How do we do birth in this country?
I’ve heard so often lately about how we do the other side of the portal – death – so well. And I agree. In the pandemic restrictions, it is all the more marked and poignant, how deeply respectful and courageous and supportive we are in times of death, and even with the restrictions we still found way to honour and support the dead and the bereaved.
Respectfully, I put it out to you that we are not so good with birth.
And I’m not talking bald statistics of live outcomes. I’m talking, we don’t live in a culture that teaches us how amazing and powerful womens bodies are when it comes to birth. Birth is secret and hidden and the preserve of a medical system, not our bodies, even though, incredibly, we can conceive a foetus, grow it to a full-grown-baby, and after that baby is born, we go back into our lives to care for that child forever by ourselves, by our own knowing and learning and intuition and loving and for some reason, the bit in-between each pregnancy and each new motherhood – ie birth – we must blank out, as we hand ourselves over to a system external to us, let them take charge of everything, to pluck these fabulous babies out of our bodies and hand them back to us.
Birth in itself is treated entirely as an intervention to our bodies, instead of being something that we do. As soon as we cross the threshold of a hospital, we are carted along in a litany of subtle and not-so-subtle interventions, of people, tools and systems. Hospitals are, after all, for sick people: but most birthing people are not patients. Once in hospital, the cascade of interventions begins. You the pregnant woman are on the conveyor belt, you are on the clock. You are in a system that by its very design distrusts your body to do its own thing.
I can hear the whataboutery already. That women used to die a lot in childbirth before modern obstetrics. I have some thoughts on that – but yes, I nod in agreement. The ancestors who died giving birth. I know.
I’m not about to play down playplay risk or trauma. Childbirth is not without risk. That’s why we have midwives and obstetricians. Even the most straightforward of births need someone there; and even at that, there are still women who go it alone (freebirth).
Personally, I wanted someone – a midwife – to be there, respectfully at a remove, so that ultimately I would do it alone.
To me, birth is personal and sacred as sex.
I don’t ever expect for something serious to happen to me: my perspective is a simple idea that my body grew this baby, so it will birth this baby; not a very radical idea. But I have the safeguards in place all the same: a midwife (last time I had three!), in the next room from me, in my home, and my partner at the threshold between. If complications arise, it is my midwife who will pick up on that, with me, and deal with it, as my midwife did with my second birth described here. Or if it’s serious, I would rely on my midwife to recommend a transfer to the heavy duty services if I needed them, or even just in case. Otherwise everyone just waits, watchfully and curiously and deeply respectfully in a kind of timelessness. For everyone else besides me, the hardest part can mostly be the seemingly interminable unknown.
Most of the time, if baby is positioned well, there is unlikely to be a change in risk (and baby position is something we have weeks in advance to work with). Birth is HUGE but also it’s really not complicated: the uterus gets full and starts to get ready to expel the baby; baby wriggles down (clever baby!) and vagina enlarges like a miracle to let baby out (much like the other sex’s genitalia enlarges at certain times). (They can do it, so can we).
There’s pain and vocalising and more to it than that, and in its way that’s mostly fine too (way more about it all another day). The calmer, the quieter, the safer the mama feels in her environment, the easier this is. Trust me. Trust women!
That’s as simple as birth can be. So why do the heavy duty, worst-case-scenario people get to call all the shots? No disrespect to obstetricians, and I’m sure they’ll understand my meaning here but they are literally the last people I’d want to see at birth, because in fairness to them it is not their job to attend normal deliveries. That’s for the midwives. That’s why we need more homebirth midwives and more Midwifery-Led Units (MLUs), and we need midwives to be in charge of their own field of care, which they are not: isn’t that incredible?
The system is currently so beyond overkill, that I can hardly come up with a close enough metaphor to emphasise it for you, but how about this: I didn’t need to be inside a hospital for my births, in the same way as I don’t need to be inside a hospital when my kids do risky stuff like play on bouncy castles or trampolines* I bet few ER staff like seeing their own kids on trampolines or bouncy castles, and yet we can’t prepare for the worst-case scenario in every event that carries risk by ensuring it take place inside a hospital, just in case, can we? That would be ridiculous.
To me, having all birth take place inside a hospital is ridiculous, and what’s worse, having birth all but completely presided over by hospitals is completely wrong. We have our obstetricians for when the worst case scenarios come to fruition, which they unfortunately do, like the difficulties than can and do happen to kids on bouncy castles and trampolines. In these scenarios, obstetricians, and ER staff (if they don’t mind me drawing them into this), do a vital job.
You might ask, well, how can we tell who is going to have a difficult birth? This is why we have the National Maternity Strategy: we have protocol for evaluating normal, medium and high risk, and arrangements are made well in advance.
We are not walking landmines, waiting to spontaneously combust once labour starts.
Even in a homebirth, midwives continue to evaluate the risk. That’s their job. With my homebirths, I didn’t need to have an ambulance on standby: though that’s exactly what I did have as part of the package with a hospital-based homebirth team (the ambulance crew will even make a call to the property weeks in advance to case the joint for access); this was of no consolation to me, in fact it kind of spooked me: but it certainly was something the grandparents were glad of knowing.
And I don’t mean to be disingenuous to every complicated, traumatising birth experience women have had: I see you. My heart aches to raise the profile of your experience too and to increase the conversation around birth trauma because believe me I can hear its silent scream all around me. You may well have been terribly let down in birth and continue to be let down now. Supports and information for difficult experiences are available here
For normal risk pregnancies, we have access to private homebirth (see Private Midwives Ireland and Community Midwives Ireland) and we can have all our care through them, without ever having to go to the hospital, except perhaps for ultrasound: and even that can be arranged privately. You have to pay for this, and if you can afford it or if you have health insurance, I recommend contacting them: it’s really worth knowing about this option. Much better for a normal risk pregnancy than paying for private consultant care. Not having to get in a car and leave your house once labour starts; and having all your care at home; what’s not to love? But there are not enough homebirth midwives, so contact them early, and make sure they know demand is there. Some hospitals have homebirth units: ask them about it. More midwives please, for all.
My point, as if I can’t labour it enough, is that we don’t need hospitals to take the lead on birth at all. We need to gently, politely, firmly extricate most birth from the infrastructure of hospital hierarchy, separate it out and let the midwives take full charge of the work they do. My hands wring when I hear of midwives having to fight for every new tiny advancement and updating and facility in their own job; midwives are saints to put up with what they have to. I couldn’t do it.
Just think of it: the new maternity unit in a local hospital was designed and delivered without asking even one midwife for input.
In case we are in any doubt as to the constricted kind of agency that I know hospital midwives have in their job, consider this week’s dreadful news that one of our only MLU’s is set to close: information simply delivered like a bombshell to the people this directly effects, the pregnant women and the midwives who run it, by the people who have absolutely nothing to do with its crucial day-to-day services (see petition and for more on this below).
And we know how easily maternity units lay the law to women about who can attend the birth and when: the pandemic restrictions impacted pregnant people even more, and were swept in almost wordlessly though they are completely without evidence and fly in the face of WHO’s own guidelines. They haven’t received much outcry, because as one new mother said, this was her first baby and she didn’t know any different. The only slight reversal of restrictions in one unit which had completely banned birth partners turned out to be to honour the dads, who obviously wanted to be present at their child’s birth: but not to allow them to be of support to the woman. We are letting women down. To me, the pandemic restrictions serve to emphasise how important it is that we remove most birth from hospitals.
And when I hear of women having to come up with ways to beg and charm and choose their words carefully to get consultants to “allow” them to have any kind of say in their own births, I wither. A theme in antenatal information is often advising women how to negotiate their own care, as if they are wartime diplomats. Every time a woman tells me she managed to evade an unwished-for, and not evidence-based, intervention, I punch the air in celebration for her: but also, it kills me! I feel like telling women to just put their foot down, roll up their sleeves and simply demand the kind of care they know they need, because they are the service users after all, they are the clients at the end of the day, and this is their birth, their baby, their bodies.
But in the current set-up, women, and midwives, are up against it. Even in a homebirth unit that’s based out of a hospital, the midwives still answer to hospital bosses: you know, the worst-case scenario people, who in turn answer to faceless insurance companies and faceless board members, in a loooooong-held tradition of seeing women as incapable. I came up against it myself once my pregnancy started to go “overdue”. In the picture I share here, of me and my bump, I was almost 42 weeks. That’s wayyyy too pregnant for hospital policies, who have a (totally arbitrary) cut-off point. If I had been one more day pregnant than I was when I went into labour, my midwives would not have been allowed to attend me. We were all powerless, and even at that it was a fight to “get away with it” for that long. It’s a rigmarole that organises midwives as lower down in the hospital hierarchy than obstetricians (crazy), and birthing women as the lowest common denominator, with little or no agency in their own experiences.
This is all very wrong.
It’s not that long since we’ve had the 8th Amendment removed, which affected ALL pregnancies here, both unwanted and wanted: and had been actively employed against women having agency in their own births as recently as 2016. We have a long way to go yet before women are fully honoured and respected and properly supported in pregnancy and birth. I look down at my own body, which grew and birthed three babies, here in my own quiet corner of the universe, and wonder what on earth those external faceless hierarchies should have to do with the sacred, personal, private process of birth.
We need to provide appropriate care according to women’s choices, and that means more homebirth midwives: I know interest in homebirths increased during the pandemic lockdown! Is it any wonder? And it means creating more midwife-led units, whether co-located on hospital properties, or completely standalone, where midwives have exclusive charge of their clients (yes! clients! Not patients!) and a good relationship between them and their local obstetrician units; for when we need them. We have a lovely document called the National Maternity Strategy which provides quite well for what I’m talking about, it’s not being implemented, and it’s time that it was.
I write this on a weekend where we have had terrible news that flies breath-takingly in the face of everything I’ve just written: the purported closure of Cavan MLU: one of our only two MLUs! This closure has been announced without any reason given by decision-makers – who are of course not midwives – which just underlines my point that women are not seen as having any agency in their care, and is another damning blow to what choice women have. Please support the Irish Midwives Association and sign the petition to Save Cavan MLU here
* Since writing this piece, my trampoline metaphor well and truly battered, separately, in relation to Covid by our current Minister for Health https://www.independent.ie/irish-news/politics/health-minister-stephen-donnelly-withdraws-covid-19-risk-comparison-to-trampolining-39481062.html