Source: mycity4her.com
When I first reported for duty at my first hospital, I was posted to the labour room. Although I have conducted delivery during my medical school years, it pales in comparison to what I had to deal with as a houseman.
I learned that everything that I learnt in books is not the same in real life. The patient in my books were faceless. The patients I see in the wards have family and friends. They brought to me their life stories. They came from all walks of life. There they are, sharing their precious life moment with me – this newly graduated houseman who knows little about life compared to these women. I was perpetually scared that I messed up someone’s birth or cause grievous harm due to my inexperienced hands.
I remembered a young teenage mom asking me – would it hurt? I said I don’t know – I have not given birth before. I remembered how I hated how some insensitive health care personnel in the labour room (not all) acted around first-time-mothers who ask too much. Or around that many times mother that kept crying out in pain – telling them to suck it up.
I hated sending mothers to operating theatre. No matter how much I explained to the mothers why they need this intervention/operation, they kept asking me back and some were unable to fully understand or comprehend what I am saying. At the same time, the longer time I spent explaining to them – the intervention became more delayed and their baby become more distressed. Sometimes, even after interventions taken, the outcomes remained bad. I remember how I hated seeing flat lifeless babies coming out and afterwards, I hated explaining to husbands that their wife or child is having complications after birth.
I remembered telling myself I don’t want to ever give birth. How naive I was then.
As time goes by, I became more experienced and managed to handle many births on my own. I began to understand that as doctors – we have limited ability to control the outcome of childbirth. My hatred against things surrounding childbirth subsided into acceptance of this fact. Often, medical interventions save lives but a lot of it remained in God’s hands. We as health care providers are just tools of His will.
Even as my experience and confidence grew, I still felt nervous every time I handle a birth as no two births are the same. Even a seemingly low risk birth could turn complicated and life threatening in a blink of an eye. Because of this fact, I am always aware that childbirth while often safe for majority of women, there is still risk involved even in controlled hospital setting. I always thought if things can go wrong in hospitals, surely it is worst if childbirth happened at home unassisted. During childbirth, if problems not anticipated and intervened, they can cause irreversible harm or in some unfortunate cases, even death.
What happened when the doctor becomes the patient?
When I finally got pregnant, I became that annoying first time mother who asked the same million questions to the doctor. Despite having conducted so many child births – nothing prepared me for going through it myself. I found myself questioning how maternal care was delivered in our country. How at the time, husbands were separated from wives at the time of need. The wives had to go through this life changing moment surrounded by strangers. Alone and scared, labouring mothers felt undignified having their private parts probed and exposed without care while delivering their babies in open air wards with only flimsy curtains protecting their privacy.
Source: www.wearethecity.com
I wanted a better, gentler birth experience for myself but at the same time, I did not want to compromise on my safety. I began to research about births to seek that safe, empowering birth I wanted to have.
I found out that in many parts of the world – mothers everywhere have been pushing for a change in how births are conducted. They are rejecting medicalised birth and demand more natural methods of delivery. They wanted a more dignified way to birth. Not in sterile, cold hospital labour rooms but in their respective warm, secure homes surrounded by familiar faces of family like in the old days. Women wished that births not to be treated like sickness and mothers not to be treated as patients. Labour rooms should not be run like factories with long queues of women giving birth in clinical precision of a production line.
What causes mothers to ask for natural birth? Aren’t hospital based physician managed births is safer for both mother and child?
While medical interventions have made childbirth safer, they are also not entirely risk free. Complications can result from medical interventions can harm both mothers and/or baby in the process. In many countries, low risk pregnant women are subjected as well to routine intravenous infusions and oxytocin in labour. Women without obstetric complications are encouraged to have electronic fetal monitoring and epidural analgesia. As labour intervention has become more widespread, assisted delivery and major surgery became common. Their complication rates became higher as well.
Horror stories of mothers feeling violated and disrespected by health care workers at the point they were most vulnerable. Procedures done without consent leaving mothers feeling violated. Some mothers even equated it to feeling of rape. This bad experience shaped their perception of health care providers and they began to distrust doctors as a whole. Some even resorted to unassisted childbirths as a way to get the kind of birth that they wanted without medical interference.
What is unassisted childbirth (UC)?
UC is the process of intentionally giving birth without the assistance of a medical or professional birth attendant outside health care centers (usually home). They are also known as free birth, DIY (do-it-yourself) birth, planned home birth without medical assistance, unhindered birth and couples birth. The women who chose to do UC may do so because they do not feel supported and respected by existing health care providers.
Unfortunately, the option of unassisted childbirth is not without risk. There are very little data surrounding unassisted birthing practice. Concerns arise whether it is ethical or even legal in some cases. Issues like informed consent and medical liability often left unaddressed leading to a lot of misunderstanding between mothers and health care providers.
Doctors are mainly concerned over medical liability in the event of medical harm or even death of the mother or baby during an unassisted childbirth. Should the attending persons during the birth held liable if any complications arise? In the case of death – can they be charged with involuntary manslaughter? Involuntary manslaughter meaning a person has caused death unintentionally through recklessness or negligence by participating in unassisted childbirth.
Source: www.telegraph.co.uk
Mothers who chose UC often cited as being well informed and aware of the risks involved. Health care providers on the other hand often questioned this fact and often wonder if the mothers know of the risk involved. Planned home births were associated with significantly higher neonatal death rates or in simpler words, associated with more baby deaths. It seemed that less medical intervention = more neonatal deaths. Many asked whether a decision to do UC without being properly informed of this fact as well as other risk involved would make any person involved with UC be medically liable in the event that things go wrong.
However, not all about planned home births are bad. Unsurprisingly, planned home births are associated with less medical interventions. With less medical interventions also meant mothers are less likely to experience birth intervention related cervical/vaginal lacerations, haemorrhage and infections. Isn’t that good for mothers?
Where do we go from here?
To me – the best kind of birth is a safe birth for the baby but gentle to the mother. A birth should have the mother be in control and aware of her rights as a patient. A mother should be a well-informed participant of the birth process by making informed decisions through out labour process.
Health care providers should act as patient’s advocate by making sure childbirth to be safe for both mothers and children. They need to make sure that patient’s rights respected and not violated. They also need to educate and make sure that mothers get correct information from reliable sources. Health care providers should also follow evidence based practice in managing birth to ensure that mother’s safety is not compromised at the same time. Effort should be made by health care providers to reach out to mothers by holding open dialogues as well as including mothers in maternal health care policy making. This means making a change in our health care system to ensure optimal childbirth outcome.
How are we doing so far?
Gentle birth approach or mother friendly initiative has been started in some of public as well as private hospitals. Steps are made to de-medicalise birth and lowering unnecessary intervention rates. Husbands are welcomed to accompany their wives in labour. Now, many new hospitals have well partitioned/separated labour rooms to ensure mother’s privacy is safeguarded. Mothers are not prohibited to eat and drink in labour and they are allowed to move freely during labour as well as to give birth in any positions. Episiotomies also should no longer be a standard practice in Malaysian hospitals (as per WHO guidelines). But the effort is still in early stages but this is still a promising start.
Planned home births or births in Alternative Birth Center (ABC) supervised by trained midwives for low risk mothers is another option that can be offered for mothers who wanted safe out of hospital birth experience. In fact, a United States prospective cohort study shows that planned home births with certified professional midwives was associated with lower rates of medical intervention with similar intrapartum and neonatal mortality to that of low risk hospital births. Perhaps this is the middle ground our maternal health care should head next – more patient/community centered, less hospital based approach.
*Neonatal mortality / death rates = includes all deaths in the first 28 days of life.
Dr. Nur Hidayati is a mother of one and also in training to be an internal medicine specialist with special interest in infectious disease and nephrology. She is a permanent columnist for the Malaysian Medical Gazette. Learn more about her on The Team page.
This is the personal opinion of the writer and does not necessarily represent the views of The Malaysian Medical Gazette.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]
References:
- Richard Johanson, Mary Newburn & Alison Macfarlane. 2002. Has the medicalisation of childbirth gone too far?. BMJ 324: 892-895. doi: 10.1136/bmj.324.7342.892.
- Wax et al Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. http://www.ncbi.nlm.nih.gov/m/pubmed/20598284/
- Johnson K.& Daviss B Outcomes of planned home births with certified professional midwives: large prospective study in North America’ BMJ 2005; 330: 1416 http://www.bmj.com/content/330/7505/1416