstition — that if you plan a UC, and don’t have a midwife, and have an unassisted birth, and don’t worry, then everything will work out just fine; but that if you ask to plan a midwife-attended birth or you can’t quite squelch your fears, then you’re asking for trouble, and something negative will happen.

Sometimes complications happen in unassisted births — refusing to have a midwife there is not a talisman against that evil; although I do understand and accept that sometimes midwives (even very relaxed and hands-off midwives) can interfere in the normal birth process, and may even introduce some types of risk or “intervention” that wouldn’t have been there before. Some people think that even the midwife’s presence in the room is an intervention; others do not want to have the midwife intrude into their birth space to check the fetal heartrate. But if a complication arises, and there isn’t a midwife there — then what? In the Discovery Health Channel show “Freebirthing”, the American woman they showed having a UC ended up with a retained placenta, so she went to the hospital (where it ended up coming out on its own, without any intervention). Had she had a midwife, she might have avoided the hospital entirely — either because the midwife would have helped, or just let her know that what she was experiencing was “a variation of normal” or whatever.

So, yes, midwives have to know a lot of the potential negatives of birth, including what to do — how to intervene, when to transfer to a hospital and/or doctor. And I’m sure it does make them not trust in the usually perfectly normal process of birth quite as much as someone who has never seen nor heard of a bad outcome. And they may intervene a little too quickly at some points. But the alternative may well be a dead baby, and who wants that? If there is no trained person, and complications arise and the mother does not have intuitive knowledge that something is wrong (which is, after all, a possibility!), then someone could be very badly hurt or even die. That’s life. That’s death. Most births will turn out just fine — unassisted, midwife-attended, obstetrician-attended, low-risk, high-risk, VBAC, elective repeat C-section.

If I were to plan a UC, I think that my not knowing all of the complications that can arise (which midwives do know) would bother me more than having a midwife there who might possibly step into my birth space, because I like to know and understand all facets of a process or event before stepping into it. So, were I to plan a UC, I would take a lot of time to research the common complications… and then rather than it being, “midwives’ training in how to handle complications would inevitably instill fear in the birth process,” it would become that my training (or lack thereof) in how to handle complications would inevitably instill fear in my birth process. For my part, I’d rather turn the training and fear and study of complications over to someone else, so that I can get out of my head and into la-la-labor land.


“Extreme Motherhood” on 20/20 this Friday

At least, it’s supposed to air this Friday (I believe it still airs at 10 Eastern, 9 Central, but check local listings). The last few times it’s been scheduled, it’s been preempted at the last minute, so I’m not holding my breath. But, just in case it does, I’m passing along the info!

Here is what I’ve heard:

Segments include homebirth (both unassisted and midwife assisted), serial surrogates (women that have numerous babies for other women), “fake babies” (life like dolls), long-term breastfeeding, and orgasmic birth.

We’ll see what it ends up like. My expectations are fairly low, so I know they won’t be dashed, but I’ll be curious to see how it finally ends up.