- Email: [email protected]
It's my baby and I'll try if I want to
Perspectives
Book It’s my baby and I’ll try if I want to Surely there must be more books written on childbirth than on any other healthrelated topic. Initial visits to my local bookshop, after learning of my expectant status, revealed an overwhelming range of volumes on birth and pregnancy. So overwhelming, in fact, that I usually decamped to the design section and escaped with a glossy picture-book full of the sort of smart minimalist interiors that would soon be far beyond my reach, exchanged for the joys of motherhood. But Sheila Kitzinger’s contribution to the childbirth genre stood out from the crowd. It is, like many of its ilk, full of handy practical tips. What sets it apart is the author’s absorbing social and political perspective. In 1962, Kitzinger, a social anthropologist, published The Experience of Childbirth with the aim, not of making birth easier for individual women, but of changing the political and social contexts in which they gave birth. That first edition, she admits in the introduction to the revised 2004 version, was almost apologetic in tone, asking merely that women in childbirth “could be treated as human beings, might be consulted about what was done to them, [and] could learn ahead of time what was likely to happen and how they might be treated”. The 1960s, says Kitzinger, were days when “shaving the mother’s perineum until it looked like a hard-boiled egg, administering massive doses of castor oil in an attempt to stimulate the uterus into action, insisting that the women be bed-bound and forced to lie in a supine position throughout labour and birth, as well as routine episiotomy, were common and largely unquestioned. The term ‘informed consent’ had no meaning in childbirth. Women were supposed to be ‘good patients’ and to do what they were told.” In the UK in 1962, epidurals were uncommon, caesarean rates were less than half what they are today, there were no ultrasound examinations to pinpoint a due date, and electronic fetal monitoring wasn’t available. The spread www.thelancet.com Vol 364 August 7, 2004
of these now common practices Kitzinger implicates in what she calls the “medicalisation” of birth. Yes, she says, we should be thankful for modern interventions in high-risk pregnancies. But, we should recognise that unnecessarily complicating or expediting normal births can leave women feeling traumatised and even “emotionally mutilated”. She is not alone in decrying the rise of surgical procedures in childbirth—but perhaps alone in her plea for maternal empowerment. In the UK, debate on how women give birth has focused on the increasing rate of caesarean sections—now over 20% in some areas, of which 7% are in response to a mother’s request. Earlier this year, the National Institute for Clinical Excellence (NICE) responded by publishing guidelines in which they advised that women should not be allowed caesareans on demand. But, as Germaine Greer noted in The Guardian (April 29, 2004), NICE do not seem to have considered that for decades women have been indoctrinated into viewing birth as primarily a medical procedure. As she puts it: “After years of keeping us legs akimbo in the lithotomy position, our rulers now want us to jump down and push.” She points out that the discussion has centred on women’s fear of pain or apparent view of caesarean as a lifestyle option (women who allegedly are “too posh to push”) but hasn’t addressed whether, in fact, the truth is that the experience of labour and vaginal delivery in a UK hospital is simply deeply off-putting. Indeed, as I read The New Experience of Childbirth, I realised that my anxieties surrounding birth had very little to do with physical pain, but everything to do with being dehumanised and gobbled up by a system that would process me as an object. A victim of what Kitzinger calls “the institutional violence that is all too common in some large hospitals in which women are processed through childbirth like products on a conveyor belt”. A quick sweep of internet chatrooms for pregnant women confirmed
that I am far from alone. So, full to the brim with Kitzinger-inspired enthusiasm, I set off to my next antenatal appointment with one aim in mind. I was going to organise myself a homebirth. So long as my pregnancy remained uncomplicated, it seemed the only acceptable option for me. In her book, Kitzinger had warned that I might encounter opposition from friends, family, and care providers. I had, however, imagined that resistance would take the form of a coherent counter-argument to my plans. “Not sure”, shrugged the obstetrician when I asked how to start planning to have my baby at home. “You’ll have to ask the midwife—it will be her decision”. Her decision? Anti-autonomy alarm bells were ringing. “But I’m not scheduled to see a midwife, only obstetricians”, I said. “Oh no, you will see a midwife”, she reassured me. My shoulders dropped with relief. “You will be cared for by midwives when you come in during labour.” Shoulders returned to around ears. “Labour?” I began, “Isn’t that a bit late to start discussing where the birth might take place? And, err, won’t I be at home having the homebirth—not in hospital?” Slightly annoyed, the obstetrician came clean. “Listen, to be honest, I don’t know anything about this, because I don’t actually work here.” This news was not terribly comforting. Did she mean that she was a locum? Or was she passing by on her way to work as a bank teller when she stopped off at the hospital to try her hand at a spot of antenatal care? “Ask the person at the front desk; she should be able to help”, she finally advised, keen to put a full stop to the discussion. Data are hard to find, but Kitzinger estimates that fewer than 3% of women in the UK have their babies at home. Compare this with the Netherlands, where this figure is around 30%—and the rate of caesarean section is an exemplary 7%. In the UK, obstetricians are unused to women who want to opt out of hospital-based care and unsure how to help them; also many women perhaps
The New Experience of Childbirth Sheila Kitzinger. Orion Publishing Group, 2004. Pp 248. £10·99. ISBN 0-75286-137-9.
493
Perspectives
are not really aware that they can choose where their babies are born. Certainly my own experience has been that, although pleasant to deal with, obstetricians are committed to the type of care they want to provide. My requests to deviate from the norm are met with surprise, and then suspicion. Months on from asking for a homebirth, I have yet to negotiate the logistical and administrative maze that will lead to a meeting with a midwife who is prepared to even discuss organising one. Perhaps it would be easier to give up and join the production line. In need of a top-up of earthmotherly empowerment, I took myself along to hear Kitzinger talking at the Cheltenham Science Festival. The audience, mainly new or expectant mothers, with a sprinkling of health-care workers, were almost all devotees of her message of power, autonomy, and choice. The exception was an obstetrician who had just come off a long shift. She worried
that following Kitzinger’s advice could lead to unrealistic expectations during labour, and ultimately to disappointment and feelings of failure if medical intervention occurred. Surprisingly, Kitzinger was not in complete disagreement. “Preparing for a homebirth is like planning an outdoor picnic in the English summer”, she cried gaily. “You always have to be ready to change your plans.” Such pragmatism is reflected in her book. Kitzinger does not pit herself against medical professionals. She is aware of the benefits of modern obstetrics and that many women want the types of pain relief and reassurance that a hospital can provide. And she points out that UK health providers work under enormous pressures of limited resources and understaffing. But Kitzinger is clear. She believes the medicalised way of birth is not the only way, and not, for most women, the best way. Her views may not be palatable or
relevant for everyone. Many women prefer to relinquish autonomy and devolve decisions about care to doctors and nurses, which is, she acknowledges, a legitimate choice if it makes them feel most comfortable and safe. Likewise, women who live in countries with appalling rates of maternal and infant mortality might find the fight to demedicalise birth very puzzling. And the 30% of Dutch women who give birth at home? They must wonder what all the fuss is about. So where are pregnant women now, 40 years on from Kitzinger’s first attempt to improve our lot? Are we in control? Autonomous? Able to choose? Certainly the leaflets in my antenatal clinic are peppered with all the right buzz words, but, during my pregnancy so far, that is all they have been—just words.
W P Sharpe The Lancet, London NW1 7BY, UK
In brief Book Births and deaths
Improving Birth Outcomes: Meeting the Challenge in the Developing World Judith R Bale, Barbara J Stoll, Adetokunbo O Lucas, eds. National Academy Press, 2004. Pp 354. $49·00. ISBN 0-309-08614-0.
Difficult Consultations with Adolescents Chris Donovan, Heather Suckling. Radcliffe Medical Press, 2004. Pp 144. £21·95. ISBN 1-85775-882-X.
494
The spectre of maternal mortality still looms horribly over the developing world, where, every year, over 90% of these half million deaths occur. Despite being preventable, haemorrhage, sepsis, unsafe abortion, eclampsia, and obstructed labour still claim most of these lives. To their credit, the authors of this Institute of Medicine book recognise that without addressing adverse social, cultural, and economic environments, clinical interventions, no matter how effective, cannot be a panacea for the enormous global burden of maternal and infant morbidity and mortality. Their discussion of neonatal morbidity and mortality and fetal mortality is brilliant and up to date. But, curiously, while a whole chapter is dedicated to HIV/AIDS, malaria is sparsely mentioned. Many readers will disagree with the assertion that malaria has not been shown to be a risk factor for perinatal mortality. Overall, it is comprehensive, authoritative, and lucidly written. Although the recommendations sound broad and
familiar, priority areas for action could be selected on the basis of the space they’ve been accorded. Thus, I could speculate that HIV/AIDS will continue to attract substantial research dollars, while stillbirth and birth defects will almost certainly receive increased funding in the near future.
Hamisu M Salihu [email protected]
Book It’s good to talk
ing the extent to which adolescents should take responsibility for their health (Lancet 2004; 363: 2009), confidentiality, the temptation to slip into a parental role, and lack of continuity of care. The focus is on emotions engendered by consultations, for instance, the tendency for health professionals to blame themselves if things go wrong. Self-blame, they note, can be compounded by the pressure of feeling that a unique opportunity to exert a positive influence at a crucial time has been missed. The authors remain non-prescriptive, discussing issues without, sometimes frustratingly, presuming to offer solutions, or even advice. They express concern over increasing emphasis on measurable outcomes, which “militates against the quality which we feel will result from improving the consultation itself”. Their conviction that the consultation is at the heart of good general practice, and good adolescent health care, is infectious.
Adolescents can find it difficult to make sense of what’s happening in their rapidly changing lives. And it can be hard to help them to do so—either as parents or as doctors. Based on discussions by a multidisciplinary Balint group set up by the UK Royal College of General Practitioners’ adolescent task force, this book aims to stimulate doctors to reflect on consultations with young people. While acknowledging that not all consultations with this age group are difficult, the authors identified common themes: the value of building a trusting Lesley Morrison relationship, the role of the family, decid- [email protected]
www.thelancet.com Vol 364 August 7, 2004
Book It’s my baby and I’ll try if I want to Surely there must be more books written on childbirth than on any other healthrelated topic. Initial visits to my local bookshop, after learning of my expectant status, revealed an overwhelming range of volumes on birth and pregnancy. So overwhelming, in fact, that I usually decamped to the design section and escaped with a glossy picture-book full of the sort of smart minimalist interiors that would soon be far beyond my reach, exchanged for the joys of motherhood. But Sheila Kitzinger’s contribution to the childbirth genre stood out from the crowd. It is, like many of its ilk, full of handy practical tips. What sets it apart is the author’s absorbing social and political perspective. In 1962, Kitzinger, a social anthropologist, published The Experience of Childbirth with the aim, not of making birth easier for individual women, but of changing the political and social contexts in which they gave birth. That first edition, she admits in the introduction to the revised 2004 version, was almost apologetic in tone, asking merely that women in childbirth “could be treated as human beings, might be consulted about what was done to them, [and] could learn ahead of time what was likely to happen and how they might be treated”. The 1960s, says Kitzinger, were days when “shaving the mother’s perineum until it looked like a hard-boiled egg, administering massive doses of castor oil in an attempt to stimulate the uterus into action, insisting that the women be bed-bound and forced to lie in a supine position throughout labour and birth, as well as routine episiotomy, were common and largely unquestioned. The term ‘informed consent’ had no meaning in childbirth. Women were supposed to be ‘good patients’ and to do what they were told.” In the UK in 1962, epidurals were uncommon, caesarean rates were less than half what they are today, there were no ultrasound examinations to pinpoint a due date, and electronic fetal monitoring wasn’t available. The spread www.thelancet.com Vol 364 August 7, 2004
of these now common practices Kitzinger implicates in what she calls the “medicalisation” of birth. Yes, she says, we should be thankful for modern interventions in high-risk pregnancies. But, we should recognise that unnecessarily complicating or expediting normal births can leave women feeling traumatised and even “emotionally mutilated”. She is not alone in decrying the rise of surgical procedures in childbirth—but perhaps alone in her plea for maternal empowerment. In the UK, debate on how women give birth has focused on the increasing rate of caesarean sections—now over 20% in some areas, of which 7% are in response to a mother’s request. Earlier this year, the National Institute for Clinical Excellence (NICE) responded by publishing guidelines in which they advised that women should not be allowed caesareans on demand. But, as Germaine Greer noted in The Guardian (April 29, 2004), NICE do not seem to have considered that for decades women have been indoctrinated into viewing birth as primarily a medical procedure. As she puts it: “After years of keeping us legs akimbo in the lithotomy position, our rulers now want us to jump down and push.” She points out that the discussion has centred on women’s fear of pain or apparent view of caesarean as a lifestyle option (women who allegedly are “too posh to push”) but hasn’t addressed whether, in fact, the truth is that the experience of labour and vaginal delivery in a UK hospital is simply deeply off-putting. Indeed, as I read The New Experience of Childbirth, I realised that my anxieties surrounding birth had very little to do with physical pain, but everything to do with being dehumanised and gobbled up by a system that would process me as an object. A victim of what Kitzinger calls “the institutional violence that is all too common in some large hospitals in which women are processed through childbirth like products on a conveyor belt”. A quick sweep of internet chatrooms for pregnant women confirmed
that I am far from alone. So, full to the brim with Kitzinger-inspired enthusiasm, I set off to my next antenatal appointment with one aim in mind. I was going to organise myself a homebirth. So long as my pregnancy remained uncomplicated, it seemed the only acceptable option for me. In her book, Kitzinger had warned that I might encounter opposition from friends, family, and care providers. I had, however, imagined that resistance would take the form of a coherent counter-argument to my plans. “Not sure”, shrugged the obstetrician when I asked how to start planning to have my baby at home. “You’ll have to ask the midwife—it will be her decision”. Her decision? Anti-autonomy alarm bells were ringing. “But I’m not scheduled to see a midwife, only obstetricians”, I said. “Oh no, you will see a midwife”, she reassured me. My shoulders dropped with relief. “You will be cared for by midwives when you come in during labour.” Shoulders returned to around ears. “Labour?” I began, “Isn’t that a bit late to start discussing where the birth might take place? And, err, won’t I be at home having the homebirth—not in hospital?” Slightly annoyed, the obstetrician came clean. “Listen, to be honest, I don’t know anything about this, because I don’t actually work here.” This news was not terribly comforting. Did she mean that she was a locum? Or was she passing by on her way to work as a bank teller when she stopped off at the hospital to try her hand at a spot of antenatal care? “Ask the person at the front desk; she should be able to help”, she finally advised, keen to put a full stop to the discussion. Data are hard to find, but Kitzinger estimates that fewer than 3% of women in the UK have their babies at home. Compare this with the Netherlands, where this figure is around 30%—and the rate of caesarean section is an exemplary 7%. In the UK, obstetricians are unused to women who want to opt out of hospital-based care and unsure how to help them; also many women perhaps
The New Experience of Childbirth Sheila Kitzinger. Orion Publishing Group, 2004. Pp 248. £10·99. ISBN 0-75286-137-9.
493
Perspectives
are not really aware that they can choose where their babies are born. Certainly my own experience has been that, although pleasant to deal with, obstetricians are committed to the type of care they want to provide. My requests to deviate from the norm are met with surprise, and then suspicion. Months on from asking for a homebirth, I have yet to negotiate the logistical and administrative maze that will lead to a meeting with a midwife who is prepared to even discuss organising one. Perhaps it would be easier to give up and join the production line. In need of a top-up of earthmotherly empowerment, I took myself along to hear Kitzinger talking at the Cheltenham Science Festival. The audience, mainly new or expectant mothers, with a sprinkling of health-care workers, were almost all devotees of her message of power, autonomy, and choice. The exception was an obstetrician who had just come off a long shift. She worried
that following Kitzinger’s advice could lead to unrealistic expectations during labour, and ultimately to disappointment and feelings of failure if medical intervention occurred. Surprisingly, Kitzinger was not in complete disagreement. “Preparing for a homebirth is like planning an outdoor picnic in the English summer”, she cried gaily. “You always have to be ready to change your plans.” Such pragmatism is reflected in her book. Kitzinger does not pit herself against medical professionals. She is aware of the benefits of modern obstetrics and that many women want the types of pain relief and reassurance that a hospital can provide. And she points out that UK health providers work under enormous pressures of limited resources and understaffing. But Kitzinger is clear. She believes the medicalised way of birth is not the only way, and not, for most women, the best way. Her views may not be palatable or
relevant for everyone. Many women prefer to relinquish autonomy and devolve decisions about care to doctors and nurses, which is, she acknowledges, a legitimate choice if it makes them feel most comfortable and safe. Likewise, women who live in countries with appalling rates of maternal and infant mortality might find the fight to demedicalise birth very puzzling. And the 30% of Dutch women who give birth at home? They must wonder what all the fuss is about. So where are pregnant women now, 40 years on from Kitzinger’s first attempt to improve our lot? Are we in control? Autonomous? Able to choose? Certainly the leaflets in my antenatal clinic are peppered with all the right buzz words, but, during my pregnancy so far, that is all they have been—just words.
W P Sharpe The Lancet, London NW1 7BY, UK
In brief Book Births and deaths
Improving Birth Outcomes: Meeting the Challenge in the Developing World Judith R Bale, Barbara J Stoll, Adetokunbo O Lucas, eds. National Academy Press, 2004. Pp 354. $49·00. ISBN 0-309-08614-0.
Difficult Consultations with Adolescents Chris Donovan, Heather Suckling. Radcliffe Medical Press, 2004. Pp 144. £21·95. ISBN 1-85775-882-X.
494
The spectre of maternal mortality still looms horribly over the developing world, where, every year, over 90% of these half million deaths occur. Despite being preventable, haemorrhage, sepsis, unsafe abortion, eclampsia, and obstructed labour still claim most of these lives. To their credit, the authors of this Institute of Medicine book recognise that without addressing adverse social, cultural, and economic environments, clinical interventions, no matter how effective, cannot be a panacea for the enormous global burden of maternal and infant morbidity and mortality. Their discussion of neonatal morbidity and mortality and fetal mortality is brilliant and up to date. But, curiously, while a whole chapter is dedicated to HIV/AIDS, malaria is sparsely mentioned. Many readers will disagree with the assertion that malaria has not been shown to be a risk factor for perinatal mortality. Overall, it is comprehensive, authoritative, and lucidly written. Although the recommendations sound broad and
familiar, priority areas for action could be selected on the basis of the space they’ve been accorded. Thus, I could speculate that HIV/AIDS will continue to attract substantial research dollars, while stillbirth and birth defects will almost certainly receive increased funding in the near future.
Hamisu M Salihu [email protected]
Book It’s good to talk
ing the extent to which adolescents should take responsibility for their health (Lancet 2004; 363: 2009), confidentiality, the temptation to slip into a parental role, and lack of continuity of care. The focus is on emotions engendered by consultations, for instance, the tendency for health professionals to blame themselves if things go wrong. Self-blame, they note, can be compounded by the pressure of feeling that a unique opportunity to exert a positive influence at a crucial time has been missed. The authors remain non-prescriptive, discussing issues without, sometimes frustratingly, presuming to offer solutions, or even advice. They express concern over increasing emphasis on measurable outcomes, which “militates against the quality which we feel will result from improving the consultation itself”. Their conviction that the consultation is at the heart of good general practice, and good adolescent health care, is infectious.
Adolescents can find it difficult to make sense of what’s happening in their rapidly changing lives. And it can be hard to help them to do so—either as parents or as doctors. Based on discussions by a multidisciplinary Balint group set up by the UK Royal College of General Practitioners’ adolescent task force, this book aims to stimulate doctors to reflect on consultations with young people. While acknowledging that not all consultations with this age group are difficult, the authors identified common themes: the value of building a trusting Lesley Morrison relationship, the role of the family, decid- [email protected]
www.thelancet.com Vol 364 August 7, 2004