So, how was childbirth for you? Lob that question to any average mother and she will usually step into gallows humour. “Imagine a trussed chicken passing a melon through its bottom,” is one reply I had. “Like having my genitals fed through a mincer”, was another. A female comedian once described it thus: “So many strangers saw my private bits that I may as well sign up for the centrefold of Razzle.”
But more women may be suffering lasting trauma than we have realised. As many as 1 in 20 now suffers post-traumatic stress — experiencing flashbacks and panic attacks not unlike soldiers at war, according to psychologists’ studies. Sheila Kitzinger, pictured right, a childbirth author, asserts in her new book that part of the reason is that women are increasingly seen as “products on a factory conveyor belt”. Her language gets stronger. She says that the obstetrical management of modern labours, the “harpooning” of women to a fetal monitor, the interventions to hurry the process with ventouses, drugs and Caesareans, amount to “institutionalised violence”. Her book, Birth Crisis, concludes that though birth is safer than ever, it has become disempowering and deeply traumatic.
There are horrific accounts such as the woman who had an episiotomy (a surgical incisive to prevent tearing) that cut into her rectum. Another who had a Caesarean in which the obstetrician sliced into her baby’s cheek. There is talk of bladders being punctured, of anaesthetists misplacing the epidural and penetrating the membrane surrounding the spinal cord. “The birth of my baby was horrendous,” says one mother. “I feel I was violated.” Here is another testimony: “I waited three hours to be stitched up and the doctor was groaning about being woken and what a mess it was. When I complained about the pain she said: ‘What do you expect?’ ”
If you weren’t frightened before you certainly would be now. But isn’t that exactly what the pregnant woman doesn’t need? “I believe women should hear it as it is,” says an unrepentant Kitzinger. “They should be treated as adults, not reassured constantly. There are many wonderful births but we should not forget those who are left in a state of anxiety.” She spends hours a week talking to women hiding their trauma. Some, she says, use words such as “violence” and even “rape”.
When they do pluck up the courage to tell their GPs, their distress is often misdiagnosed as postnatal depression. Kitzinger says: “If you are suffering panic attacks and flashbacks, antidepressants may make you worse. A woman might be referred to a counsellor, but even counselling hasn’t always been open to understanding that the way you are treated in childbirth, and whether you feel empowered or disempowered can affect how you feel afterwards.”
The answer, she believes, is a return to more midwife-led births, and to let pregnant women make their own choices. Unsurprisingly, she is right behind the Government’s new initiative to make home births more widely available, though she describes it as “very late, very overdue”. Kitzinger doesn’t blame the doctors. The problem lies with “the management structure which is geared to efficiency, to reducing the time spent doing any task, to completing goals and targets”. “Giving birth by the clock — it is a dangerous technology,” she says. “And the more clock-watching, the more intervention takes place.”
Many people’s response to this might be: “Yes, but fewer babies die in labour than ever before” (Kitzinger acknowledges this). Professor James Walker, spokesperson for the Royal College of Obstetricians and Gynaecologists and consultant obstetrician at St James’s University Hospital, Leeds, says that as recently as 70 years ago, 1 woman in 300 died in childbirth.“I remember days without epidurals, with traumatic births, long labours with no analgesia,” he says. “It is still like that in some of the world. Fifty years ago women here were frightened of dying in labour. This isn’t to say they we couldn’t do better today in improving the experience, improving satisfaction, but let’s not lose sight of the fact that maternity units in Britain save an average of four women a year by their interventions.”
Walker agrees that some women do suffer trauma but argues that it is not necessarily associated with highly mechanised births. A study in Nigeria in the past few years, based on the same criteria (as Western studies) found that the rate of traumatic stress at six weeks postpartum was higher than in the West. That study also found that it is the emergency aspect of intervention that is traumatic, not the intervention itself. Emergency Caesareans and forceps deliveries emerge as equally bad in causing trauma, and normal vaginal delivery and elective Caesareans equally good. “Sheila Kitzinger is important in putting forward a certain view that helps to balance other views,” he says. “There is a certain amount of truth in what she is saying.” But the figure of 1 in 20 was “higher than many would accept”.
“There is a lot of evidence that women do find childbirth traumatic. That is not necessarily down to modern medicine — it’s just that some women find childbirth quite traumatic. Most women giving birth in hospital have a positive experience.”
But there are worrying aspects to the slick management of modern labour. Kitzinger points to the risk of babies being born “before they are ready” because of artificially inducing with drugs once they are ten to 14 days overdue. “Due” dates are estimates, Kitzinger says. A study this year by the March of Dimes Foundation found that in 1992 the most common length of pregnancy in the US was 40 weeks. Ten years later it was 39 weeks. In that time there had been a 12 per cent rise in late preterm births, or babies born between 34 and 36 weeks, largely due to better monitoring. Nancy Green, the medical director of the March of Dimes, says that though this had led to a decline in deaths, there is “concern that at least some of the rise in assisted early births is not medically justified”.
Kitzinger complains that even obstetric terminology puts women’s bodies down. If the baby doesn’t engage in a favourable position, she has an “inadequate” pelvis. A cervix slow to dilate is “incompetent”. Too many unnecessary episiotomies are still performed. In the 1980s when 70 per cent of women had them (the figure has reduced considerably), Kitzinger investigated episiotomy and the suturing of the perineum. She concluded, controversially, that it was “our Western way of female genital mutilation”.
Her point is that the often impersonal nature of maternity units does not have to be this way. There is a new approach where a midwife gets to know women, then she or a partner midwife will be there during and after birth. This is in contrast to “team” midwifery where a woman can meet ten midwives.
Mervi Jokinen, the Royal College of Midwives’ practice and standards development adviser, says: “The RCM is supportive of enabling women to see pregnancy and birth as a normal life event. We believe that maximising normal birth in the context of maternal choice is safe and offers short and long-term health and social benefits. This is why the RCM, including other stakeholders, through the campaign for normal birth, is bringing the issues raised in Sheila’s book to the forefront of modern maternity care.”
Professor Walker says: “The problem is that in any system you can go too far, and the medicalisation went to the point in the 1960s and 1970s where delivery rooms were designed to look like operating theatres. First, you need to make sure you can keep the mother and baby alive, then you look at improving the experience. Now we have realised that the birthing experience is important. We may intervene more often than we should, but if we intervene less often than we should then women will die. We have to try to find the balance.”
Kitzinger ends the book with a quotation from Professor G Kloosterman, a champion of midwifery, who said: “The only thing required from bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine — nil nocere (do no harm).”
Birth Crisis, published by Routledge, £12.99
Additional reporting by Ella Stimson
