Tag Archives: Birth

16 Oct

Book Review: The Birth Partner, by Penny Simkin

Penny Simkin is an author, doula, childbirth educator, and birth counsellor.

I was advised to read this book prior to my first job as a birth doula, and having now read it through, I will probably take it with me when I get the call. Aimed at dads, doulas and other birth companions, and packed with details of what happens before, during and after labour, it is not a small book, but its chapters are easily accessible and logically arranged.

The long section on normal labour is particularly useful. Each stage is broken down into a description, followed by what the mother feels, what a birth partner might feel, what a caregiver would be doing, and what a doula would be doing. There are suggestions for self-care and coping strategies appropriate to the challenges of each stage; it’s a real step-by-step manual.

There is a medical level of detail on pain relief, and this would need to be read and absorbed beforehand rather than at the time, but it remains a book to dip into during the process for an idea of what is happening and how to deal with it.

For when things don’t go to plan, the book covers instrumental and caesarean birth as well as other interventions. Helpfully value-free, Simkin sets out the things to take into consideration, and strategies for decision-making.

A comparatively short section at the end covers the baby’s first few days, and post-partum recovery; again with a what to expect/how to support the mother focus.

My one criticism of the book is its US-centric language, which makes me suspect that some of the procedures described may differ in the UK. But women’s bodies are the same all over the world, and ways of supporting a birthing mother are universal.

This book is a must-read for anyone working in birth, and for birth partners who prefer a lot of detailed information in a format they can refer to both before and during labour.

03 Jul

Book Review: Life After Birth, by Kate Figes

Kate Figes seems to make a living writing about how awful things are. According to her, birth is awful, and motherhood is awful, and if you haven’t done either of these things yet, this book is pretty certain to put you right off. Reading it during pregnancy would be an extremely bad idea.

In keeping with the genre, Figes presents her rationale, which is that motherhood is difficult and lonely and nobody tells you that beforehand. Here she is in good company; Rachel Cusk‘s slightly depressing motherhood memoir comes to mind. In fact so many authors have written about how nobody tells you how awful motherhood is, that I’m starting to suspect that it might not be true.

Despite the age (2000) of my edition, Life After Birth sets out the context with an explanation which remains topical today, explaining how birth has become so safe for women, that the focus is now almost exclusively on the wellbeing of the baby (see our review of Optimal Care in Childbirth for the bang-up-to-date, academic version of this). However, in a tone of thin sarcasm, most of the book delves into all the things it is possible for a mother to do wrong, and presents motherhood as unfeminist and slightly idiotic.

On the front cover, a quote from The Times describes Life After Birth as a manual; but it would be disingenuous to describe this as a manual, since nowhere does it contain suggestions, strategies or support for the wide range of unpleasant experiences she describes. What comes across is a series of rather peevish attempts to justify her own feelings and decisions; for example in her attempt to debunk the well-evidenced attachment theory on page 63, and her language when referring to authors with whom she clearly disagrees, namely Deborah Jackson (“Leaving a child to cry himself back to sleep apparently teaches him to be resigned to his impotence” – my emphasis – p.117) and Sheila Kitzinger, who “believes” that certain babies are more likely to have sleep problems (p.119). It’s a shame she doesn’t adopt this same circumspect tone when advocating homeopathy to aid recovery from a Caesarean birth, on page 32.

Each chapter contains enough references to give the impression of academic authority, and these hang together with a long string of generalisations and personal anecdotes, rendering the whole thing fairly meaningless. For example, pregnant women “are unlikely to have close friends who are also pregnant.” (p.143) and “Women on the other hand find themselves suddenly defenceless and dependent on a man they may not altogether trust.” (p.145).

Reading this makes me feel sad for whatever complex awfulness this woman went through in her relationships when she became a mother, but it is hard to identify with much in this book, even having been on my own rollercoaster of motherhood only a few years ago. Naomi Stadlen shows that it is possible to be honest and realistic about motherhood without painting an entirely bleak picture. As for Kate Figes, the positive aspects of motherhood finally get a whole paragraph on the last page, but I’m afraid these fears of “being labelled ‘selfish,’ ‘immature’ or ‘not fit to be a mother,'” (p.245) are far from universal, and if these are your fears, this is not the book to help resolve them.

20 May

Tropes about homebirth

I like Alice Roberts, she is interesting and clever. Some of the things she has written about birth have given me plenty to think about, and it’s good for me to think. This evening twitter drew my attention to an article in which she claims to take a “scientific approach to having a baby.” The article may be a year old, but it is relevant in the light of new guidance from NICE recommending that more women should give birth at home.

This of course has flushed all the extreme advocates of both hospital and homebirth right out of the woodwork, so here’s trope number one:

We all have to be for one thing and against the other.
Surely it’s a little more nuanced than that.

And it’s those nuances that make up the rest of the tropes.

Human birth is difficult and dangerous.
Except, not for everyone. Where does this information come from? What’s the evidence for that statement, as made by Roberts in the above article, and followed up by this statistic: “about five per 100,000 women die in childbirth and four per 1,000 babies” So, we’re not dropping like flies. And yes, in some cases that’s because modern medical intervention improves outcomes. But it’s also because in many cases, women’s bodies are apparently surprisingly good at giving birth. Up to date medical knowledge, high standards of midwifery training, and modern cleanliness are also factors, but these things are not exclusive to hospitals.

A healthy baby is the only important outcome.
Postnatal trauma is a real thing. Where the risk of a poor outcome to the baby is very small, maternal satisfaction with the birth process is actually highly relevant. The “healthy baby” trope buys into the patriarchal system where women must be compliant and put her unquestioning trust in the doctors; furthermore she should be grateful that they “deliver” her healthy live baby, no matter what they did to her, often without fully informed consent, in order to achieve that. The draft NICE guidelines acknowledge the importance of maternal satisfaction with the process; this is not the same as prioritising the process of birth over the goal of a healthy baby; it is simply stating that birth is a process. Giving birth is a huge physical and psychological event, and to reduce women to precious vessels whose only role is to produce live offspring is patronising at best.

A high proportion of women planning a homebirth end up transferring into hospital, so why bother?
Roberts quotes a 45% transfer rate for first time mothers, 12% for subsequent births. Of course, nobody goes into hospital before actually going into labour unless they’re suffering some severe condition such as pre-eclampsia. This is not an argument against labouring at home, and does not necessarily mean that those mothers who transfer in have less satisfaction. If we could take the value judgement out of home vs hospital, we could look at this as encouraging women to labour at home and only go in if necessary, rather than framing it as failure to birth at home.

If you need intervention, it’s instantly available in hospital.
Not true. You may have to wait a couple of hours for an anaesthetist to be available, or for the previous woman to move out of theatre. So plenty of time for that transfer.

Well duh, of course there’s a lower risk of intervention at home, because you can only carry out intervention in hospital.
This still isn’t an argument against homebirth, and it is one of the main reasons women might choose to birth at home. Yes, obviously, the tools are not available. If an intervention is necessary, then a transfer is going to be needed. But an intervention is less likely to be necessary where women give birth in a calm home-like environment. Statistics demonstrating a lower incidence of intervention in planned homebirths include those who transferred and then experienced intervention, because that happens.

Homebirth advocates present the research findings with the wrong priorities because they have An Agenda.
And by “wrong priorities,” we mean priorities that differ from hospital birth advocates. From Roberts’ article:

look up “home birth” on the National Childbirth Trust (NCT) website, […] the findings are laid out in exactly the opposite order to that in the original research paper and the RCOG’s statement: women having a home birth are more likely to have a “normal birth” without intervention; home births are safe for women having a second or subsequent baby; lastly: home birth increases the risk to the baby for first-time mums. The main outcome investigated by the study is the last to be mentioned.

What NCT are doing here is normalising straightforward birth. It’s all semantics, innit? If you do follow Roberts’ link to NCT, you will see that the risks are clearly mentioned. In fact, it took me several attempts to replicate Roberts’ results by searching NCT’s website; the first few articles I came up with were clearer, more accessible, and included links to relevant information from The Birthplace Study and the NHS.
I would argue that hospital birth advocates also have An Agenda.

Homebirth is unethical and dangerous
In January The Independent headline claimed that homebirth was “as dangerous as ‘driving without putting your child’s seatbelt on’.”
The always excellent NHS Choices website responded to this with the conclusion:

A case could be made that rather than discouraging home births, we should instead be improving the levels of support to women who choose to home birth and so reduce the risk of complications.

Perhaps that’s where we should leave it. This isn’t about our different choices making us good or bad people, or our different experiences making us successful or failures. It’s about informing and supporting families, even those whose priorities aren’t the same as yours.

Views expressed here are my own, and do not represent the views of NCT.

04 Apr

The science of birthplace

My work now includes talking to parents-to-be about where they choose to give birth, and so this subject is of increasing interest, particularly since the skeptics I hang out with suck their teeth a little when we get on to the subject. To be quite frank, I suck my own teeth. It’s very hard to weigh up the pros and cons of a subject in which even the most scientifically minded get rather emotionally invested. I will conclude, perhaps, that we all give different weight to different outcomes, and that’s parenting for you, which means that I am as usual chasing my tail and asking “why can’t we all just get along?”

This is a complex and emotive topic, and few people seem able to write about it without their passion leaking through. So let’s state upfront that my passion is to support parents to make their own informed decisions, decisions they will have to live through, and live with, about an event that is in many cases earthshattering in the experience itself, and in its ramifications. Giving birth is a very big deal. Yes, it’s a normal physiological process and women’s bodies are well-adapted to perform it; but let’s bear in mind two very important provisos here:

  • It’s 2014. We give birth in very different conditions than those to which our bodies are adapted; and
  • Birth is safer in England than it has ever been, and this is down to a range of factors including modern techonology and hygiene.

But giving birth is not simply a physiological process. It is a profound life event affecting our bodies and our view of our bodies, affecting our families and other relationships, affecting us in social, financial and psychological ways that cannot possibly be accounted for in a simple birthplace study. Therefore birthplace studies tend to base their conclusions on measurable outcomes, usually neonatal death, injury, or oxygen deprivation to the baby. Some studies also consider some physical outcomes for the mothers, such as whether she experienced medical interventions or whether she went on to breastfeed. Very few studies consider birth trauma as an outcome.

Which? Birth Choice has a very clear set of tables comparing outcomes for hospital obstetric units, midwife-led birth centres, and homebirth. This is based on the 2011 study Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study BMJ 2011;343:d7400. If you click through to the tables in the report you find risks for ALL births reported as 4.3 adverse outcomes per 1000 births. This is then broken down to show the differences for first births (5.3/1000) compared with second or subsequent births (3.1/1000), and broken down still further to show risks according to place of birth. As has been reported, the risk of an adverse outcome at a planned homebirth for a first baby shoots up to 9.3/1000. As has not been reported, the risk of an adverse outcome at a planned homebirth for second or subsequent baby drops to 2.3/1000. The study concludes that “The incidence of adverse perinatal outcomes was low in all settings.” The headlines, meanwhile, focus on the relative risk: 9.3/1000 is more than twice as high as 4.3/1000, therefore homebirth is twice as dangerous as hospital birth.

Parents need to be given these numbers along with a little bit of information about how to make sense of them, which is where the Which? page is useful. But they also need the opportunity to consider what other outcomes are important to them, given that the absolute risk of adverse outcomes is so low. The Which? page gives information about the likelihood of intervention in various settings, and parents may want to consider this as a factor in their decision making.

Meanwhile, all this pitting of hospital birth against homebirth results in Birth Centres being overlooked. Birth Centres are intended to offer a home-like setting, with midwife-led care. They are often located within hospital settings, so the obstetric facilities are on hand. Our birthplace study referenced above shows that the risk of adverse outcomes is comparable to an obstetric unit, while the likelihood of intervention such as instrumental birth or caesarean birth is lower. A 2012 Cochrane Review of Home-like versus conventional institutional settings for birth by Hodnett et al supports this:

Home-like institutional birth settings reduce the chances of medical interventions and increase maternal satisfaction, but it is important to watch for signs of complications.

One thing that is important to beware of is using data originating in the US, since the model of midwifery care in the US is very different to the UK. This perhaps is a subject for a later post, and probably not by me.

Finally I want to come back to the definition of an adverse outcome, where once again women are reduced to the precious vessels, solely charged with but not entirely trusted to bring this baby to the world unharmed and perfect in every way. What about outcomes for mothers? I have heard Sheila Kitzinger speak on the subject and read some harrowing accounts of childbirth:

one reason why many women have low self-esteem and cannot enjoy their babies is that care in childbirth often denies them honest information, the possibility of choice, and simple human respect…..

Studies from 2003 and 2004 found that up to 6% of women show full PTSD symptoms following an experience of birth where they felt scared, helpless and vulnerable. While all the focus is on outcomes for the baby, women’s lived experience is belittled and ignored as a decision-making factor. This is why parents need to be given all the information, and not frightened into seeing hospital birth as the only safe choice for their babies, regardless of how it will feel for them; and the information given needs to include more than just the risk of adverse outcomes for the baby.

14 Jan

Firstborn by Katherine Gallagher

For years I dreamt you
my lost child, a face unpromised.
I gather you in, gambling,
making maps over your head.
You were the beginning of wish
and when I finally held you,
like some mother-cat I looked you over –
my dozy lone-traveller set down at last.

So much for maps,
I tried to etch you in, little stranger
wrapped like a Japanese doll.

You opened your fish-eyes and stared,
slowly bunching your fists bracing on air.

With kind permission from Katherine Gallagher

20 Jun

Book Review: The Hormone of Closeness, by Kerstin Uvnas Moberg

The Hormone of Closeness: The role of oxytocin in relationships, is the second book I’ve read by Kerstin Uvnas Moberg on the subject of oxytocin, the hormone involved in childbirth, bonding and so much more.

Moberg posits an explanation of attachment theory wherein oxytocin underpins the child’s sense of security through enhanced wellbeing, increased calm, and a sense of satisfaction. She terms the innate and evolutionarily necessary need for closeness and contact with others as “skin hunger,” to equate it with hunger for food. This casts touch and its effects in a useful new light, showing how breastfeeding is about so much more than the transfer of milk, for the mother and the baby.

While much of the evidence in the book is drawn from lab studies on rats, her arguments are logical and compelling. Lay readers might skip the scientific stuff about what goes on in the brain, and read instead the fascinating description of the mother-baby relationship in the first place, which is then drawn into the wider context of our social interactions, stress levels, and the way we live.

Looking forward to the implications of the development of synthetic oxytocin, Moberg acknowledges that artificially increasing oxytocin levels, thereby increasing the tendency to trust, might not always be a good thing, particularly in a setting where we would not naturally be trusting. Evidently it would be better for the individual, and for society as a whole, to find natural ways to increase the world’s oxytocin levels. To illustrate this, she looks at the doula phenomenon, where a trusted woman present at birth can have a positive outcome, by allowing the birthing mother to tune into her body and allow levels of oxytocin to rise, facilitating labour and bonding with the new baby.

She finishes by looking at the possible consequences of our increasingly separate lives, and with a call on behalf of future generations to consider how to bring back social closeness, that “all of us on earth could live in peace and harmony with one another.” [p157]. This is an enlightening and affirming read.

***

To order The Hormone of Closeness with a 25% discount, just follow the link and use the discount code KH25 at the checkout.

[Disclosure: review copy provided by publisher]

15 Jan

Book Review: Bumpology, by Linda Geddes

Bumpology is an attractive and accessible book with a very clear and logical layout, which compensates for the lack of an index. It is as easy to dip into as it is to read from cover to cover; I know because I did both.

This is a marvellously comprehensive collection of research evidence and occasional comment upon the lack of research evidence, for all the advice and received wisdom relating to pregnancy, birth and early parenthood. As Geddes says, the science is out there, but it often takes some digging to find it.

Geddes looks at the big issues such as place of birth, breastfeeding, and all those things you’re told you can’t eat during pregnancy; as well as bringing in some colourful sections on how the growing baby develops in the womb, what senses function from birth, and the role of newborn reflexes. This in itself is a useful part of learning to empathise with the baby, and might influence parenting choices.

I am used to reading far more dogmatic books (from all over the birth and parenting spectrum), so this measured tone is very refreshing. Research in this area on the whole appears to be very thin, often studies are very small or based on the behaviour of lab animals. The book does not offer many definitive answers, but its general message is not to take advice for granted, since much of what we are told from the moment we even start to think about having a baby has no basis in fact. This very important point was made by Octavia Wiseman in a recent Midirs article (July/August 2012:p22), pointing out that much health advice is risk-averse, undermining parental choice, and that “explaining to women the limitation of our evidence base is the first step to take when asking them to make ‘informed’ choices.”

It is lovely that the text is scattered with anecdotes about the author’s personal experience, but for the most part this book is about facts not feelings. It largely ignores ‘soft’ aspects such as how parents feel about risk, and how mothers experience birth and early motherhood. Statistical comparisons of different aspects of birth look at outcomes and define those in terms of health of the baby and mother, taking little account of how women feel during and after the experience. For example lying down or being mobile during labour may make no difference to the outcome in statistical terms, but different women may experience these scenarios as more or less positive. Lying down in a room full of medical staff may feel disempowering; a woman being made to walk around may feel bullied. Working with parents both antenatally and postnatally, I know that scientific evidence may not always be the most important factor when making decisions. A good example of this would be the decision to share a bed with your baby: whether, according to various studies, this increases the risk of cot death; or whether it increases your child’s self-esteem, are less likely to influence the decision to bedshare than the fact that it might just be easier not to have to get up in the night. This does not, of course, detract from the fact that parents can and should be made aware of the evidence in order to make an informed decision; and to be fair, Geddes does not set out to explore the qualitative aspects of parenthood, but to present the facts and figures, and bust the myths: a very worthwhile mission.

I would recommend Bumpology to anyone expecting a baby, but I think it is also essential reading for anyone working with parents, antenatally or postnatally. It is so important for us to get our facts right, to counter the myths and enable parents to be confident in their decision making. Very few of the books I’ve seen are so robustly evidence-based, and an awful lot of people working with parents will repeat advice without giving any critical thought either to the evidence behind it, or the effect it might have in an individual situation.

Bumpology Blog
Sense About Science
Linda Geddes on Radio 4’s Today Programme with Belinda Phipps, CEO of NCT

07 Nov

Book Review: Confident Birth, by Susanna Heli

Confident Birth is an attractive book with a well-argued premise that empowering women with confidence in their own bodies and a good understanding of what happens during birth is a deeply positive move. Heli asks why we should be so afraid of childbirth, when maternity care has never been better; perhaps a quick dip into Birth & Sex would provide some insight: Kitzinger points out that we may have medically safer outcomes, but the psychological experience of contemporary childbirth may be something to fear. Heli focuses on the modern expectation of painless instant gratification in a consumer society, and explores the role of pain in labour, to help women develop tools and strategies for listening to their bodies and making positive decisions.

The first section of the book explores our attitude to pain and childbirth, with some exercises for the pregnant women, and short birth stories to illustrate her points. The second section offers four tools for coping with pain in labour, and the third section offers useful guidelines for the support person.

Confident Birth is aimed at the pregnant woman who wishes to prepare herself for a positive experience of birth. It uses language of empowerment and trust in the body and the instincts. It skirts the mystical, and while occasionally idealising labour (for example, describing it as “something to deepen our emotional intelligence” p.19), Heli does not demonise intervention. The gentle, encouraging tone makes it highly suitable for expectant parents; there is a good clear description of what labour is actually like, including physical and emotional sensations, and what the woman might need at different stages. It would also make an excellent handbook for a birth doula.

*****

To order Confident Birth with a 25% discount, just follow the link and use the discount code KH25 at the checkout.

02 Nov

I’ll have what she’s having: A review of Birth & Sex by Sheila Kitzinger

I bought Birth & Sex after hearing Sheila Kitzinger speak with an energetic passion that belies her frailty, a few weeks ago; the talk was part revision of the history of obstetrics, and many parts eye-opener.

A few days later I read on a skeptical website a description of orgasmic birth as “the ultimate first world problem.” [Deliberately unattributed]: making women feel guilty for not having an orgasm during labour. It’s that familiar argument that informing people about how things could be is mistaken for setting impossible aspirational targets for all women. Throughout the book, Kitzinger dips into history, revealing how birth has become depersonalised, the mother and her needs sidelined, and the only goal a healthy baby.

After a fascinating chapter on genital anatomy and an exploration of sex in pregnancy, she goes on to explain the processes that impact on a woman’s experience of labour. She is not telling women that they should have an orgasm during birth, any more than that they should have an orgasm every time they have sex; but describing conditions which it is often in the woman’s power to create, that allow her to behave spontaneously. In fact the comparison with having sex is instructive, since goal-oriented sex is likely to be less satisfying than loving, fun, comfortable, spontaneous and uninhibited sex, all of which are applicable to birth.

Kitzinger shows how other cultures celebrate birth movements, for example in north african bellydancing; but how the gradual introduction of a bed into the birth environment forces women to accept a more passive role, and has gradually led to a production line approach, “without wasting doctors’ time, and free of any female emotions that might complicate the process.” [p.69]

She goes on to explore the use of language around birth, rooting this right back in the usurpation of female mother goddesses by a male creator, taking the power of fertility away from women. In modern terms, the medical language used to describe birth using the terminology of risk and words like “delivery” put the power in the hands of the doctors. The language used by women following a traumatic birth is significantly similar to that used by rape victims; I have heard examples of this myself and have to ask if empowering and informing women can really be a bad thing.

With a slightly disappointingly small section on breastfeeding, the book ends with a discussion of sex after childbirth and how this might be impacted by a traumatic, violating experience or a positive birth that can enhance the way a woman feels about her own body. Kitzinger also considers the impact of the birth on a woman’s partner and his or her feelings about sex; along with the impact of the transition to parenthood. I love her description of the first year after birth as “chaos and glory” for the couple [p.148].

Birth & Sex does not seek to demonise intervention, but asks for perspective in its use, and reminds us that birth is a complex psychosexual experience with the potential to be life-enhancing. In the prevailing culture, how much choice do women really have? This book takes on one small segment of a society in which women’s bodies are still objectified and their minds still belittled, to an astonishing extent. To deny women this information is to deny them choice and consent in the way they live and labour.

*****

To order Birth & Sex with a 25% discount, just follow the link and use the discount code KH25 at the checkout.