Mary-Rose MacColl’s The Birth Wars was released in 2009. It’s been on my to-read list since then and I was reminded of it whilst reviewing her most recent novel In Falling Snow – itself a story about motherhood. I think when in your own motherhood journey you read The Birth Wars might impact greatly on your response to it. I suspect if I’d read it in 2009, after two challenging but tolerable birth experiences, I’d have been able to put my academic cap on and review it like any other text; I’d have examined its readability, the quality of the research and the credibility of its hypotheses (all good, by the way). Instead, reading it now, after a third, traumatic, disempowering birth experience which may well have long term health consequences, my response was visceral. It made me angry, sad, relieved and curious. I found myself shouting at it, becoming an armchair activist for women’s rights. Protest, of course, tends to go hand in hand with war.
The ‘wars’ under the microscope here are the daily battles waged across the spectrum of maternity services between (very broadly) the ‘mechanics’ who support medically-monitored, hospital based births and the ‘organics’ who favour a woman-centred, probably midwife-led, natural birth, ideally in a birth centre or at home. As you read this, you have no doubt already begun choosing a side. It’s the sort of thing hotly contested on parenting web forums and thrown into the spotlight by tragic news stories where one side or the other fails their patients. MacColl takes us on the birthing journey via the stories of midwives, obstetricians, allied health professionals and parents, coming to the conclusion that women and babies are being put at risk by the two opposing sides’ unwillingness to cooperate. The book focuses on the Australian situation, as it follows on from MacColl’s involvement in a major review of maternity services conducted by the Queensland Government, but there are comparisons made to alternative, international models as well.
Like any good war correspondent, MacColl has been careful to represent this as a complex, heterogeneous battle; it is far too simplistic to talk in terms of knife-happy medics and hippy homebirthers. And this is not an unqualified criticism of health professionals either who, MacColl acknowledges, face untold systemic challenges and believe in patient wellbeing, whichever side of the birth wars they occupy. Rather, the critique is questioning how maternity care models might integrate these two different belief systems within one hospital system (given that the vast majority of Australian women will give birth in hospital) so that women may have more say in labour and birthing processes. Greater integration (and communication) may also save lives in cases where the beliefs of medical staff impact on how quickly treatment decisions are made, such as how long a woman labours before intervention, for example.
Ideologically, as a nation (and we’re not, of course, alone in this) we have decided that birth is a dangerous and risky process which should be monitored, and we’ve implemented laws and best practice standards that respond to this. As a woman progresses through antenatal care in the mainstream system, she is far more likely to hear about the risks (her age? her family history? the baby’s position? the blood tests?) than to be given positive feedback about the bloody amazing job her body is doing. At the same time, as consumers (if you like) within this system, many women demand this type of feedback. We are risk-averse. We like certainty. We may even sue if a birth does not go as well as hoped. We are complicit in the hospital system keeping a watchful eye on our pregnancies. Obstetricians and some hospital-based midwives support this methodology with a focus on perceived safety; whereas others (mostly, but not exclusively, midwives) suggest that pregnancy is a natural biological process – not an illness to be treated – and that, if supported and allowed to progress at an individual pace, a woman can do a good job of monitoring her own body. Obstetricians can quote the figures on why caesareans are safer in many cases, or why VBACs are not, whilst midwives have as many reports under their arms to support the opposite view. MacColl argues that the inability of these two factions to work together is leaving women bewildered and impacting on quality of care.
In gathering feedback from the trenches, MacColl generously shares her own birth stories, along with parent interviews and quotes taken from anonymous survey responses gathered for the maternity services review. Like any coffee shop conversation with a group of mothers, some stories are heart-warming, whilst some are simply alarming. There are good and bad outcomes whichever ‘side’ a mother has decided to align herself with. I baulked at the first description of a caesarean, chosen by the mother as an easier, more certain option than labouring. My own experience of caesarean deliveries has been anything but ‘easy’. Thankfully I was rewarded (?) with some horrific descriptions of the process later in the book. Not that I want to start ranting about my own birth stories – but this is the sort of text that encourages conversation. If you are a mother, you can’t read it without reliving your own experiences, without reacting.
The book opens with the story of a baby being delivered at a midwife-led natural birth centre. It was the preference of the mother –who was healthy with a low-risk pregnancy – to deliver in a less sterile, medicalised environment, without intervention or pain relief. It is the way many women hope to deliver but only a few are lucky enough to win the (literal) lottery and be accepted into a centre like this one. Unfortunately, the birth did not go as planned and as complications set in, the mother was transferred to the hospital’s birth suite where she would eventually be fighting for her life while her baby, tragically, would lose that fight. Subsequent analysis of this case showed a litany of administrative hold-ups (during transfer) and risk factors that went unnoticed or unreported by midwives determined to let this mother labour naturally for as long as possible. Obstetricians were not welcome in this birth centre, despite its close proximity to the hospital. If an obstetrician had been involved earlier, would the outcome have been any better? Another tragic story tells of a home birth emergency where doctors were abusive to the family upon their eventual arrival at hospital and refused their accompanying midwife admission to the labour ward. These very personal stories are used to demonstrate cases where the ideological positions of medical professionals are getting in the way of safe birth outcomes.
It struck me as I read, however, that there are two streams of this battle being fought. One is the tension between the mechanics and the organics; the other is about mothers and their perceptions of risk, certainty and rights. Women seem to want freedom, choice and control over their own bodies; they expect to be consulted about decisions, to be given all the facts and to be treated as individuals. Fair enough. But they also want certainty about the delivery outcome. Unfortunately, nature can be cruel and unpredictable and when things go wrong, there is a desire to blame someone (other than nature) for what happened. Consequently, much of the debate about birth practices is a debate about ‘risk’: is it ‘safer’ to have a baby through a hospital system that tests, monitors and intervenes? Statistically, yes it probably is, if we view it in terms of live births and maternal mortality, especially if compared to days of yore, but it’s not that simple.
I’ve heard myself and friends say things like ‘it doesn’t matter how you deliver as long as you have a healthy baby and a healthy mum’, but this also depends on how you define ‘healthy’. Healthy does not just mean ‘alive’. It might be measured in terms of an enormous range of indicators like a mother being psychologically ready for parenthood, physically strong enough to tend to the needs of a child and able to breastfeed if she chooses. MacColl touches on long term studies which point to risks of asthma, depression and delayed development in children born via certain delivery methods, regardless of whether they were deemed ‘healthy’ at birth.
Additionally, the book notes the slippery slope that can come about through medicalised birth practices. Changes in the accepted standards for situations like vaginal delivering of breech babies and for VBACs have meant that these are commonly discouraged in Australia (and in the UK, in my personal experience, just for point of comparison). This means that midwives are less able to build up the skills to cope with these types of births, so mothers are less and less likely to ask for them. It also means that a woman who has a first caesarean due to a (arguably) non-emergency situation (like a breech baby, for example) may well end up having all subsequent children by caesarean. This was the case for my own births, the third of which left me in intensive care after numerous complications. Had I been offered (or been brave enough to argue for) a natural breech delivery the first time around, would I have avoided a near-death experience years later? Was I given enough information? Enough choice? Was I a casualty of the birth wars? Unfortunately, I am not a medical doctor, nor a psychic. Like most new mothers, I did the best I could with the information I had about the risks involved at the time.
MacColl draws an astute analogy of ‘risk’ around her love of swimming at Byron Bay. She drives from Brisbane to Byron, where she heads out into open sea from the rocky headlands. As she swims, she is hyper aware that she’s in shark territory and (humorously) mentally plans her possible response to an attack. She gives no thought whatsoever to the long drive on a notoriously treacherous stretch of road. Around one person per year is taken by a shark in Australia, while many thousands die in car accidents. Risk is about perception; encouraged by fear of the unknown, how regularly we participate in an activity and what hits the headlines of our news services. Because mothers must trust practitioners to convey to them the risks involved in a birth, they are ultimately at the mercy of the individual belief systems/preferred methodologies of the practitioners with whom they come into contact.
MacColl’s comparisons with international examples are interesting. The Netherlands leads the charge for midwifery-led care. There, around a third of women give birth at home and epidurals are a rare exception. The UK is also cited as a country encouraging of home birth however my own experience, having my first bub there, taught me that some of their push towards home birth is motivated by chronically over-crowded hospital wards moreso than a woman-centred ethos. These countries also have tiny landmasses meaning hospital transfers, when needed, can be done fairly quickly. MacColl talks a little bit about the additional challenges for rural and remote services in Australia where vast distances between homes and hospitals can mean life or death.
MacColl’s purpose in producing this book is to draw attention to the deficits existent in Australian maternity services and ask obstetricians, midwives and other health professionals to start finding ways to work together to ensure women have greater choice about delivery methods and more streamlined ante and post-natal care. For expectant women (and their partners), it is worth being aware that these ideological wars are taking place – not just at the most obvious level between authoritative surgeons and bohemian alternative lifestylers – but at all levels of maternity care, and sometimes in very subtly disempowering ways. It is important to know that you, as a patient, have a right to say no to any tests or procedures, to request a different midwife or doctor, and to birth at home if you want to – but you do so at your own risk (whatever that may be!)
The Birth Wars is published UQP. I thank the author kindly for my copy.
I also recommend Mary-Rose MacColl’s online journal which you can find here.