A Passion for Birth

by Sheila Kitzinger

  I found myself in conflict with feminists who saw birth in very simplistic terms of women’s right to labour without pain, and failed to analyse it in terms of institutional power and women’s relative powerlessness.

  In 1975 Spare Rib, the radical campaigning feminist magazine, tackled the subject of childbirth. It followed what amounted to a revolutionary article in the Sunday Times of 24 October, 1974, by Louise Panton and Oliver Gillie, who claimed, ‘Normal childbirth in hospital has become pathologised.’ Birth had not been debated by feminists before this, perhaps because it seemed less to do with women’s political and social rights than with female biology.23

  Spare Rib quoted from the British Medical Association’s handout for pregnant women You and Your Baby, and exposed its sexism.

  The authors went on to quote from the National Childbirth Trust’s Expectant Fathers: ‘A woman is inclined to link the big moments in her life with clothes so when she is going to have a baby her thoughts run on “little garments” … Your wife may well be attracted by a pram that either looks like her neighbour’s or is the exact opposite (!) depending on whether she is an individualist or the reverse; it will be up to you to see that the brakes work and the handle is the right height for easy pushing. Don’t forget that you may want to take your child out yourself sometimes!

  Caring for a baby may have little in common with a manufacturing process but your wife’s gratitude will repay you if you simplify feeding, bathing and cleaning routines with intelligent application of a little time and motion study.’24

  The Spare Rib article focused on pain as the main issue. It called for the development of medical technology to make birth pain free: ‘It is the right of every woman to give birth painlessly’. At that time feminists were not concerned with the power imbalance between the medical system and women giving birth and unselfconsciously lent their support to the system that I believed was abusing them. Without producing any evidence the authors asserted, ‘Undoubtedly, hospitals with all their faults are the safest places in which to give birth. For this reason we think we should press for improvements in hospitals rather than support a move to more home confinements.’ I was appalled at how my sister-feminists could fail to support woman-centred birth.

  When the British version of Our Bodies, Ourselves came out, it unfortunately described birth in American terms, as if it were always conducted by obstetricians, assisted by nurses – and ignored the role of midwives. I believed that the failure to support midwives was a big mistake and meant that, in effect, feminists were promoting an American model of childbirth in which the male obstetrician was king, to such an extent that the book talked throughout about ‘him’.

  Revolution started in 1982, with the Royal Free Protest, when 5,000 women came out on to the streets for the right to move around and give birth in any position they wished, to be active birth-givers rather than passive patients. The childbirth organisations, feminists, midwives and mothers joined hands and realised their common cause. Women could no longer be ignored. To reclaim the uterus women have to confront the might of the medical profession, the power of the international drug companies – and all our own self-doubts and fears and anxiety. I believe each one of us who dares to be assertive speaks for other women who have no voice.

  Birth is a major life transition. It is – must be – also a political issue, in terms of the power of the medical system, how it exercises control over women and whether it enables them to make decisions about their own bodies and their babies.

  Researching Induction Experiences

  Department of Health statistics published in 1976 revealed that 41 per cent of labours were induced. Many labours were also accelerated, having started spontaneously, and these were often not recorded. In fact, some hospitals set up intravenous drips for all labouring women. It meant that 70–80 per cent of women in these hospitals were attached to an oxytocin drip to stimulate the uterus. It stretches the imagination to believe that this proportion of women had something so wrong with them that they could not be allowed to labour spontaneously.

  When I had studied women’s experiences of induction in the 70s it was obvious that most women didn’t want to be induced unless it was absolutely necessary. A minority sought it for social reasons, but the vast majority had little opportunity to discuss whether they wanted it or not, and it was often done without explanation or consent. The result was that they felt assaulted. Some were lucky to have explanations because these were given to students and midwives over their supine bodies. But for most women who were induced the birth experience was marred by a sense of helplessness. There was wide variation between hospitals, too. Some induced an astonishing 75 per cent of labours, while in others inductions were below 12 per cent, even though the women were the same mix of high and low risk.

  Active Management had aimed at medico-surgical control of childbirth and women’s spontaneous activity became industrialised. Its inventors explained that it resulted in ‘a regular and orderly turnover of work in a planned manner’. It ‘rationalises work flow in delivery suites which usually are “bottle-necks”; continuous fetal monitoring for every woman, with monitors placed centrally at the nursing station so that observers can see the state of the fetus without needing to stand beside the patient’s bed, and the management of labor so that it is short … The Active Management of labor necessitates that obstetricians take over, not just a single aspect of delivery, but responsibility for the whole process of parturition. Our control of the situation must be complete.’25

  I was influenced by the research by Iain Chalmers and others who analysed 9,907 births in Cardiff between 1968 and 1972, where one obstetric team imposed Active Management and another had a more relaxed approach. There was no difference in the condition of the babies, but more urinary and genital tract infections in the actively managed mothers, and the authors concluded that active management had done nothing to improve perinatal outcomes.26

  Professor Alec Turnbull, in Oxford, commenting on the way in which maternity units competed with each other to introduce new techniques, pointed out that because the national perinatal mortality rate fell steadily over the period when these manoeuvres were increasing, a cause-and-effect relationship was assumed which engendered a false feeling of security about the value of obstetric intervention. Much of the technology now used in obstetrics was introduced, and became routine clinical practice, without adequate research and with no strong evidence of its advantages. It is difficult for a woman who is told, ‘This is done for the benefit of mother and baby’ to query the use of electronic fetal monitoring or an oxytocin drip, for example. Moreover, many hospital rites are taken for granted by members of staff and performed as a matter of course, so that to question them seems almost insulting.

  A Birth Revolution Starts

  The 1970 British Perinatal Mortality Study had revealed that with induction three times more babies suffered respiratory depression than after spontaneous labour. Of course, labour was induced in some cases because the babies were at risk. But a combination of the powerful, rapidly recurring contractions of induced labour and pain-relieving drugs to enable the mother to cope with this kind of labour may have contributed to breathing difficulties in the newborn baby. There was also an association between forceps deliveries, Caesarean sections, babies going into intensive care and rising trends of induction and acceleration.

  Yet rates of induction multiplied. Tim Chard, a professor of Reproductive Physiology, commented: ‘Spontaneous labour is now an abnormality.’27 In 1975 the latest statistics available from the Department of Health were for 1972. There was a 30 per cent rate then, compared with 26 per cent in 1970 and 18 per cent in 1958. By 1974 some hospitals were reporting rates of over 60 per cent. It could be assumed that the average was a good deal higher than 30 per cent. Kick-starting labour, along with time limits on the stages of dilatation and expulsion, came to be a routine element in the obstetric control of childbirth. Induction was just another way of managing labour.r />
  A television programme in 1975 contributed to altering the induction rate in the John Radcliffe Hospital in Oxford overnight: in the three months before the programme, the induction rate had been 61 per cent; in the three months after the programme on induction, the induction rate was 37 per cent. It demonstrates the effect of television publicity.

  Professor Alec Turnbull, who had been a strong proponent of induction and the active management of labour, lowered the rate to 9 per cent following the study in Cardiff.28

  Research on induction is fraught with difficulties. One problem is that as the rate increases more low risk mothers get included in the induction group and perinatal mortality falls in that category. Effects of induction per se are no longer being measured. This can give quite an erroneous impression that synthetic oxytocin is less hazardous than it is. Women at greatest risk are those who go into labour pre-term. Pre-term babies weighing less than 2,000 gms accounted for 60 per cent of neo-natal deaths were included in the group of labours who were not induced, giving the impression that it is dangerous to begin labour spontaneously.

  At that time there was no research into women’s personal experiences of these induced labours. Yet accounts I was receiving suggested that induction profoundly affected the experience of birth, as well as leading to a host of other interventions.

  Though I had no funding and there was no question of doing a randomised controlled trial, I decided to explore women’s experiences and in 1975 asked those who had attended National Childbirth Trust classes around the UK in the previous year to let me have copies of the birth reports they sent to their antenatal teachers. I did not ask any specific questions about induction or the use of oxytocin to control labour. 614 women whose labours had been induced responded, and 224 women for whom labour had started spontaneously. This is a self-selected sample, and they were not asked to express opinions about induction, which was an advantage to an investigation that was not directed at value judgements but experiences.

  There was often no explanation of why labour was being induced. The general pattern seemed to be that they were told they were on a list for induction, and most accepted whatever reason was given or did not expect a reason.

  Many felt at a disadvantage during an antenatal examination: ‘He didn’t give any reason. Being minus my tights and pants I didn’t feel I was in the best debating position, and meekly accepted my lot’.

  Some women had been given ‘convenience’ reasons. Several had been told by their obstetricians that they were going on holiday. One mother, who was induced with this explanation and gave birth to a three week pre-term baby, said she was ‘bullied’ into induction. Others were induced because they lived a long way from the hospital and were told that this would ‘save the journey in labour’. One obstetrician was described as going into the antenatal clinic, having ‘a look around for anyone that looks about ready’, and saying, in the women’s hearing, that she wanted to ‘clear out’ all her due and nearly due patients. A woman who was attached to a syntocin drip overheard a midwife remarking to that ‘These three girls are being induced because there is nothing doing this afternoon’. Another, three days past the expected date of delivery, said she was ‘very shaken’ when she went to the appointments desk to arrange admission for induction at the end of the week, which she was told by the consultant was hospital policy, and the clerk said, ‘We are very busy then. Come in now.’

  Acceleration of labour once it had started was also occasionally explained as necessary in terms of administrative convenience. One woman said she was told by the obstetrician, ‘There are not enough beds for you to hang about.’ For some obstetricians induction was a privilege and they were surprised when it was not accepted. A woman said that her consultant said, ‘I guarantee no more than a 10 hour labour. When do you want to have your baby?’ Another informed a woman in early pregnancy the date when her baby would be induced and anticipated a delighted response from her when twins were diagnosed by ultrasound at 16 weeks and he announced the day, at 38 weeks, when he would deliver them. Some consultants offered a ‘package deal’ of induction and epidural anaesthesia. Women who declined found themselves in an invidious position: ‘I was informed that I would be having the baby in the next 24 hours, so they might as well induce me. I reacted rather definitely and said that I’d rather they didn’t break my waters or put me on a drip. I was immediately branded as a “nervous one” who had been “reading too much and watching too many TV programmes”’.

  A woman was told at her antenatal checkup, ‘Everything is normal. I see your baby is due on Thursday. If you have not had it by then, come in that day and we will induce you.’ She asked if she could wait until she started labour before being admitted as she wanted to have a natural birth. ‘What on earth do you mean by “natural”? All birth is natural’, the obstetrician said, and told her categorically that she must come in the very next day. Some women describe their anxiety on learning that they were going to be induced: ‘The doctor said that I should come in at five and be ready for labour to be induced the following morning. I was completely shattered. I pleaded for just two more days, but he was adamant and told me to “come in tomorrow”. No reason. I asked why. He shouted, “Don’t believe everything you read in the newspapers!” I was angry.’ A woman felt threatened when induction was ruled necessary because she was four days past term. When she said she would like to avoid this the obstetrician threatened her, ‘If anything goes wrong, it will be your fault’. Another spoke of ‘strong emotional blackmail’: ‘When I was 34 weeks he told me that labour would be induced. I said that the baby wasn’t due, so why? And he said there was uncertainty over the date of my last period. I was very upset and asked more questions. He agreed that I was very fit and said it was because the placenta gets old if the baby is overdue, and if I wanted to go full-time it was at my own risk.’ Another woman was warned that there might be ‘placental insufficiency’, was tested for this, and after it revealed that ‘everything was in order’ was still induced, against her clearly expressed wishes. Others were told, ‘You have lost weight over the last two weeks’, ‘You have gained too much weight’, or ‘Your weight is static’, or even ‘The baby is above the British national average.’

  Once a woman had already been admitted in labour she became completely dependent. Many said they felt ‘taken over’ by the hospital. One woman who queried setting up a syntocin drip was told by the obstetrician that nearly everyone was on a drip anyway, as they didn’t like mothers to have a long labour. She said that her previous labour had lasted 12 hours and she felt happy about it. ‘He said that 12 hours was far too long, and that they expected labours of six to eight hours.’

  Some women learned that the cervix was not ripe at induction. They tended to have particularly distressing and long-drawn-out labours, which were sometimes ‘switched off’ at night. They were given pethidine or sleeping pills and then restarted with an oxytocin drip in the morning. This sometimes went on for several days. Nearly half had an assisted delivery or a Caesarean section. Almost half of those babies went into intensive care, too, and a further quarter had breathing or sucking difficulties.

  Some women whose labours were induced had previously had births that started spontaneously, and they compared the induced birth with natural labour.

  A minority described this labour as better than last time: ‘If I ever have a third child, I would do everything in my power to arrange for an induced birth’; ‘My husband’s always been worried about when he should take me into hospital, and it does mean no midnight car rides and wondering what to do with the other children’; I liked being completely organised’.

  But most women said the induced labours were worse: ‘There was no rest between contractions’; ‘There was only one minute between contractions’; ‘Without warning. WHAM! Contraction after contraction, with no break between’; ‘If it had been my first I would have been shocked, disturbed and frightened’.

  Women were often left for long
periods of time with their legs up in lithotomy stirrups. Some became very anxious. Some got cold. Many reported feeling faint. Being stuck in lithotomy stirrups resulted in pressure on the vena cava and postural hypotension.

  Rates of induction varied widely between different hospitals. Hospital authorities, while able to provide statistics on induction rates, were often unable to give acceleration rates, because that information was not available even to their staff.

  The issue of mounting rates of induction of labour was debated strenuously in the media and in parliament. I worked closely with Lady Micklethwait, Chairperson of the NCT and Audrey Wise, Labour MP for Coventry South West, to raise this issue publicly by getting the topic into the media and challenging the Government to investigate what obstetricians were doing.

  My report ‘Some Mothers’ Experiences of Induced Labour’ was presented to members of Parliament in 1975 and Audrey Wise arranged an inter-party meeting to discuss the findings and recommendations with representatives of the National Childbirth Trust. I said that many people thought objection to routine induction was restricted to middle-class articulate women; I referred to more research I was doing on letters written to the Sun after it had given publicity to induction early in 1975. These were clearly from women many of whom were in lower socio-economic groups, and of 103 which I had analysed, 76% were negative about induction, 22 per cent positive, and 2 per cent not clear. Furthermore, 60 per cent expressed regret that their partners had not been with them during labour or delivery, or said that they had been lonely during labour; 21 had had severe post-natal depression; a further 20 had experiences that resulted in childbirth phobia and the decision to be sterilised.