Towards the Humanisation of Birth

A study of epidural analgesia and hospital birth culture

Elizabeth Newnham, Lois McKellar, Jan Pincombe

• Publisher: Palgrave Macmillan
• Year: 2018
• ISBN:
  9783319699622
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

This book examines the future of birthing practices, particularly by focusing on epidural analgesia in childbirth. It describes historical and cultural trajectories that have shaped the way in which birth is understood in Western, developed nations. In setting out the nature of epidural history, knowledge and practice, the book delves into related birth practices within the hospital setting. By critically examining these practices, which are embedded in a scientific discourse that rationalises and relies upon technology use, the authors arguethat epidural analgesia has been positioned as a safe technology in contemporary maternity culture, despite it carrying particular risks. In examining alternative research the book proposes that increasing epidural rates are not only due to greater pain relief requirements or access but are influenced by technocratic values and a fragmented maternity system. The authors outline the way in which this epidural discourse influences how information is presented to women and how this affects their choices around the use of pain relief in labour.

© The Author(s) 2018

Elizabeth Newnham, Lois McKellar and Jan PincombeTowards the Humanisation of Birthhttps://doi.org/10.1007/978-3-319-69962-2_1

Begin Abstract

1. Introduction

Elizabeth Newnham¹ , Lois McKellar² and Jan Pincombe²

(1)

School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin, Ireland

(2)

School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia

End Abstract

Background: Models of Care, Philosophies of Birth

There is an ongoing debate regarding the provision of maternity care, situated in the midwifery/medical dichotomy, which has permeated birth discussion since the advent of medical involvement in birth in the seventeenth century (Donnison 1988; Ehrenreich and English 1973; Murphy-Lawless 1998; Roome et al. 2015; Towler and Bramall 1986; Willis 1989). Since then, midwifery as a profession has become increasingly concerned with ‘guarding normal birth ’ (Crabtree 2008, p. 100; Fahy and Hastie 2008, p. 22; Kent 2000, p. 28). Broadly speaking, the midwifery model of birth is one that promotes the process of birth as a normal physiological process and a significant life event for a woman, which impacts on her spiritual, sexual, and psychological development (Fahy et al. 2008). The linguistic origin of the English word midwife, midwyf (meaning ‘with-woman’), is foundational to midwifery philosophy , evident in contemporary terminology such as ‘woman-centred’ care . This term describes the concept of the woman and midwife in partnership , one based on mutual trust and respect, and to provide care during this life event which is unique to each woman (Hunter et al. 2008; Leap 2000). Within the midwifery model, practitioners value women’s embodied knowledge as well as the importance of clinical knowledge and skills. They acknowledge the uncertainty of birth, while being equipped for emergency scenarios. This model also identifies the emotional qualities that can affect a woman’s labour, the subtleties of hormonal influences and the effect of the environment (Fahy et al. 2008; Lepori et al. 2008).

However, there are challenges to the midwifery concept of ‘normal’.¹ This includes changes in the definition of normal as increasingly, routinised, medicalised birth is being described as normal if it does not result in an instrumental or a caesarean birth.² Thus, augmented labour, the use of analgesics and oxytoxics for the third stage of labour may all be defined in some places as normal birth. Indeed, Davis-Floyd (2018) takes this a step further as she discusses the way that medicalised birth practices are normalised through a technocratic lens even as normal labour and birth processes are framed as risky and therefore ‘abnormal’ (see also Wendland 2007; Kennedy 2010). As such, midwives may be at risk of losing non-medical definitions of normal birth, especially as many midwives are socialised, through their education and employment, into hospitalised/medicalised birth (Crabtree 2008, p. 99; Wagner 2001).

Although it refers primarily to the normalcy of birth as a physiological event, the symbolism of ‘normal’ birth can also alienate women who have an instrumental or caesarean birth; it can signify that their experience was somehow abnormal and therefore different or lacking (Kennedy 2010). This has led to proposed terminology such as optimal birth—supporting women to have the optimal birth experience within their unique circumstances, and salutogenic birth—focusing on factors that optimise health and wellbeing rather than those that contribute to disease (Downe and McCourt 2008; Kennedy 2010).

Another difficulty with midwifery’s focus on the ‘normal’ is the potential failure to notice ‘the ways in which “normality” is historically, socially and culturally produced’ (Kent 2000, p. 30). Discussion on the construction of ‘normal’ is present in contemporary midwifery literature (Downe 2008; Walsh 2012), identifying a need for midwives to delineate midwifery definitions of normal, rather than relying on the obstetric view that birth can be normal ‘only in retrospect’ (Flint 1988, p. 35; Williams 1997, p. 235), whereby ‘[a] birth cannot be judged as normal until after it has concluded, when doctors are in a position to say that there has been no pathology present throughout the entire birth process’ (Murphy-Lawless 1998, p. 198). However, there is also a danger in the idealisation of a ‘sentimentalised’ view of birth and blanket condemnation of medical birthing practices which can provide timely intervention in emergency situations (Dahlen 2010). In a model of exemplary midwifery practice, Kennedy (2000) outlines the ‘art of doing “nothing” well’, where midwives achieve a seemingly effortless act of being present to the woman and supporting normal processing that actually involves an intense vigilance and attentiveness. There is also a genuine risk to women in furthering the dichotomy between the medical and midwifery professions (MacColl 2009, pp. 7–20; Wendland 2007).

The medical profession has provided life-saving procedures for both women and babies. Nevertheless, expanding the use of medical techniques to all areas of birth without critical examination is imprudent and potentially iatrogenic . As Mead (2008, p. 90) notes,

The situation we are experiencing today is primarily the result of good intentions, namely the desire to reduce maternal and perinatal mortality and morbidity. However, in the absence of sound programmes of research, these good intentions have contributed to an increase in maternal morbidity, particularly an increase in intervention in pregnancy and childbirth, and a disproportionate rise in caesarean sections, without a corresponding improvement in neonatal outcome.

The birth paradigm dichotomy was elucidated by journalist Mary-Rose MacColl (2009) in Birth Wars , the book she wrote after participating in the Queensland maternity review process. MacColl describes the turf war between ‘organics’ (those dedicated to working with the uncertainty of birth, with minimal disturbance of the process of birth—often, but not always, midwives and homebirth advocates) and ‘mechanics’ (those who intervene in the birth process, who see control as better than uncertainty—usually, but not always, obstetricians). MacColl’s observation is not new; she is describing the historical and continuing dialectic between medical and midwifery discourse. However, the contribution that MacColl brings to the debate is her recognition of the negative impact of this divide on women themselves.

Having professional power inequities in the birth environment introduces the possibility of danger from either perspective. Medical dominance limits women’s choices, mechanises an intricate psychophysiological process and may cause intervention-based harm. However, the case of midwives delaying transfer or ignoring a potential complication in a naïve kind of sentimentalised birth ideology (MacColl 2009, pp. 7–20) is also damaging (see Dahlen 2010). While the cases MacColl cites may be extreme, and in many cases midwives and medical practitioners work well together, the difficulty for women is to distinguish between issues of medical control and real issues of safety ; between the unnecessary or the life-saving intervention. Many women do not know, and may not be told, the risks associated with intervention in childbirth (MacColl 2009, p. 120). Wagner (1994, p. 6) declares that ‘conflict over birth technologies is a major battle in a contemporary health revolution’ because of the disagreement between midwifery and medical models of health. He notes that the ‘conflict is sharpest in the areas of birth and death where the social model seems to offer an important contribution to the orthodox medical model’ (Wagner 1994, p. 6). In other words, in areas where biomedicine is most contested, it pushes back the hardest. However, if, as has been suggested, the most significant factor affecting women’s decision to have an epidural in labour is not pain during labour, but her beliefs about childbirth (Heinze and Sleigh 2003), then it is all the more necessary to somehow bridge this divide. It is likely that social, medical and midwifery perspectives on childbirth influence a woman’s decision to have an epidural. In light of this, challenging and changing social perspectives on birth will effectively have an impact of women’s birth experiences.

Although we are working with the notion of medicalised childbirth, we do not intend to further dichotomise the two models. Rather, we propose the notion of a continuum, with intervention-free birth at one end and medicalised birth at the other, with women, midwives and obstetricians in the middle, maintaining a dialogue about what is best for individual women. For this to occur there would need to be a shift by the medical profession to understand birth as a normal process until proven otherwise, rather than as an inherently pathological process. The biomedical model has essentially been the dominant model in the birthing practices of most Western countries, particularly since the move to hospitals, an...

Table of contents

• Cover
• Front Matter
• 1. Introduction
• 2. The Epidural in Context
• 3. The Politics of Birth
• 4. Institutional Culture: Discipline and Resistance
• 5. A Dialectic of Risk
• 6. A Circle of Trust
• 7. Closing the Circle
• Back Matter