Countless women around the world give birth to babies without medical intervention in this natural process. For them, the most valuable care is the constant presence of a midwife or other skilled attendant who creates an environment which supports their hormonal and physical processes.
Midwives, the experts in physiological, undisturbed birth, have been providing – and arguing for – the supportive care of birthing mothers for decades. However, while they want to exercise their professional autonomy in order to give care which centres around the mother's individual needs – during what can be a risky time – they are increasingly battling with their employers and a professional blame culture to do so. Strict time limits on labour progress and so-called "active management of labour" intervenes in the natural process, with the aim of preventing labour delay.
But there is evidence – both clinical and experiential – which shows that labour and birth cannot be rigidly regarded as universal, mechanised processes defined by clinical parameters. Now, a new guideline from the World Health Organization (WHO) has definitively stated that medical professionals' approach to caring for and supporting women in childbirth must change to recognise this.
But surprising as this notion may be, a more humanistic model of care is difficult to implement. The WHO acknowledges that the main reason for this is the increasing medicalisation of natural childbirth processes. The "birth script" – which involves repeated use of a particular type of language (such as "failure to progress") and habitual interventions (for example, routine electronic monitoring) sets doctors and midwives as the experts and holders of the mysterious and specialist knowledge of birth.
The system gives them the control and power over women, and means they may intervene when it is not necessary or indicated by the mother. They control the experience of birth by presenting choices, chances and clinical indicators in ways which do not reinforce or even indicate the fact that the majority of births can happen with little intervention.
Freedom to decide
Research shows that how midwives and doctors communicate with women makes them more likely to make choices which are in line with the professionals' preferences. The way that things are phrased seems to pressure individuals towards certain choices. For example, using the phrase "we just need to" makes it harder for a woman to say no to intervention.
These professional preferences are often grounded in a culture of risk which does not seem to support autonomy in childbirth or respect women's ability to make their own decisions. Simply changing the language used by medical professionals when talking to and about expectant mothers can change all this, however. One glaring example is how women are referred to as "the labourer" or told about "the induction". They are people and should be referred to as such.
This idea is supported by NICE guidelines, which advise midwives and doctors to communicate in a way that creates a "culture of respect" for the birthing woman. Under this advice, she is recognised as being the person in control of the situation, not the professionals.
While having this enshrined in a guideline is helpful, it is also a damning indication of the current state of the culture of obstetrics and midwifery. At present, women do not have the freedom to make decisions without being pressured into taking certain options – such as declining invasive examinations in labour, or into giving birth in certain places – because it is believed to be in their best interests.
Midwives and obstetricians cannot avoid the fact that they need to look closely at their own practices and change the ways that they communicate. Research has shown that changing the "birth script" enables the birthing woman to understand their innate ability to birth without intervention, and make informed choices that are in line with their own needs and preferences. It can also help mothers to adapt to changing circumstances during birth, and cope better on the rare occasions that valuable medical intervention is needed, so that they still have a positive birth experience.
During pregnancy and birth, women are being disempowered during their encounters with medical professionals. The new WHO guidelines are a welcome change, but we need to make sure they are followed. Professionals must become aware of the power of their behaviour and communication during birth, and give childbearing women the opportunity and right to become more knowledgeable about what they are going through. Women must be able to make appropriate, informed decisions for themselves while accessing the safety net of expert knowledge and care.
It may be a potentially radical shift for some healthcare providers – away from a medicalised model of viewing birth in terms of risk – but the recommended practice of respectful care will give women the care and support they want as well as need.
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