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Better births - 2016 Maternity review

‘The birth of a child should be a wonderful, life-changing time for a mother and her whole family. It is a time of new beginnings, of fresh hopes and new dreams, of change and opportunity. It is a time when the experiences we have can shape our lives and those of our babies and families forever.’

No one can take issue with these opening words of Baroness Julia Cumberlege’s 2016 maternity review. Less than a year ago, the evidence-based review completed by the United Kingdom's National Institute for Health and Care Excellence (NICE) concluded that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Yet March 2016 has been a month when deep-seated disagreements about the ways in which maternity services can best promote positive birth experiences have re-surfaced with new and unexpected intensity in England and in other parts of the world.

Entrenched views of childbirth either as ‘only normal in retrospect’ or as a normal event in a woman’s life, that can be glossed as the ‘medical model’ versus the ‘midwifery model’, are centuries old. As Mark Harris pointed out in his Birthing4Blokes blog (27th February), it would be salutary for all to realize how much unconscious pre-suppositions, if examined, could help us take a bird’s eye view and seek a real debate if not a dialogue. The manner in which research, figures and personal grievances have been slung between sides in the last month has probably highlighted the questioning of evidence-based clinical practice above all else.

Neither NICE not the Maternity Review dictate a clinician type or birth setting and both make it clear that women should have freedom to make choices consistent with their needs and preferences. In continuity with her 1993 government report ‘Changing Childbirth’, Baroness Cumberlege advocates that women and their choices should be at the centre of maternity care. This includes keeping community-based maternity options functional. The wide range of mothers and maternity professionals interviewed all over England expressed reasons for choice that are vindicated not only by research findings but also by the overall improvements of outcomes in maternity services over the last decade.  In spite of the increasing complexity of maternity needs and greater pressures on the NHS, offering choices to women has proved viable and in conformity to the rising perception of birth as a human right. Altogether, the UK is showing the world that a model in which midwives play a major role in the care of low risk pregnant women can ‘deliver’ not just safety in overall numbers but also quality experiences that are known to have long term implications for children and families.

Certainly, those of us who were around in 1993 know well that continuity of care remains an ideal unlikely to be attained in the foreseeable future. It is unclear how far the sensationalized announcement of £3000 personal birth budgets in the review has contributed to divide opinions about the feasibility of implementation - already the elephant in the room of Changing Childbirth. Underlying the strong-worded arguments by detractors of the Maternity Review is the conviction that women need hospital-based interventions for their and their babies’ safety, as a stronghold of modernity, and a guarantee of (almost) trouble-free new beginnings.
Birthlight as an organization is committed to fully supporting women’s choices in a non-violent and non-dogmatic perspective. If a low risk pregnant woman, for deep reasons rooted in her family history, expresses a strong preference for either an optional cesarean or a home birth, a lack of options is likely to compromise her and her baby’s experience. One point on which everyone suspiciously agrees is that women need to be offered more information about their care options.  This is debatable. The plethora of information on the internet and in books, and the information/advice given by professionals and friends, are not value-free. The statutory statements read aloud to women previous to obtaining their ‘informed consent can cause great stress at a time of intense pressure.  When in doubt, most if not all women go with ‘what’s best for your baby’.  

Fortunately, excellent new internet sites and blogs aim to support women’s decision-making with information not easily available in mainstream sources. When is a VBAC (vaginal birth after a cesarean section) safe to undertake? Scaremongering about uterine rupture needs to be examined in the light of both statistical risk and personal choices.   Blaming the damage caused by a recent increase in instrumental deliveries seen in maternity units promoting ‘normalised birth’ upon midwives and women’s misplaced choices is futile. We need to consider whether these units are appropriately staffed and funded, and also whether working relations between midwives and doctors are antagonistic or harmonious. The often quoted report on the Morecambe Bay tragic maternal and infant deaths called for an examination of the ‘lethal mix of failures’ in context.

Beyond information and beyond the presuppositions inherited from women’s upbringing and culture, finding the way(s) to meet their needs as persons bringing babies into the world is part and parcel of pregnancy as a wonderful, even though often trying, journey of self-discovery and transition to motherhood. While birth units attached to maternity hospitals objectively seem to offer best options in response to perceived risks, the security and privacy of home are unequalled for some women. For others, conception through IVF makes any risk intolerable around birth. The recent experience of assisting my daughter in the home birth of her first baby has reaffirmed my gratitude to the midwives who opt to work in home birth teams against all odds.

One element that is crucially missing from the Maternity review, at least in its short version, is the critical part that community services outside the NHS can play in offering continuity of support in the current absence of continuity of care, which has been highlighted by NICE since 2008. From its early days in the1980s, Birthlight has pioneered community classes in which pregnant women can find a save haven week by week and return with their babies on the other side of childbirth.  Given the extensive cuts on antenatal and parentcraft education in UK maternity services over the last 20 years and the recent cuts of Sure Start budgets, grassroots organisations now play a palliative role. There is an abundance of research articles showing the positive outcomes of yoga and other body-based practices in reducing pregnant women’s anxiety and alleviating the symptoms of postnatal depression. In a best case scenario, Birthlight teachers of Perinatal Yoga, Postnatal yoga, Baby Nurture and Massage, Mother and Baby Yoga could contribute to better integrated maternity care, pre and postnatally.  Dean Ornish’s programme for the prevention and reversal of coronary heart disease in the USA provides a hopeful and successful model based on a holistic approach to care that many women are drawn to during pregnancy.

The experience of childbirth is not set once and for all in the memories of women, their partners and their babies. It is re-cast in time with new emotional twists and turns according to contextual events and processes past and present. Sensitive midwifery care AND sensitive prenatal classes include attention to the shaping and meaning-making of experience as it unfolds from the time of the first scan, and sometimes even earlier. Words, gestures and attitudes promote or undermine women’s self-confidence in their ability to first become mothers, and then ‘good enough’ mothers. The quiet space of relaxation allows a re-appraisal of the changing self with acceptance of the new, and trust that the unknown can be coped with using resources at hand. Even if the lottery of birth calls for unplanned intervention, women who have integrated the neuro-physiological circuitry of ‘calm-centring’ have equipped themselves and their babies with resources that are likely to prove invaluable beyond birth. The process of integration continues, coupled with baby bonding and at times including grieving and its slow resolution.
Since the momentous Cairo World Women’s Health Congress of 1995, WHO and other organisations concerned with women’s reproductive health have invited a greater focus on maternal wellbeing rather than on quantifiable outcomes. This focus is implicit rather than explicit in both the NICE report and the Maternity Review, but the importance attributed to women’s right to choose their place of birth and mode of care indexes a respect for women’s autonomy that is sorely lacking in the vitriolic writings of opponents. Women, particularly when seeking to make decisions involving their babies, are not irrational, selfish or unable to think things through. The sheer mention of an ‘incompetent’ cervix or uterus, or a diagnosis of ‘failure to progress’ during labour invites us to stand-up for human rights in childbirth and campaign against obstetric violence, be that of doctors or midwives who are not ‘with woman’.

Both the NICE research review and the Maternity Review of figures and attitudes throughout England show that the substantial body of evidence produced by research in the last few decades, even though it can be contested in part, cannot be denied. Simultaneously, women have voted with their feet to supplement their antenatal care with body-mind practices in more congenial formats, one of which has been and is still evolving as Birthlight. We play a tiny but significant part in a life-affirming worldwide network of people and organisations who share the view that medical technologies can best serve to support the wondrous physiological processes that science keeps unveiling.