During the 80s I visited midwives in many different countries. We challenged the establishment across huge swathes of the world which had been heavily influenced either by Soviet or North American obstetrics.
By the end of the 80s midwifery had been reborn in Canada and midwives were winning the long struggle to give woman-centred care. In Western Europe, new EC directives ensured that midwives, rather than being handmaidens to obstetricians, were able to take responsibility for continuous care of the woman through pregnancy, birth and postpartum.
This renaissance grew from childbirth organisations, and as my books on birth were published in 23 countries I was part of that forward thrust. In Ontario, British Columbia and Alberta, as in New Zealand, mothers and midwives together successfully challenged the power of the medical system. Through the 80s the childbirth movement exercised growing influence in countries such as Germany, and seedling movements in Poland and Hungary for instance, to help free midwives from the constraints of authoritarian medical systems. On the other hand, this was all very patchy. While small groups of midwives in Northern Italy, for example, got together to improve care and provide genuine choices – home birth is a case in point – that was lacking for most women in Italy, and the majority of midwives there were trapped in a system they dared not try to change. It was much the same for midwives in Spain.
Lecturing in the United States and Eastern Europe, I have often found that assumptions are made about normal and ‘alternative’ birth that contrast dramatically with how childbirth had progressed in Britain today. In the United States, for example, midwifery as a profession has virtually died and been replaced by assistants to obstetricians who have to sign the case notes after delivery.
In the UK obstetricians know that they rely entirely on the skills of midwives to retain some continuity of care, and in something like 70 per cent of births to catch the baby. Our whole maternity system would collapse if midwifery became further downgraded. The danger here is that birth is increasingly treated as crisis management based on risk assessment, and more and more women are classified as high risk and managed by an obstetric team. Fragmentation of care means that a woman may never see the same person twice. Notes are often not passed on.
In Italy, Russia and other Eastern European countries – where there is an autocratic and often totalitarian system of medical control, birth is treated essentially as emptying of the uterus and the model for it is abortion. In fact, in many of these countries the dominant method of birth control is still abortion. It poses a problem for these countries as they entered the European Community which has directives about midwifery training, women getting information they need to make decisions, and midwives’ right to move between European countries.48 This means that midwives should have the same levels of skills, and confidence to work with autonomy wherever they are. The Czech Republic got rid of midwives and replaced them with ‘women’s nurses’. Since 1960 the midwife has been called a nurse, and could only care for a woman after she had been referred by a doctor. Home births were effectively outlawed. And in December 2014 the European Court of Human Rights found that Czech legislation prohibiting midwives from attending home births does not interfere with women’s rights to private life!49
There are far too many obstetricians. Birth in which a woman can do her own thing has gone underground. In Hungary home births were made illegal unless attended by both an obstetrician and a paediatrician. But not all home births, only planned home births, though it is no surprise that research shows that unplanned home births are far riskier.
The UK was ahead of most other European countries in rediscovering midwifery, largely because of our campaigns as childbirth educators and the partnership between midwives and mothers. At the end of the 80s and beginning of the 90s I worked with colleagues in the childbirth movement to lobby Parliament and get good coverage in the media. We provided evidence to the Health Committee of the House of Commons. In 1992 its report was published which stated: ‘There is a strong desire among women for … continuity of care and carer throughout pregnancy and childbirth and the majority of them regard midwives as a group best placed and equipped to provide this.’50 It recommended the development of midwifery-managed units, in and outside hospitals, and best practice models of team midwifery care, and concluded that midwives should have a right to develop and audit their own professional standards. In fact, team midwifery failed to give women-centred care. It talked about ‘grossly obese teams’ and recommended case-load midwifery and one-to-one care.
The romantic notion of the midwife in touch with earth’s secret lore, gathering herbs at full moon and dispensing them to cure every ill – the way midwives have often been represented in California – gave way to a realistic perception of professionals who audit their own work, assess the quality of research relating to all aspects of care, and are responsible to increasingly well-informed and critical consumers.
In Britain the Midwives Information and Resource Service – I was on its Editorial Committee – made research much more accessible to midwives and students.
An important development was research by midwives themselves. In the UK and Scandinavian countries midwives were critically evaluating obstetric and midwifery interventions of all kinds, and demystifying ritual hospital practices. This had a direct effect on care. Enemas and shaves were discarded. For years pushing had been a strenuous exercise entailing commanded, prolonged breath-holding and heaving, enthusiastically encouraged as if by football team supporters.
By the end of the 90s a woman could have her partner with her, or anyone else with whom she wanted to share the birth experience, including family members, women friends, and her other children. This wasn’t the case for Northern Ireland, which was still heavily obstetric-paternalistic, and protest was brewing there.
As the 2000s dawned, there were lower rates of induction for ‘post-maturity’ – because a woman was a week over her dates, for instance – episiotomy rates plummeted, and also as a direct consequence of midwife research, a more relaxed approach to pushing and the length of the second stage.
Internationally, outreach work was firmly in the hands of midwives, if only because most obstetricians were not eager to work with the poor and did not fancy being stuck in unsavoury urban areas or in rural outposts.
Aboriginal midwives were beginning to provide care in their own communities. In New Zealand I had already explored with Maori women their concern to rediscover traditional childbirth practices. This was increasingly accepted by Pakeha midwives, who discovered traditions of good midwife care that had been lost in modern hospitals.
In the 1990s midwives in the West started to develop a clearer view of where their strengths lay. They broke out of isolation, began to link with midwives in other countries, and realised that they faced common problems. Till then a midwife often had little idea of the power politics in the health care system in her country, and even less in other countries. A new direct entry education began to develop alongside instruction which saw midwifery as either a top-up to nurse training, an extension of caring for sick people, and a way of producing compliant workers who prepared patients for the obstetrician, kept them quiet, and cleared up afterwards.
Yet some midwives felt cheated by change. They accepted, like good little girls, their subordinate role in a hierarchical hospital system headed by obstetricians and gynaecologists. When Italian midwives were told that they must no longer attend home births and their role as community midwives was to be restricted to antenatal and mother and baby clinics, they did not resist. When obstetricians produced protocols for care, midwives’ only way of protest was to falsify the records so that, for example, a woman who had been happily but slowly progressing in the second stage for three hours or more was recorded on the labour chart as having a much shorter expulsive stage. It was the same for Spain.
In the Middle Ages midwives fled to Holland because it was the only country to offer them a sanctuary. Everywhere else the midwife was at risk
of being persecuted, even put to death, as a witch. Midwifery in Holland still retained its autonomy vis-à-vis the medical system more than in any other country. A third of births were at home, and midwives provided total care for normal pregnancies and births.
In Australia the first midwife-attended home births took place for which mothers did not have to pay. Pilot programmes, with Government funding, were initiated. But there was still a long way to go. In many countries the home birth midwife found herself outside the official system. In most states of the US, the only way she could work was as an underground midwife, risking suspension, litigation and imprisonment. For these midwives it is rather like Christians in the catacombs. There is a great story to be told of midwife heroines all over the world who have been marginalised by the medical system, outlawed and criminalised, for their commitment to childbearing women and families. In medieval Europe they were burned at the stake as witches. In California they were put on trial for practising medicine without a license.
A vital element in a midwife’s work is to protect women from potentially harmful interventions, and to ensure, as far as possible, that birth is not treated as an accident waiting to happen or turned into a medical crisis.
Women suffer post-traumatic stress disorder when they have been powerless and denied choice. They endure births in which technology dictates everything that occurs, and where authority is vested in those who design the protocols.
In helping to bring a human being into the world midwives stand at the crossing-point of generations, and share a journey that is a major life transition. I believe that midwives are the guardians of physiological birth, and an important element in my work must be contributing to midwife education.
Human Rights And Midwifery
Dr Agnes Gereb, a qualified obstetrician, had her third child at home just before she held the first conference in Hungary in the late 1990s.
In 2003 a group of us attended and spoke at the second home birth conference she organised. This included Dr Marsden Wagner, previously Director of Maternal and Child Health for the European Region of the World Health Organisation (WHO). After the conference we met with Hungarian Ministry of Health officials and senior obstetricians, who did not accept the evidence that home birth was a safe option for healthy women with an uncomplicated pregnancy.
In 2007 Agnes was struck off the medical register for attending home births.
As an EU member, Hungary accepts that women have the right to give birth at home. But no midwives had been given licences to practice outside hospital, so this right was effectively undermined.
Agnes had been struck off the obstetric list for helping at home births, and then studied to become a midwife in Semmelweis University, was certified in 2005, and gained a BSc in Midwifery in 2010. In October of that year she was detained in a high security prison in Budapest charged with ‘negligent malpractice’ and assisting at home births without a licence. She was arrested and put in chains because she called an ambulance when a woman in the discussion group at her birth centre went into preterm precipitous labour and Agnes caught the baby. She had advised this woman not to have a home birth. Both mother and baby were doing well.
In Hungary, while all birth outcomes in hospital were subject simply to an internal investigation, if it is considered necessary, out-of-hospital incidents are automatically treated as crimes. Agnes was remanded in custody for 30 days, her appeals were rejected, and though she had not been found guilty of any of the charges against her, her imprisonment was extended on 23 November 2010 by another 60 days. She was locked in a 6 m x 6 m cell with three other women for 23 hours out of the 24, forbidden to see her young children, strip-searched, and her body orifices probed before and after every visit in full view of visitors – including those from human rights MPs and her own lawyer.
The Hungarian Independent Midwives, a very small group, issued a statement of support, but midwives internationally were slow to follow since she was not registered, and the rumour went round that she was an obstetrician masquerading as a midwife. I explained to these organisations that she could not register as a midwife in Hungary because she did home births. She worked with 14 independent midwives who were also unable to register. I briefed the Royal College of Midwives in the UK, who later issued a statement calling for her release.
Wendy Savage and I produced a petition calling on everyone concerned about this to contact their Euro MP to put pressure on the Hungarian parliament to act so that women had the right to give birth at home with a trained midwife.
Petition on Behalf of Dr Agnes Gereb
We, the undersigned, object:
To the failure of successive Hungarian governments to regulate out-of-hospital birth in Hungary for the last 22 years, and thus failing to provide a legal framework to support and ensure Hungarian women’s constitutional right to choose the place and manner of their birth.
To the arrest of Dr Agnes Gereb.
To the criminalisation of out-of-hospital midwifery services in Hungary due to a lack of government regulation.
To the treatment of Dr Gereb in prison.
We respectfully demand:
That the Hungarian authorities release Dr Gereb immediately.
That the Hungarian authorities suspend all current criminal cases against midwives until out-of-hospital birth regulation come into effect.
That the Hungarian authorities involve international and/or Hungarian experts with experience in the field of out-of-hospital birth to participate in the drafting of the regulations concerning planned, out-of-hospital birth in Hungary.
We maintain that incorporating the option of planned out-of-hospital birth into the range of options offered by the Hungarian health care system will also improve the quality of hospital births in Hungary, for the greater safety and satisfaction of mothers and babies.
Dr Gereb’s arrest and its implications for the institution of out-of-hospital birth in Hungary directly affect the right of Hungarian women to choose their place of birth. Hungarian women now need the Government’s assistance to be able to take advantage of this right accorded to them under Hungarian and European law. We urge the Hungarian government to act swiftly in addressing this human rights issue for the women of Hungary.
We feel strongly that the conditions of imprisonment for Dr Agnes Gereb are both excessive and unnecessary. We wish to express our grave concern over these conditions and the treatment of Dr Gereb in prison, including the denial of the visitation rights of Parliamentary representatives. We urge the Hungarian government to act swiftly to bring to an end this unlawful and undignified treatment, in the full knowledge that the international community is watching Hungary’s handling of Dr Agenes Gereb’s case.
I took on the task of keeping the Royal College of Midwives fully informed and linking them up with midwifery organisations in other countries who were unaware that Agnes was a qualified midwife. So this was an important issue concerning midwifery rights in the EU.
There is a historical background to this midwifery crisis. In 1944 the Nazis had deported and killed 540,000 Hungarian Jews. Many midwives were Jewish. As a result there was an acute midwife shortage. In 1951 the Hungarian government passed a law that all women must give birth in hospital and be delivered by a doctor. Hungarian mother Anna Ternovszky, pregnant with her second child in 2010, took her country to the European Court of Human Rights to defend the right to home birth. The court ruled that women have the right to decide where they give birth and that meaningful choice in childbirth is a human rights issue.51 More recently, though, in what Birthrights describes as ‘a blow to women’s reproductive rights in Europe’ the Court found that Czech legislation prohibiting midwives’ attendance at home births did not interfere with women’s right to private life52 – meaning that the governments’ obligations to pregnant women are now unclear. Ms Dubská is appealing the decision.
Agnes had always been a rebel. In 1977 she was charged with smuggling fathers into a hospital labour ward. Her punishment
was to be banned from practice for six months. Some years later the head of that clinic declared proudly that his institute was the first to allow fathers into the labour room.53
Agnes had come to the first International Home Birth Conference we held in London in 1986. After that she set up the Alternatal Foundation and organised an International Home Birth Conference in Szeged in 1992. Dr Beverley Chalmers, WHO Consultant, and I were joint patrons, and speakers included Wendy Savage, Marsden Wagner, Michel Odent, and feminist midwife campaigner Lesley Page.
International protest prodded the Hungarian government into stating that Agnes was not registered as a midwife and that in future the government would control home births.54 The Freebirth Support Group responded that she was not registered because no one offering home birth services was allowed to be.55
Free Agnes Gereb
Jailed for helping women give birth
Dr Agnes Gereb, a qualified Hungarian obstetrician and midwife, and international homebirth expert, was taken into police custody on 5th October – minutes after attending to a woman who had unexpectedly gone into labour at Dr Gereb’s homebirth centre in Budapest.
Dr Gereb is respected worldwide for her work on behalf of pregnant women. She has championed the right of women to choose how they give birth and had herself attended many thousands of successful home births.
She has been held in prison since 8th October and her imprisonment has recently been extended for a further 60 days. Under Hungarian law she can be held without trial for up to a year.
Agnes has been charged with ‘reckless endangerment committed in the line of duty’ and could face imprisonment for between one to five years.
She is confined to her four-woman cell for 23 hours a day, and has been subject to strip searches, is allowed one 10-minute phone call every week and is limited to one hour of access to two of her family per month.
A Passion for Birth Page 31