Keeping Normal Birth
NORMAL
NORMAL
=
HEALTHY
Numerous guidelines exist…
guidelines for overall care
Research for specific care
Books
Section 1: Ways of Seeing
1. From being to becoming: reconstructing childbirth knowledge
2. The role of pain in normal birth and the empowerment of women
3. Birth and spirituality
Section 2: Aspects of normality 4. Normal birth: women’s stories
5. Midwives' practices in eleven UK maternity units 6. Midwives constructing 'normal birth'
Section 3: Evidence
Yet there is a problem…
Drop in normal delivery rates
Rise in caesarean section rates
but with differences in obstetric practice
– between countries
– between regions
– between units
OECD Health Data – 2002/3
Live births by CS
Netherlands 129/1000 Norway 137/1000 Denmark 145/1000
UK 170/1000
USA 211/1000
Paradox
Preventing abnormality – FEAR
Promoting normality – TRUST
Where does the problem lie?
social and cultural?
political and economic?
__________________________
women?
midwives?
doctors?
Social and cultural
Medicalisation of childbirth
Perception of advantages and
disadvantages of caesarean section
– media, celebrities…
Caesarean section on demand
– wide geographical and cultural variations
Political and economic
National organisation of health systems
– private or public health sector
Financing of maternity services
– private or public maternity services
– midwife, obstetrician, general practitioner – global or by item payment/reimbursement
Complex issues
Be careful
Don’t oversimplify
Social, political, economic
Get informed!
Get involved!
Get voting!
Funny thing is…
No matter what the
political system is, the problem of
medicalisation of
childbirth has increased
in industrialised
Funny thing is…
and the reduction in perinatal mortality slowed down as
hospitalisation
increased!
We all know it…
Midwives are independent autonomous practitioners
responsible for normal birth Midwives are independent
autonomous practitioners
responsible for normal birth.
So, if it is not the midwives’ problem, it must be the fault of either
the women
or the obstetricians
Really??????????
A professional practitioner a midwife
is responsible and accountable for
her practice
Midwives know that …
The keys to success include:
– support and care in pregnancy, childbirth and the postpartum period,
– adequate care and preparation in the household,
– systematic detection of complications
What is normal birth?
“spontaneous in onset, low-risk at the start of labour and remaining so throughout
labour and delivery. The infant is born spontaneously in the vertex position
between 37 and 42 completed weeks of
pregnancy. After birth, mother and infant are in good condition.
World Health Organization (1996)
Normality includes…
Spontaneous onset of labour
Labour is considered as a continuum
Holistic, alternative methods of pain relief, water, ambulation
Permit food and fluids
Spontaneous physiological rupture of membranes
Encourage mobility
Calm, gentle and non-threatening environment
Auscultation or intermittent monitoring
Normality excludes…
Induced or augmented labour
Timing of labour
Medical methods of pain relief
Withholding food and fluid in labour
Artificial rupture of membranes
Restricted mobility
Institutionalisation of birth – hospital
Continuous fetal monitoring
Routine vaginal examinations
Midwives are generally …
nice people,
who try to do their best for the women they care for,
who know about WHO guidelines,
who know that pregnancy and labour
are ok really,
MIDWIFERY PRINCIPLES
MIDWIFERY PRACTICE
Ga p
Ga p
But that is theory!!!
In practice,
– hospital birth
– continuous monitoring
– epidural analgesia
Paradox
Preventing abnormality – FEAR
Promoting normality – TRUST
likely to progress normally
Variations in practice
social context
peer pressure & resistance to peer pressure
level of knowledge
perception of risk
Midwives vs. midwives
My practice is more liberal than your
practice!!!
Midwives vs. midwives
Comparative optimism
– individuals perceive that they are less likely to make errors or bad judgments than others
– divorce rate – 50%
but… philosophy of units...
nutrition in labour
but… philosophy of units...
rate of
vaginal examination in labour
but… philosophy of units...
100
80
60
40
use of
Pinard/Sonicaid during labour
Paradox
Preventing abnormality – FEAR
Promoting normality – TRUST
likely to progress normally
What can midwives do?
“One thousand women were allocated at random to one of two perineal management policies, both
intended to minimise trauma during spontaneous vaginal delivery. In one, the aim was to restrict episiotomy to fetal indications; in the other, the operation was to be used more liberally to prevent perineal tears. The resultant episiotomy rates
were
10% and 51%
respectively.”
What can midwives do?
Listen to women
TRUST WOMEN’S BODIES
Understand research principles
Read papers critically
Undertake research
Evaluate your practice
Evaluate your practice
P0χ² = 1013.755 df 2p < 0.001
P1+χ² = 512.710 df 2p < 0.001
Parity Normal FD/VE CS Total
P0 No epidural 85.5 13.1 1.4 2506
Epidural 42.4 38.0 19.6 2171
P1+ No epidural 97.8 1.9 0.4 4146
Epidural 78.3 14.6 7.1 787
Total 7846 1460 581 9887
