Thursday, June 14, 2007

Hegemony of normal birth

An article in this month's issue of Nursing Inquiry presents one of the most compelling and complete descriptions of current issues in midwifery philosophy that I have read. 'With woman' philosophy: examining the evidence, answering the questions by midwives Carolan and Hodnett use the advent of direct entry midwifery in Australia to address several philosophical conflicts within midwifery.
... [C]hanges to midwifery education in the UK, Australia and Canada meant that it was no longer a requirement for midwives to have completed nursing studies before studying midwifery. A new emphasis on birth as a normal life event was evident and normal births were no longer considered to require additional nursing skills. Although this move towards promotion of birth as normal, and midwives as the specialists of normal birth, is a positive one and a view endorsed by both authors, it nonetheless gives rise to several concerns and questions. For example:

* Do non-nurse midwives have sufficient clinical skills to care for pregnant women with serious comorbidities?
* Is it possible to focus on normal and yet still be acutely sensitive to early indications of complications?
* Does an emphasis on normal birth as primary goal:
* detract from the experience of women who do not have normal births?
* lend itself to a different form of authoritarianism where women are 'persuaded' to birth in a certain way?

As this review progressed three areas of concern became evident. The first relates to educational issues and questions whether direct entry midwifery education is sufficient to equip new midwives to care for pregnant women with significant comorbidities. The second issue relates to the creation of a hegemony, in which normal birth is the ideal and any other form of birth is a potential source of disappointment, guilt and/or failure. This understanding has the potential to detract from the experiences of women who have medical interventions. The third and final concern relates to a promotion of the midwife–woman relationship as all-important.
Not surprisingly, I found the section on Valuing Of Normal Birth particularly thought provoking:
... [T]he term 'normal birth' pervades midwifery literature and midwifery textbooks to such a degree that a struggle for hegemony is a legitimate concern. Many publications suggest a contest between medical intervention, paternalism and control on the one hand, and the midwife providing 'woman-centred' care and acting as the woman's advocate on the other. Several discuss 'protecting' normal childbirth and reacquainting women with their natural propensity to birth... Throughout there is a suggestion of competing forces: midwives as guardians of vulnerable childbearing women vs. physicians wishing to take over and medicalise pregnancy...

As a newly appointed midwifery lecturer, this adversarial undergirding has been both a shock and a revelation to me(first author). I had previously considered that we were all on the same side, with the common aim of providing best care for childbearing women. Moreover, the current emphases within midwifery create an interesting paradox. At the same time as a move towards women empowerment, midwifery care and normalisation of birth, changing demographics in Australia and globally show a growing trend towards older maternity and an increasing demand, by women, for caesarean section... Overall, childbearing women, considered to be 'at risk' for pregnancy and maternal complication, are ever more likely to give birth surgically, and ... approximately 15–25% of pregnant women are currently deemed to be at high risk for pregnancy complication in any given year. Additionally, there are many women having babies today who could not have reasonably contemplated pregnancy in the past. Examples include sufferers of diseases such as cystic fibrosis and cardiac disorders, who are now experiencing greater lifespans and better quality of life ... The parameters of fertility technology are continually expanding and offer hope of pregnancy to many women who would have previously been considered infertile. For these women, a 'normal' birth may not be possible or particularly desirable.

... This dichotomy of increasing technology and medicalisation on the one hand, and midwifery moves to re-claim 'normal birth' on the other, gives rise to some important questions. For example:

* Do 'at risk' women value natural childbirth or 'women empowerment'?
* Does the current emphasis on 'normal birth' disadvantage women giving birth by caesarean, in terms of a lesser valuing of their experiences?

Overall, it is difficult to determine whether women who are deemed 'at risk' for pregnancy complications are particularly interested in achieving normal birth and - or woman empowerment. Increasing demand for caesarean section, particularly among well-educated women, mothers over 35 years and health professionals, suggests that they may not be. Other evidence suggests that many women over 35 years consider their pregnancy to be an exceptional event (a miracle) and are anxious not to jeopardise the perceivably vulnerable pregnancy in any way, and this is especially true of women who use reproductive technology to conceive...

The second question above is an important one in this of increasing surgical birth. At present the evidence suggests that, although many women choose or concede to caesarean birth, they also experience a variety of negative feelings following caesarean delivery. Unplanned or emergency caesarean section seems to intensify the negative impact... Altogether, it is clear that many women already suffer considerable psychological distress following caesarean birth and there is some evidence to suggest that a percentage of women are acutely sensitive to even minimal undervaluing of this mode of birth. For example, in Carolan’s (2005) study, several participants described a distressingly limited discussion of caesarean section in prenatal classes and an emphasis on vaginal birth as penultimate, and as something most women 'could achieve'. This understanding led to later feelings of inadequacy and guilt. Therefore, it would seem important that midwives do not inadvertently add to women’s angst by even subconsciously undervaluing this mode of birth.
Carolan and Hodnett raise similar issues to those I have raised. Does the emphasis on 'normal' birth (or even the use of the term 'normal' birth) contribute to an improvement in the care of women, or does it represent a new authoritarianism on the part of midwives in their role as medical professionals? Have midwives created a hegemony where the midwives' values take precedence over the patients' values? Has this hegemony led to an atmosphere in which other births are not valued and in which women are indoctrinated to believe that their is only one 'right' way to give birth? Midwives, and homebirth advocates would do well to ask themselves these questions as well as an additional question: does the current philosophy of midwifery best serve women, or best serve midwives?

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