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Dignity and death in childbirth: the conflict between satisfaction and safety

by Denise Tiran(more info)

listed in women's health, originally published in issue 211 - January 2014

October 2013 saw the inaugural conference for the newly-formed Birthrights charity, which explored why women giving birth in the UK are frequently dissatisfied with their experiences, and even traumatised by the loss of dignity during labour. A survey by Mumsnet, an online forum for expectant mothers, identified that 26% were given no choice about their preferred place of birth and 24% were subjected to intimate procedures such as vaginal examinations and forceps delivery without having given consent. Sometimes these procedures were even undertaken without the health professional having introduced themselves (Turner 2013).

 

A contributory reason for the phenomenal number of legal cases seeking compensation in the UK may be the dire shortage of midwives, at least 2300 more being required. Midwife shortages often lead to closure of over-stretched maternity units, requiring mothers to seek care at neighbouring units which are themselves stretched to capacity.

 

In November 2013, a review by the National Audit Office (NAO) found that 20% of the entire NHS maternity services budget is now spent on cover for malpractice litigation, amounting to a staggering £482 million. Insurance cover is primarily for law suits involving alleged mistakes during labour or Caesarean section, particularly those which result in damage such as cerebral palsy in the baby.  This figure equates to approximately £700 per birth, coincidentally also the estimated cost to the NHS of having a normal birth (Sky News 2013). The UK Caesarean section rate has risen alarmingly in recent years, in some NHS trusts being close to 30% (Birth Choice UK 2013), despite the well-known potential short- and long-term sequelae of operative delivery. 

The NAO report identified that, in the UK in 2011, 133 babies per 1000 births were stillborn, and the maternal mortality rate was 8.2%. This is devastating for those involved, but set in context, Britain remains a country in which pregnancy and childbirth are relatively safe. Compare this with the astounding statistics for countries such as Afghanistan, Niger and South Sudan, all having been named at different times as “the worst place in the world to give birth”. In rural parts of Afghanistan for example, it has been estimated that one woman dies from a pregnancy or birth-related complication every two hours (RAWA News 2013).

These statistics represent two ends of a wide spectrum, with high physiological risk on the one hand, and high psycho-social risk on the other. Pregnancy and childbirth are normal life events, the culmination of a woman’s role in society and the primal function of a woman’s being. Childbirth should be a family and community (social) event, a joyous and happily anticipated (psychological) event. However it has become a high risk (physiological) event, even in westernized countries which have the professional expertise and financial budgets to manage the demands of the service. Emphasis is placed on the physio-pathological safety of the mother and, in the UK, USA and other first-world countries, this is often at the expense of psychological and sociological satisfaction and wellbeing. Conversely, in poor and under-developed areas of the world, satisfaction can be measured in terms of deliverance from a dangerous health episode in a woman’s life. Merely the fact that she - and hopefully her child - survives is cause for celebration, and there is little space for the niceties of compassion and dignity.

A contributory reason for the phenomenal number of legal cases seeking compensation in the UK may be the dire shortage of midwives, at least 2300 more being required. Midwife shortages often lead to closure of over-stretched maternity units, requiring mothers to seek care at neighbouring units which are themselves stretched to capacity. Similarly, there are many factors (although not excuses) which may account for maternal dissatisfaction, only one of which is the limited numbers of midwives to care for an ever-growing clientele.  The birth rate in the UK in 2012 was 813,000, an increase since 2011 of some 93,000.  Despite the government’s assertion that more midwives are being trained, there remains a dire shortage of midwives and those who continue in practice are over-worked, exhausted and feel under-valued.  This can have a direct effect on care of women, making them feel as if they are a “nuisance”, that the midwife is too busy to answer questions or do anything more than just rush into the labour room to record observations or - worse still - to look at the monitors.

In Africa and other under-developed areas of the world, women do not have the luxury of choice. The effort of attempting to access professional help can in itself be dangerous - walking through the African bush can expose them to predators, both animal and human. It is also costly, since care must be paid for and being away from home means they are not available to work. Alternatively, there may simply be no readily accessible professional help available, leading women to seek help from other local women or traditional birth attendants, or in many cases, to give birth without any help at all.

It is interesting that, in the UK, increasing numbers of women are opting to progress through pregnancy and labour without a maternity professional being present, in other words to give birth unassisted, sometimes called ‘freebirthing’. There is, however, a difference between these women and those in under-developed countries, in that women who ‘freebirth’ have made a conscious decision to do so, having researched the relevant issues. They are usually women who are in touch with their bodies. They are aware of the situation in which they put themselves and take steps to prepare comprehensively for the birth. They also, of course, have immediate recourse to the maternity services in the event that something goes catastrophically wrong.

The November 2013 annual conference of the Royal College of Midwives spent much time on debating what constitutes ‘safety’ in childbirth in the UK (personal attendance of the author). In addition to midwives, there were presentations from obstetricians and a representative from the Action against Medical Accidents, who challenged delegates to consider whether ‘choice’ should be superseded by ‘safety’ in any decision-making.  Of course, any woman wants to be helped to give birth to a live healthy baby without complications for herself. There are, in fact, very few women who actively choose to decline medical treatment when faced with major emergencies and complications in childbirth. Those who continue along a course of action which appears, to midwives and doctors, to be ill-advised and dangerous, often do so because they do not fully understand the implications and because they are acutely anxious and frightened.

However, this debate between safety and choice extends beyond the emergency situation. Doctors have traditionally viewed labour as ‘only normal in retrospect’ and frequently adhere to the ‘just in case syndrome’, opting to manage women in a paternalistic way, investigating and pre-empting possible complications which, in reality, only occur in a minority of women. Conversely midwives view all labours as normal until they deviate from a (fairly wide) spectrum of physiological normality. The role of the midwife is to provide holistic - bio-psycho-social - care and this emphasis results in a more well-rounded approach to the woman, her baby and her family as a whole.

‘Choice’ is seen as improving satisfaction, whereas ‘safety’ implies lack of choice for the mother, but these terms are not mutually exclusive. It is possible to offer a woman a variety of options even in the most dire of situations. An extreme example of this is the situation in which a mother who has just given birth has a torrential postpartum haemorrhage but declines a blood transfusion due to her particular moral or religious beliefs. She can still be offered the option of intravenous fluid replacement and/or iron supplementation - or, indeed, no treatment at all - but she needs sufficient information to enable her to make an informed decision about the implications of so doing. Her choices may not be as flexible or as wide as they could have been in different circumstances, but the mother can still have a voice in what treatment she receives, making her feel valued by working in partnership with the professional team.

Similarly, the issue of ‘choice’ does not have to be at the expense of safety.  Facilitating women to choose their place of birth, for example, may on occasions contradict the opinions of individual maternity professionals, but those opinions are usually based on knowledge and experience, both positive and negative. An obstetrician or midwife who has previously been involved in caring for a woman or baby who died is far more likely to try to persuade another woman to comply with added safety measures in order to prevent a similar situation occurring. However, a woman who has, let’s say, chosen to give birth at home to twins despite having had a previous Caesarean section is perfectly at liberty to do so, although most doctors would advise against it. The responsibility of the midwife is to provide her with all the information she needs to prepare her, whilst taking steps to avoid, where possible, specific problems which may have contributed to her previous circumstances. Legally, the midwife is obliged to provide care wherever the mother gives birth (interestingly a doctor can decline unless it is an emergency).

It is known that litigation occurs more commonly in maternity cases than in any other clinical speciality. Losing a baby - or worse, a mother - is emotive and life-changing for the whole family and it is natural to want to blame someone. Added to this is the fact that babies damaged at birth may need life-long round-the-clock care, the significance of which is often not wholly acknowledged until the child is older and the parents are ageing. It is for this reason that the Civil Liabilities Act allows up to 25 years for someone to take a case to court for alleged negligence. Furthermore, the cost of years of constant medical and social care for these children is enormous, so any pay-outs by the courts (or out-of-court settlements by NHS trusts) need to be anticipated in terms of millions.

Sometimes, court cases can be avoided by individuals or trusts owning up to having made a mistake - but this is extremely difficult to do, since any admission of error can so easily lead to the very court cases they sought to avoid. Families which are devastated by the loss of the normal healthy baby they expected, or by the loss of a mother, look for reasons - they blame themselves, their care-givers and the institution in which that care was provided. Many would, however, salvage some degree of ‘satisfaction’ from the situation if only someone had talked to and empathised with them, explained what had happened and considered the implications for the future.

Perhaps we should return to where we started - the lack of dignity afforded to women in pregnancy and childbirth. Where a midwife or doctor attempts to develop a relationship with the mother, getting to know the family, the mother’s fears and anxieties, her preferences for labour and the reasons behind them, it is far easier to work with the mother. Despite the lack of staff, the long hours and difficulty in providing one-to-one care, there is no excuse for being rude, off-hand or unsympathetic to women. A caring relationship can go a long way towards enhancing the mother’s labour experience, improving her satisfaction and enabling her to feel involved in the decision-making. There will always be some women for whom emergency situations develop in which the urgency of the situation temporarily overtakes the attention to psycho-social wellbeing, but this can be addressed in the days following the labour. Some maternity units now offer ‘birth after-thoughts’ clinics to enable women to talk through their labour experiences, and some midwives specialize in bereavement counselling, not just following a baby or mother’s death, but also to help families to come to terms with the loss of their expectations.

Talking to women can also go a long way towards reducing their anxieties and fears, enabling their bodies to work more efficiently and not to be adversely affected by the surge of cortisol, adrenaline and noradrenaline which can so often interrupt the progress of labour. Complementary therapies can aid relaxation and prepare women to cope with labour pain, rather than fighting it. Continuity of care - or even better, continuity of carer - can ensure a more cohesive approach to the pregnancy and preparation for the birth. Above all, any strategies which can reduce interventions such as induction of labour or Caesarean section, and which facilitate normality in childbirth contribute to a childbearing population in which women are satisfied and which also makes childbirth safer.

References

Birth Choice UK 2013 Caesarean section rates Viewed online 11.11.13 at www.birthchoiceuk.com/Professionals/index.html

RAWA News 2013 Afghanistan: Stark, beautiful - and a danger to mothers. "The worst place in the world to give birth." 14 October 2013 Viewed online 11.11.13 at www.rawa.org/temp/runews/rawanews.php?id=3393

Sky News 2013 Maternity negligence cover: NHS spends £482m Viewed online 11.11.13 at www.capitalfm.com/on-air/news-travel/uk-world-news/maternity-negligence-cover-nhs-spends-pound48/

Turner B. 2013. Why are half of UK women not getting the birth they want? The Telegraph 17 October 2013 Viewed online 11.11.13 at http://www.telegraph.co.uk/women/mother-tongue/10385992/Why-are-half-of-UK-women-not-getting-the-birth-they-want.html

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About Denise Tiran

Denise Tiran MSc RM RGN ADM PGCEA, a practising midwife, university lecturer, complementary practitioner and author, is an acknowledged international expert in maternity complementary medicine, and Director of Expectancy Ltd. Previously, Denise worked as a midwifery tutor and then as Principal Lecturer at the University of Greenwich, London, where she developed one of the UK’s first practice-based degree programmes on complementary medicine. Her unique complementary therapies NHS antenatal clinic at Queen Mary’s Hospital in Sidcup, southeast London (1994-2004) was “Highly Commended” in the 2001 Prince of Wales’ Awards for Healthcare in London.

Denise has written several professional textbooks and over 40 journal papers, as well as two books for expectant mothers. She is regularly consulted by the Royal Colleges of Midwives and of Nursing on complementary medicine. She was a member of a joint Royal College of Nursing / FIH working party on midwives’ and nurses’ Fitness to Practise complementary therapies. She has recently been appointed Chair of the Education and Standards Committee of the Federation of Antenatal Educators and its Consultant on maternity complementary therapies. She may be contacted via info@expectancy.co.uk       www.expectancy.co.uk

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