Disrupting birth

Central to the care of pregnant and birthing women are the relationships that sustain them and their families in the transition to parenthood. Pregnancy and birth care have traditionally been relationship-based: a woman knew the local women who assisted at births; she saw familiar faces when her time came.

As we saw in Janet’s story, birth has now become highly medicalised for many. No longer a normal event in the course of life, it is now treated as an illness that requires medical attention. Some of that medical attention is life-saving: appropriately timed intervention saves lives. Yet much of it is unnecessary, and potentially harmful.

As a result, what we are witnessing globally is that women are less likely to experience normal physiological birth. The majority of women experience some medical intervention during pregnancy and birth – and it comes at a cost:

• Caesareans carry an increased risk of death for women and may affect future pregnancies.
• Babies may suffer injuries from forceps or vacuum extraction.
• Women’s emotional and mental health may suffer from birth-related interventions.

(Goer, et al, 2012.)

The value of medical care isn’t under dispute, but the amount of intervention needs to be addressed in order to ensure optimal physical, emotional and psychological health of women, babies and families.

How was Janet’s experience disrupted?

We heard in Janet’s story that she didn’t know or have a relationship with any of her caregivers. At every stage, she saw a new face, with different advice, and all of them rushed. She had to retell her story to every new care provider. There was no-one that knew her whole story, for her to talk with, to discuss her fears, to plan her birth with. There was no-one who could see the whole picture and take it all into account.

It’s easy to see how a cascade of intervention can happen in this situation: Janet wasn’t sure about being induced, but her concerns were dismissed without discussion, and she wasn’t given a choice – she was simply told that it was necessary.

She wanted a natural birth, but between the intensity of an induction and a midwife (whom Janet had never met) encouraging her to accept pain relief, she had an epidural.

An epidural meant Janet could no longer move or change positions easily and her labour slowed down. She was told more medication was needed to speed contractions up again, but who could she discuss this with? Who was there to advocate for her? She had to implicitly trust doctors and midwives she’d never met and who didn’t know her. The next thing she knew, she was being rushed to an emergency caesarean.

Once the baby was born, there wasn’t anybody dedicated to help Janet and Mike’s transition to parenthood. She really wants to breastfeed her baby but there’s no one person who she knows, trusts and can contact for guidance – instead she’s sought help where she can and has received different advice at every turn. This has left her confused, with an increased sense of failure as she struggles to cope.

How common is fragmented care?

Janet’s experience is not unusual. The way maternity care is organised means women are likely to see different care providers throughout their pregnancy. In most countries, it is unusual for women to know the person who provides care during labour and birthing. Access to consistent support and advice in the postnatal period after the baby is born is also not the norm. This approach to providing maternity care is described as ‘fragmented care’.

When care is delivered within fragmented models, women must find their own way to navigate their maternity experience. While some women are resilient and able to effectively navigate their way through such systems to ensure their needs are met – many women like Janet feel the system has failed them. The ongoing costs of this intervention-fueled fragmented maternity experience are countless.

Disrupting the normal physiology of pregnancy and birth in this way may have lifelong effects. Research in the fields of developmental origins of health and disease, epigenetics, and the effects of trauma, along with our emerging understanding of the human microbiome, demonstrate that what happens during birth and in the early days after birth may affect the woman and child for the rest of their lives. (Babenko, et al, 2015) and (Dunlop, et al, 2015).

Unnecessary and avoidable intervention that disturbs birth impacts chronic disease like asthma and diabetes, mental health, and social relationships including bonding and attachment. (Goer, et al, 2012.)

What’s the alternative?

Women cared for by a known midwife are less likely to have an epidural, experience fewer episiotomies or instrumental births (forceps or vacuum) and are more likely to have a spontaneous vaginal birth. Women are less likely to experience preterm birth, and are at a lower risk of losing their babies. (Sandall et al, 2016.)

The continuing relationship between the midwife and woman means the midwife develops a deeper knowledge of the woman and her family, ensuring she avoids the pitfalls associated with fragmented care.

There is growing awareness of the wider consequences of disrupting the normal processes of pregnancy and birth. What happens around the time of birth can have major effects on lifelong wellbeing for mother, baby, and the family.

The message? What happens at birth matters.

Over to you

Does the term ‘fragmented care’ describe your experience of maternity care?

References

1. Goer, H., Romano, A., & Sakala, C. (2012). Vaginal or Cesarean Birth: What is at stake for mothers and babies. New York: Childbirth Connection.
2. Babenko, O., Kovalchuk, I., & Metz, G. (2015). Stress-induced perinatal and transgenerational epigenetic programming of brain development and mental health. Neuroscience and Biobehavioral Reviews, 48, 70-91. doi:10.1016/j.neubiorev.2014.11.013
3. Dunlop, A. L., Mulle, J. G., Ferranti, E. P., Edwards, S., Dunn, A. B., & Corwin, E. J. (2015). Maternal microbiome and pregnancy outcomes that impact infant health: A review. Advances in Neonatal Care, 15(6), 377-385. doi:10.1097/ANC.0000000000000218
4. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5