Who's Afraid of the Big Bad Birth

AIMS Journal, 2013, Vol 25 No 3

An AIMS talk by Kathryn Gutteridge, July 2013

Heading up to Birmingham with a couple of birth enthusiasts was a great start to an evening of birth talk. We arrived at the beautiful venue early and were able to mingle as others arrived and find out who was coming. There were many local midwives, as well as doulas, yoga teachers, antenatal teachers and mums who came to hear Kathryn speak.

Kathryn has been working as a midwife since the 1980s, through community midwifery, and now as a consultant midwife. She is heavily involved in research, hoping to complete her PhD from this, and this meant that her information is not only current, but includes a wonderful amount of case study, often from her own experience or experiences from within her trust. Kathryn was also (and still is) responsible for setting up the two very successful birth centres in Birmingham, Halcyon, a stand-alone midwifery centre, and Serenity, a midwifery centre alongside a consultant unit.

Kathryn began the evening giving us a wonderful image of her start to midwifery, of the community she worked and trained in and how this normalised birth for her in a wonderful way. She began her midwifery career in a community in which home birth was the norm and her experience reflected this. Midwifery training in which she had the privilege to learn about birth by watching and by being present with women, seeing, hearing and sensing progress in labour.

Women take their memories of birth and those who supported them to the grave, good and bad. Kathryn asks midwives, would you want to be the midwife who is remembered as 'the bad one'?

We were shown a blog post of what women's views of birth were, mainly that it was 'scary'. Not only that it was scary but that the 'fear' makes the birth longer and worse so we should try to avoid being scared. This in turn makes women even more scared! So Kathryn pulled out research that looks at what women are afraid of, the facts of maternity health and how women's life today and approach to birth today differs from in previous decades. Kathryn looked at the change in the mid 20th century from home birth to hospital, how doctors were advised to get more involved with birth so that their patient numbers would grow.

She covered the move to hospital births, which was meant for those in poverty whose homes or situations were considered more dangerous for home birth, but which actually became the place where middle-class women were encouraged to go, where analgesia was more readily available.

Kathryn looked at the power that political, legal and medical professionals have had over birth and women's choice since the 1920s, evident even from conservative calls to women voters.

Kathryn touched on other roots of fear for women, circumstances that can create huge problems for pregnancy and birth. Women who have eating disorders, who have suffered sexual abuse, those whose mothers had a traumatic birth and constantly told the story or those with traumatic experiences of birth themselves. The main three sources of information about birth are family and friends, TV/media and medical information, with the first two being a constant source of information through women's lives. These representations are very powerful whether positive or negative and are hugely influential in how women form ideas of birth.

Kathryn visited the morbidity and mortality report, to see whether the fear of injury and death was justified. This shows that most injuries and deaths are caused not by birth, but by surgical complications, hospital-acquired infections, haemorrhage (which can be caused by mismanaged or over-managed births) or suicide, which stands as the second highest cause of maternal death.

This information, although not new, is still horrifying to be reminded of. There is a lot wrong with current maternity services, she emphasised, if the lack of support before, during and after birth can create so much trauma.

Kathryn recommends an increase in antenatal visits, and that these need to be in the early weeks of pregnancy when women are forming their ideas and fears about birth. The lack of informed support during this time is currently damaging. Without the positive and normal images of birth from family and community that used to be present, women are often now left alone and uninformed until almost 24 weeks of pregnancy.

As a mum who had a previous caesarean I was particularly interested in the comments Kathryn made about caesarean section. There needs to be a huge improvement in looking at the true impact of an emergency caesarean. Alongside this there needs to be more accurate representations from obstetricians of the risks of caesarean surgery, the benefits of vaginal birth and the comparisons of the two.

An image that stood out from the presentation was the image from one hospital of a smiling couple and surgical team during a caesarean – this was used as the hospital's main maternity services image! How interesting (and frightening to me) that a hospital should see that as such a normal part of birth that it should be how they advertise their services.

Kathryn pointed out that women are already uncertain about their body's ability, what birth entails and how long it can last. When they are told that, 'If they go for a vaginal birth they can have anaesthetic including an epidural but they will need to wait for a doctor to prescribe this,' or 'There is a lot of indignity and blood involved in birth which can be “avoided” with a caesarean,' or that 'Big babies won't fit anyway' and 'Babies may become distressed with birth' it leads to the increased belief that the body will not work correctly, heightening anxiety and often leading a woman into 'choosing' a caesarean section. This is a frightening consequence of the lack of some professionals knowledge, understanding and trust in the process of normal birth.

Kathryn looked at some recent research that showed anxiety levels over birth were increasing every year and that those being diagnosed with tokophobia are also increasing. Tokophobia is a phobia of birth which can be either primary – when the fear comes before a woman has experienced birth, often from some other trauma in earlier life – or secondary – where the phobia has been caused by a previous birth experience. There are women who are looking for ways of avoiding birth, through abortion or caesarean section, as well as those avoiding repeating previous birth trauma through caesarean section or by birthing alone at home.

Finally, Kathryn looked at how we can reduce fear through the midwifery model of women-centred care. She suggests there are three main points:

• The birth environment. Attitude, behaviour, trust, safety, strength and belief of birth as normal.
• The relationship between the woman and midwife being one of belief and trust.
• Grounded knowledge of birth.

Then Kathryn asked us, 'What can we do?' This led to a great discussion about current practice, access, availability, choice, language, unnecessary interventions and unhelpful recommendations, respect and lack of it, lack of education in schools, and professional fear influencing lay fear. However, many of the changes that need to happen are within institutions, within policy, and within the culture of birth as it stands. There are certainly no quick answers.

The birth centres that Kathryn has set up are great places in terms of finding good practice. Women's choice is respected, they have midwives that they know and trust. Kathryn insists that trainee midwives and doctors within her Trust spend time within her birth centres. This is to ensure that they are seeing normal birth as part of their training and has been very well received. This is a shining example of changes that need to be made across the country.

Some suggestions from the floor were: campaigning for more and better antenatal provision and support and for more postnatal support; more midwives and one-to-one care; better use of language so that women are more aware of their choices; reducing unnecessary interventions such as induction for post dates; better education for children and teenagers, focusing on a respect, acceptance and celebration of women's bodies, menstruation and subsequently birth; allowing midwives the time, space and support to truly be able to support women and protect their birth space and believe in them.

The change, Kathryn concluded, has to come from women. Women need to acknowledge that things are not how they should be and push for change. A wonderful evening that left me with lots more questions. This is definitely an area that needs revisiting frequently.

Also a special thanks to Chloe Bayfield, without whom these talks would simply not happen!