Two halves should make a whole instead of two sides to make an argument..

I had a lengthy debate on night duty the night before last, a frank exchange of words and honest disagreement with an obstetric doctor about water birth. Ever since I have been coming up with the best one liners and examples of evidence that has failed women in obstetrics over the years. The Term Breech Trial¹ which used all women regardless of risk, dramatically increasing the caesarean section rate almost overnight,  early studies on post partum haemorrhage that again threw everyone in the same bucket regardless of risk, Freidman’s curve² that pigeon holed women into progress expectations that were unrealistic and eventually re-evaluated etc.. And I literally sit here pounding at the keyboard in a mood that leaves my humour a little sidelined from the usual.

 

I’m sorry guys I don’t know if I can make his one funny, it’s a passion post and not of the heartfelt kind. It’s the fire in your belly, make you grit your teeth kind of frustration that keeps rearing its ugly head in the back of your mind as you think and think and think about it. (Sorry keyboard you are really copping it today).

This is me all Lioness today – Roooaaarr!

This essentially professional debate about water birth really highlighted the difference between some obstetrically minded and midwifery minded people and that VERY unfortunately for some, there is no overlap. Obstetrically minded people can be midwives and they can be doctors, they can be people off the street. Obstetrically minded people have an ability to completely cut off the human that is having the experience. They are able to quantify everything in their mind based on statistics and measure success in morbidity and mortality. There is little regard for the person who is giving birth, their feelings, their fears, their sense of self, their support people. It’s all just black and white. On this occasion, a person readily dismissed waterbirth as a safe option for birthing due to poor outcomes allegedly caused by waterbirth although there is no definite proof of cause. The evidence was an admission to special care nursery with respiratory distress following waterbirth.  Babies are often admitted to special care nursery for observation with signs of respiratory distress due to an array of other reasons, like caesarean section, prolonged seconds stage, prematurity, just to name a couple. This cannot be the sole reason for concern and it cannot be pinned to waterbirth or dry land birth.

 

What this obstetrically minded person was trying to convince me of was that water birth is not safe and that we are not telling women the truth about it. I nearly fell off my chair! She based this assumption on four outcomes, which frankly is ridiculous. As we are all trained to know that evidence considered to be rigorous DOES NOT COME FROM A SAMPLE OF FOUR!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Sadly in the birthing world there is an unexplained phenomenon that sometimes gathers obstetric events of similar nature together, be it PPH’s, third degree tears, premature labour etc. You simply cannot call a way of birthing into question based on four cases. I am not saying this phenomenon is the reason but it could be and that statement holds about as much statistical value as the statement that all water births are unsafe because of four cases. Risk is everywhere, sadly just because you do not have a water birth does not mean that you will avoid a negative outcome. Equally, just because there is risk does not mean you will not have a straight forward, beautiful, empowered birth.

Which brings me to my next point, statistics are generated to test hypotheses. However statistical analysis is an art and we all know, as with painting and photography that not everyone can do it. How many “studies” have you heard of lately that have been overturned due to incorrectly interpreted data or even that they had fabricated the data altogether? Fact is only fact for a moment in time and then another person comes along, tests a hypothesis which makes us all question what we thought we knew. I am not saying that evidence is not used for good reason, it is important part of guiding our practice, but it must be rigorously tested for currency and validity. What I am highlighting about evidence today is that it is temporary. Another important fact that I will highlight here is that you can gear research to fit a desired opinion. Anyone who has studied at a tertiary level and has written a persuasive piece can attest to this. There will usually be two sides of an argument with evidence to support each one. If you are lucky you will find literature reviews that compare and contrast the evidence and  attempt a balanced review. And if you are open minded enough it may even change your view and create a more balanced overview.  But if you are not, you can use your carefully selected evidence to frighten people when it is delivered in the right way to completely alienate them from their desires and make them have the birth YOU consider to be “safe”.

Also referred to as coercion or intimidation.

Now back to these obstetrically and midwifery minded people.

In an ideal world we would both cross over and share ideas with respect for each other’s professional experience and insight. Midwives being specialists in normal birth and obstetric doctors being specialists in the abnormal birth. Often this happens in practice. Some of the most woman centered and professional team members within maternity workplace are engaged in sharing information to assist each other instead of judging or criticizing. However, in my observation of obstetrically minded people it is very much an “us and them” way of thinking that leaves the midwives feeling as though they are worthless and redundant, as though their years of training and experiences amount to nothing once that person walks in to the room. I dare say there are few things that can be more poisonous to a midwife and birthing woman.

 

Midwives from my own experience and the many that I have watched who are true midwives, not doctors assistants, have access to things that obstetrically minded people will never see. They are not privy to a world of safety and wholesomeness surrounding birth. Midwives will prioritize putting a woman first, her baby as part of that whole, the two are not separate. When you care for the mother that includes the little person inside her. We appreciate and understand that birth is not just about morbidity and mortality. It is an unforgettable life experience that she will tell her daughter about when she is having her own children. The birth of a baby is a moment in time that is beautiful. Midwives appreciate that, they take care of the medical side of care but they also connect with the feelings as an important part of their business. They create lasting professional relationships. They see the woman as an identity that is multifaceted, complex and enduring – she is not just a statistic, not a machine. Midwives value choice, empowerment and satisfaction as important parts of pregnancy, labour, birth and new motherhood.

Being the moderate midwife, as I have said before, I am not right wing or left wing. I sit in the middle. I sit beside the woman because she is the one who is in the middle, with her baby. Obstetrically minded people and midwifery minded people should be able to openly converse without mistrust of each other and be open to a change of mindset or at least develop more balanced perception. We need a mutual appreciation for our differences and come together to really hear each other. We are both en route to the same hospitals for the same reasons although you’re driving your Mercedes and I’m in my Mazda, we may take different directions but we end up at the same place. We both want healthy mothers and babies, but that means different things for both of us. We take care of normal, holistically and intuitively and when it becomes more complicated, we engage your help. We are educated, safe, sensible people caring for women who need it. We read evidence too, but we apply it to real life human beings instead of mechanical devices who need to be considered without piling fear on top of them preparing them for adversity they may have avoided without your poisonous words.

 

Ultimately we are all humans helping humans do human things. Perhaps getting off that large stallion will help you to gain a more human perspective.

OK one funny…

 

And of course, I hold great respect for the obstetric doctors who I call my colleagues that are equally midwifery and obstetrically minded. Thank you for valuing the woman in a culture that doesn’t say that you have to. It is a gift and deeply valued by the women you care for and the midwives who care for them.

 

The Moderate Midwife.

 

Sigh, that’s a little better, but I’m sure there will be more on this.

 

 

1. Hannah M, et al. (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet; 356(9239):1375-1383.

 

2. Friedman EA 1955, Primigravid labor: a graphicostatistical analysis, Obstetrics and Gynecology, vol. 6, no. 6, pp.567-89.