A Passion for Birth

by Sheila Kitzinger

  Hansard of 8 July 1975 reported an interchange between Audrey Wise and David Owen, the Secretary for Social Services. In an official enquiry initiated in December the year before Dr Owen disclosed that induction as a percentage of all hospital births in England had risen from 13.7 per cent in 1963 to 31.5 per cent in 1972. Audrey asserted: ‘Pregnant women are not a production line. Interference with this process without adequate knowledge is reprehensible.’ Other Labour and Conservative MPs also voiced their concerns. Mrs Knight said induction was as high as 50 per cent in some hospitals and added: ‘Most women believe that delivering babies is not a nine to five, Monday to Friday business.’ And Mrs Colquhoun stated: ‘Women are being asked to have their babies in office hours only.’ Dr Owen agreed: ‘There is justifiable concern at the possibility of induction taking place for administrative convenience.’

  The debate about induction started a series of enquiries into what was happening in childbirth and vigorous public debate about the risk of unnecessary obstetric interventions. This provided stimulus for further research and – very important – funding of randomised controlled trials, more Government enquiries, and the publication of papers stating policy for the future: the Winterton29 and the Changing Childbirth30 reports, and a new focus on psychological and social consequences of a birth experience that had become dehumanised for many women and completely out of their control.

  A Home Death

  I was working on a new book, Education and Counselling for Childbirth, when my Mother had a brain haemorrhage and asked me to come to her. As I walked into her room, she said, ‘You have done birth, Sheila. Now do this.’ She was in bed by a window looking out onto the garden, vivid with flowers and trees, surrounded by bird song.

  The book, which would be published in 1977 the following year, was the first one ever written for antenatal teachers. I sat by her with my reference books, knowing that she would be happiest if I got on with things while I stayed close. She opened up her spectacle case, took out her glasses, put them on, but obviously could not see. So she simply, and with a conclusive gesture, carefully folded them, slipped them in the case again, and placed it on her bedside table. That was that! It was a gesture of acceptance.

  Mother could no longer swallow, and I knew that she would not want to be kept alive artificially. So apart from making sure that she was well hydrated, and wiping out her mouth with a glycerine swab so that it was moist and comfortable, I concentrated on lapping her in luxury. I gave her bed-baths using her favourite soap with a strong carnation scent, reckoning that the sense of smell may stay strong till the end.

  The GP visited and suggested that we move her into hospital so that she could be tube-fed. I consulted Father and we both agreed, ‘No. She would want to be at home. She wouldn’t want invasive procedures.’ Later he told me that he wished he had the courage to care for his father that way when he was dying. Instead, he had him admitted to hospital and everything was done to prolong his life by every means possible. Looking back on it, he thought it was wrong, and now he felt guilty.

  Three days and nights passed. Suddenly she gave a little cry and stopped breathing. I had just gone off to the bathroom. I think she felt there was a space. It was how she wanted it to be.

  Her friend Theresa Hooley wrote:

  She died at Candlemas; her bright spirit –

  a world’s white candle – burns upon its way

  to other spheres of service and of merit,

  a living light in the Eternal Day.

  Lucy, my brother David’s American wife, had come to stay, taking over at times when I needed to sleep. She was shocked that Mother was not in hospital. She was very distressed. Afterwards she told me how utterly different it was from how it would have been in the United States: there death was removed from the home wherever possible, the family would not have been expected to deal with dying first-hand, and for her it was all too painfully intimate. People were insulated from it – specialists took over – first hospital, then the morticians. She needed time to come to terms with this and to talk about the cultural differences as she was finding this much too difficult to cope with emotionally.

  Mother’s death was a practical demonstration of something Dame Cicely Saunders, who founded the hospice movement, once said to me backstage at a conference where we were both speaking, ‘You and I are doing the same work’.

  Death is the next great transition that we all go through. We need to prepare for and reclaim it, as we are now reclaiming birth.

  CHAPTER EIGHT

  CHALLENGING THE SYSTEM

  The Place Of Birth

  In the early 70s just about everybody assumed that hospital birth must be safer than home because that was where the experts and all their latest equipment was based. I thought about ways of bringing obstetricians, paediatricians and birth activists together to explore ways in which the environment for childbirth shaped what happened and affected both the woman and her baby.

  One idea of mine was to arrange regular lunch meetings of doctors, researchers and others at the NCT in London, offering some interesting salads and cheeses, good bread and a glass of wine, at which a practitioner or researcher gave an informal paper and we discussed it in a relaxed, non-partisan atmosphere. The first of these was in 1958 and they were collaborative rather than confrontational, focusing especially on home birth. The result was a star-studded group of obstetricians, neonatologists, general practitioners, psychiatrists and psychotherapists, sociologists, midwives, breastfeeding specialists and mothers.

  John Davis, professor of Paediatrics and Child Health at Manchester, and later Cambridge, discussed how a centralised, impersonal and bureaucratic maternity service inhibited spontaneous physical function, and called for the humanisation of hospitals. Michael Moore, a family doctor, spoke about the importance of good antenatal care so that women could choose home birth if they wanted to.

  John Ashford, professor of Mathematical Statistics at Exeter, analysed regional neonatal mortality figures at home and in hospital and asked whether they were too high in hospital births – 48 per cent in consultant units and 20 per cent in GP units, according to the latest available figures from 1958. He doubted whether this made birth any safer. Iain Chalmers, an obstetrician and statistician at Cardiff University, presenting an epidemiological view, made a case for experimental studies of home and hospital birth to evaluate different birth places, and suggested that hospital birth could introduce its own risks.

  Marjorie Tew, a statistician at Nottingham University, produced evidence to support the case against hospital deliveries. David Baum, the bright, shock-headed young neonatologist at Oxford, described a way of organising neonatal intensive care so that it supported families.

  Martin Richards, Social Psychologist at Cambridge and specialist on the consequences of early separation of mothers and babies, showed how, though it was assumed that it must be better, hospital failed to provide a place of safety. Gerard Kloosterman, Professor of Obstetrics at the University of Amsterdam, and Director of its Training School for Midwives, described the Dutch system of home birth and was a powerful advocate for it.

  Luke Zander and Michael Lee-Jones, both GPs, and Chloe Fisher, a midwife in Oxford, spoke about the role of the primary health care team in pregnancy and postnatally and showed how GP obstetricians needed to work with a closely integrated group of midwives, nurses and health visitors. Chloe described the opportunities and frustrations of a community midwife. Luke drew on his work in undergraduate and postgraduate education, and Michael looked at the details of administration. Whereas in 1948 over two thirds of GPs were in single-handed practices, by 1971 over 80 per cent were in partnerships or group practices, with a range of paramedical staff attached. Lewis Mehl stressed home birth research in the United States and revealed the disadvantages in the current technological trend in childbirth.

  Joel Richman, Head of the School of Sociology at Manchester Polytechnic, and Bill Goldthorpe, Consultant Gynaecologist at Thameside Hospit
al were working together to study patients’ perceptions of illness. In our group they spoke about what can be done to make birth a positive experience for fathers and talked about the ‘cultural conspiracy’ against fatherhood, described how it started in pregnancy, and made recommendations. They pointed out that fathers present at birth are generally more satisfied and in the United States sue less frequently!

  A Freudian psychoanalyst, Peter Lomas, and former GP specialist in postnatal breakdown, focused on elemental features of the helping relationship. He pointed out that behaviour in hospitals is not always as rational and scientific as it seems and that a lot of action is heavily ritualised.

  I reported on my first small study of women’s experiences of birth at home, and described the research I had done in 1975, asking women who had attended NCT classes how they felt about home and hospital. Perhaps other women wouldn’t agree with them, but the chances were that they might put into words something which others found it difficult to say, and a random sample of 2,000 mothers all over the UK by Maureen O’Brien of the Institute for Social Studies in Medicine published later that year bore this out. Women chose home birth largely because they wanted to be protected from interventionist obstetrics, could have one-to-one midwife care from someone they knew, and thought that they could bond more smoothly with their babies in a setting where stress was reduced. At that time women in hospital were often separated from their partners during birth and from their babies afterwards. Women chose hospital birth because they thought it was safest. They were much more likely to describe distressing labours than home birth mothers.

  But it was hard to get permission to have a baby at home. I asked, ‘Is pregnancy an illness of which a woman must be “cured” by an obstetrician? Or is it part of a developmental process in which a couple grow to be parents and the family welcomes a new member?’ Decisions made about the quality of maternity care should be the concern of society as a whole. These are not exclusively, nor even primarily, medical decisions, but ethical ones. They involve a responsibility we must all share.

  We built up a heap of evidence about home birth, looking at it from many different points of view and bringing a wide range of skills. I compiled this material, adding contributions from other specialists. I approached Oxford University Press and asked them if they would be interested in publishing it as a book. The Place of Birth came out in 1978, edited jointly by John Davis and me, and sold well.

  Professionals And Campaigners Start To Work Together

  It was also in 1978 that the National Childbirth Trust approached obstetricians and heads of midwifery, proposing to acknowledge that women had a right to make informed choices about how they were treated in pregnancy and childbirth.

  Tony Smith, editor of the British Medical Journal interviewed Lady Micklethwait, the NCT President, Professor Richard Beard of St Mary’s Medical School, London, an obstetrician who listened to, and learned from, women, and Kathleen Shaw, Divisional Nursing Officer for Midwifery at the West Middlesex. The result was a joint paper, Expectations of a Pregnant Woman in Relation to Her Treatment.31

  Tony Smith asked Philippa Micklethwait what requests a woman was most likely to have. She said that she could if she wished have a person of her choice with her throughout labour, and when her baby was born could hold it as soon as possible, feed when she wished, (unless either mother or baby required urgent attention) and that professional advice would be readily available to her for as long as she needed it when she returns home.

  Richard Beard did not consider it simply a matter of explanation, and observed, ‘The obstetrician and midwife are considered the guardians of the fetus and a mother with any ideas of her own presents an obstacle to care and put its life at risk.’

  Perhaps this reads as rather low key now, but it was the start of a breakthrough in communication between campaigning organisations and medical professionals.

  Learning From Women – ‘The Good Birth Guide’

  Maternity hospitals were first set up in the eighteenth and nineteenth centuries as charity institutions for impoverished women and unmarried women giving birth in shame and degradation, who often had to give up their babies afterwards. They offered the raw material for obstetric practice and were used to demonstrate obstetrics and gynaecology to medical students.

  Hospitals remain bureaucratic and hierarchically organised institutions. They have to be managed so that the different parts of the whole structure work together efficiently. In these circumstances it is easy for a caregiver to abdicate responsibility for focusing on the needs and wishes of those they are supposed to be looking after and the main concern is to oil the wheels of the system.

  In the 1970s it was very difficult for a pregnant woman to find out anything about maternity hospitals in her area. If it was her first baby, she might not even know the questions to ask, or if she had recently moved to a different part of the country, have only the vaguest idea of what lay behind those imposing doors.

  I believed that we needed information. My idea was to learn about women’s experiences of large and small maternity units all over the country, to hear what they appreciated, what they did not like, and how they thought things could be improved, and collect these together so that pregnant women had a basis on which to find out more. I also discovered that midwives and doctors themselves often did not know what was being done in other hospitals.

  It struck me that we had books that rated restaurants and hotels, but nothing to help women choose where to give birth. My brother-in-law Hilary Rubinstein had published The Good Hotel Guide where people wrote in about hotels in which they had stayed. Unlike the Michelin guides it didn’t rely on experts, but was based on descriptions by guests. Why not find out about women’s experiences of hospitals across the UK in the same way? A woman can’t know what she wants until she knows what is possible. She may not be aware that she can give birth squatting, for example, or in a birth pool, or that there is a midwife-led unit where she can have one-to-one midwife care, or a home birth.

  So I conducted a breakthrough study of around 300 maternity hospitals in Britain, using accounts of care antenatally, during labour and postpartum from 1,500 women in response to my questions to those who attended NCT classes. I did programmes on radio and TV, and wrote articles in magazines and newspapers asking women to tell me about their experiences. I wrote to each hospital asking for statistics of induction, acceleration of labour, forceps deliveries, Caesarean sections and episiotomies, and about any changes that had taken place over the last few years. I asked about the care they aimed to provide and their policies.32

  As a general rule I only included hospitals about which I had received information from at least 24 women, except in the case of GP units, for which I used 12 accounts.

  Some hospitals sent sheets of grateful letters from satisfied parents. Though I realised they would be unlikely to send letters from those who were less satisfied, wherever possible I incorporated positive comments. Some stood out as offering women choice and giving sensitive care. These earned a star. Some even got two stars!

  My colleagues in the NCT didn’t want to be involved because they thought any criticism of hospitals would jeopardise the relations with staff that they were so carefully cultivating. One admonished me, ‘The Matron invites us to sherry parties now. Criticism would put an end to that. We believe in tact and persuasion.’

  In 1962 Professor Norman Morris, a professor of obstetrics and gynaecology, was one of the founding members of the International Society for Psychosomatic Obstetrics, and its president for nearly 20 years. He teamed up with progressive obstetricians from France, Italy and other continental European countries as well as from further afield – including my friend Murray Enkin in Canada. There was a launch conference in July that year in Paris, at which I spoke. Norman respected women and told them, ‘I can’t guarantee you the labour you want, but I’ll do my best for you with the labour you have.’ Norman was a friend of mine and I admired him.

 
I asked him to tell me the episiotomy rate at Charing Cross Hospital, where he was the professor of the Medical School. There was a long pause. No records were kept. He didn’t have a clue and was appalled about this. I said that I considered routine episiotomy our western way of female genital mutilation. Immediately he instructed that records must be kept.

  I asked some senior obstetricians and midwifery managers about their statistics. Replies varied from curt refusal to give any information at all to very generous four or five pages of A4. One consultant said that since these were matters of a technical nature he did not wish them to be the subject of public comment, so was unwilling to let me know anything. I was often told that these requests had never before been made by their patients. This happened with gentle birth, rooming-in of mother and baby, including at night, and the father being allowed to cuddle, change and bath the baby. The replies usually went on to state that if such requests should be forthcoming in future staff would be glad to make arrangements. It seemed a bit like a shop. The assistant says, ‘We don’t have any demand for that, madam,’ but if enough people ask, and go on asking politely, the management realises that there is a demand after all and sees what it can do about it.

  Women often didn’t ask for what they wanted, and felt intimidated by the organisation of a hospital, however kind and helpful individual members of staff were. Or perhaps they asked, but whoever happened to be on duty, who might be a junior or student midwife or an auxiliary, dealt with it to make least fuss.

  Human Relations

  The most important thing was the quality of personal relationships. Staff were ‘friendly’, ‘treated women like equals’, ‘as an adult’ or ‘an intelligent human being’, or on the contrary came over as ‘cold’, ‘impersonal’, ‘distant’, ‘brusque’, ‘patronising’, ‘condescending’, ‘rigid’ and ‘bossy’. Women said they were treated ‘like dim-witted or naughty children’: ‘They were so busy and preoccupied I felt I should have almost apologised for being there’, ‘I felt I should be saying, “I am so sorry I am having a baby. It won’t happen again.”’