She recently appeared at a court hearing shackled and bleeding from a wound caused by her restraints.
Her lawyers have lodged an appeal against her continued detention and a complaint has been made to the European Court of Human Rights about her mistreatment in prison.
Dr Gereb’s case highlights the wider issue of the criminalisation of independent midwives – Hungarian law protects a woman’s right to decide where she gives birth but in practice midwives assisting home births are denied licences by the Hungarian authorities. Midwives who do attend home births can be fined or sanctioned.
This situation is profoundly disturbing in an EU member state that professes to respect human rights and the rule of law.
We are campaigning for Dr Gereb’s immediate release.
With a track record of 3,500 successful home births, Agnes is internationally recognised as one of the most experienced midwives in the world.
Home birth was not illegal in Hungary but anybody assisting one committed a criminal offence. This included simply crossing the threshold of a woman’s home with the intention of discussing the option of home birth and sitting in her home while she was giving birth, without intervening. The Hungarian government worked on new regulations for maternity care. The law stated that after 24 weeks of pregnancy a woman had no right to refuse medical treatment, and that for 24 hours after birth she was ‘out of her mind’, and so could not refuse treatment either. Those of us fighting this midwifery campaign considered it crucially important that any new regulations established midwifery as a separate profession with its own protocols.
The State Secretary for Social Inclusion, Zoltan Balog, who was also a Lutheran pastor, visited Agnes in prison and reported that, thanks to international pressure, she was no longer strip searched and was allowed pen and paper.
Agnes told him that she didn’t trust the liaison between the medical parties and the Hungarian government. She was working for the establishment in law of an independent profession of midwifery free of obstetric control. The message she sent to her family and supporters was: ‘I have not been broken. I will not be broken.’
A vigil took place outside the Chief Prosecutor’s in Budapest to run until the following January when Agnes’s second detention was supposed to end. In fact, it was extended.
I arranged for Professor Lesley Page, then at King’s College, London, to fly to Budapest at the end of November to lecture at the Academy of Science on the regulation of maternity services, and meet with parliamentarians and obstetricians. She had been deeply involved in the rebirth of midwifery in Canada. There a midwife could not remain registered unless she had a regular proportion of home births – the complete opposite to Hungary.
Lesley called for a National Register of Midwives in Hungary to give information and guidance and handle professional misconduct complaints. The criminal justice system should not deal with professional matters. Midwives in Hungary were registered only at the hospitals where they worked. Lesley stressed that registration must be at a national level.
Yet the registration of midwives was not enough. We both emphasised that the guiding principle of midwifery must be women-centred and community-based and respect the individuality of each woman and her family.
Neither home nor hospital birth can be completely safe. All women need a midwife. Some need a doctor, too. Most studies of perinatal mortality show that there is no difference between home and hospital births. But best evidence on perinatal outcomes reveals that with home births there are lower rates of epidurals and analgesics, fewer inductions and augmented labours, and fewer Caesareans, episiotomies and instrumental deliveries.
A wave of change mounted in Eastern European countries. This started in Poland and the Czech Republic in 2010. Women in Bulgaria resisted an obstetric system in which they were told they had birth choices but actually did not. That protest was part of a wider cultural revolution and the rise of a vigorous civil rights movement.56
CHAPTER ELEVEN
THE GOOD BIRTH GUIDE – TEN YEARS ON
For The New Good Birth Guide edition of 1989 I analysed 773 detailed reports from women about their care over a three year period between September 1985 and September 1988. I asked about their general impression of the hospital, their experiences of antenatal, intrapartum and postnatal care, to tell me how things could be improved, and to say what was the best thing about the hospital. The information they gave me revealed changes in practice and in the environment for birth which had been welcomed by women. Many of these cost little. Some – those that reduced obstetric interventions and instrumental delivery and Caesarean rates – cut costs.
More pregnant women wanted to think ahead about the kind of experience they would like, the setting, the people involved, and how they wished to welcome the baby. The search for information and choice between alternatives that started with educated women had fanned out to include those women who were previously less articulate about what they wanted.
Acceptance of responsibility is part of the transition to becoming a mother, and prepares her for responsibility once the baby is born. We learn responsibility by exercising it. We learn how to be adults by being treated as adults.
The response to this on the part of many hospitals had been to try and find a new formula that would satisfy consumer demands. However, generalisations about what women want are often made as if it were a matter of discovering a magic formula which can then become a standard part of institutional practice. As a result, in many hospitals a system – well-intentioned, but rigid – had been introduced without sensitivity to individual women’s needs.
Some obstetricians still condemned consumerism as ‘just another fad’, and a dangerous one at that. One consultant obstetrician, Harold Francis, said, ‘Some patients no longer accept advice … They insist on dictating their own treatment. No other discipline in medicine has this treatment. Neurosurgeons do not have to contend with the “Good Neurosurgery Guide”.’
Women were being encouraged to be mobile in labour. In a handful of hospitals they could move about freely, change position whenever they wished, and find positions and explore movements which were comfortable and which might help labour progress. But this depended still on individual caregivers, and it was often a matter of luck; ‘When I told the midwife I wanted an active birth she went off and changed into trousers. The bed was removed from the room and replaced by a mattress, pillows and a beanbag.’ ‘I walked, rocked on all fours, knelt. I could move around as I wished. I spent most of the time walking round.’
Immersion in water was suggested by midwives who felt confident about this. At the time pools were not yet installed in many hospitals and an ordinary bathtub was used. ‘I could have as many baths as I liked.’ ‘I wallowed in a deep, warm bath and was encouraged to stay in it as long as I wanted.’ One woman described how she ‘spent seven hours in the bath.’
Intervention had been reduced. Shaves, enemas and suppositories were no longer given routinely. In some teaching hospitals rates of induction had gone down. For example, in St Bartholomew’s the induction rate fell from 20 per cent in 1983 to 9 per cent in 1984.
In some hospitals syntocinon stimulus of the uterus in labour had also decreased. John Hare, Senior Consultant at Hinchingbrooke Hospital, Cambridge, where active birth was encouraged, told me that women could be mobile right through childbirth, and 97% of women who chose active birth moved around throughout labour. Five times more women who did not choose active birth required artificial uterine stimulation. Women who lay in bed were more than twice as likely to have meconium-stained liquor and disturbing fetal heart patterns. The mid-cavity forceps rate had been much reduced by upright positions, and there were no severe perineal lacerations.
In some hospitals, too, women described squatting, kneeling or standing births, to put their hands down and receive their babies. A woman who had a forceps delivery told me, ‘I was invited to lift my baby out when the head and shoulders were delivered.’
The ban on eating and drinking in labour had been lifted in many hospitals and women could eat and drink if and when they wished. Food might be encouraged to avoid ketosis, as it was in Hinchingbrooke, where hot chocolate, toast and honey were offered.
More hospitals were striving for flexibility of care and to respect personal preferences: ‘I was asked whether I wanted the waters broken at 4 cm, so I chose not to have this done. I also stated that I didn’t want an episiotomy, nor analgesics if I felt I was coping. These decisions were supported by the midwife. I refused the fetal scalp monitor because the baby’s heart rate was coming back up at the end of each contraction.’
One important element in this was the introduction of birth plans in a third of all hospitals. Pregnant women were given booklets with information and spaces in which to write questions they wanted to raise at each visit, and there was a section in which they could express what kind of postnatal care they wanted.
There was also genuine concern to give continuity of care where possible. At that time it had been estimated that the average woman in a British maternity unit saw between 35 and 45 different members of staff in the course of antenatal, intrapartum and postpartum care. The effect was confusion, bewilderment, disorientation, failures of communication and unnecessary risk, for to have a multiplicity of caregivers, however skilled and dedicated they are, can be dangerous. Organisational changes had occurred so that small midwifery teams working with doctors were giving total care. It is rewarding for a midwife to get to know the mother during pregnancy, as in the ‘Know Your Midwife’ scheme at St George’s, London, where there were teams of four or five midwives. Pregnant women were linked to these teams, not to the consultants.
Caroline Flint’s research project on the ‘Know Your Midwife’ scheme revealed that 51 per cent of mothers in the scheme needed no drugs for pain relief compared to 38 per cent of women who were not in it. It was financially viable. Costs were 10 per cent higher for the care of women outside the scheme. In one midwife’s words, ‘The system recreates a kind of village atmosphere, where a midwife works in a small area and knows everyone well.’
It probably also resulted in safer care. Midwives were more accountable and examined their practice reflectively in small groups, exploring where they did things well and where they needed to improve the quality of care.
My earlier research had revealed that women often lacked privacy. They described people wandering in and out of the delivery room, and did not know who most of them were. One woman said, ‘I felt like an animal with so many people present during the vaginal examination’, and another, ‘There was a succession of nurses and midwives, none of whom I had ever seen before or saw again after the birth.’
This had changed: ‘My partner and I were shown to our labour/delivery room and it was made our own by a midwife knocking and waiting to be asked to enter. There was no breezing in and out.’ ‘Little things mattered so much, like midwives leaving the room when I was using the bedpan.’
Thought had been given to providing tranquil birthing rooms in many hospitals: ‘No beds, lights dimmed, a mirror to see the birth, provision of bean bags, birthing stools, bathroom and toilet en suite, tape cassette, hot tub, rocking chair, valence chair, floor mats or mattresses. Free coffee and meals for the partner and a reclining chair to rest if labour is slow.’ ‘I took in two lemon balm plants, my own sheets, a tape recorder and music tapes, herb pillow, pictures on which to focus. The staff didn’t even blink! I was shown straight into the birthing room with a futon on a carpeted floor, curtains, no lights, a valence chair, large cushions, and squatting bars.’
More Cosmetic Changes
Ten years before I had discovered that time was a central issue – time given by doctors and midwives for discussion with a mother, as well as time for her to feel that she could work with her body instead of battling against it to get the baby born. Many women felt they had been on a conveyor belt in a baby-producing factory.
Particularly in the second stage, they often found that their own rhythms were ignored and they were coaxed or commanded to push. They used words like ‘rushed’ and ‘harried’. Women were sometimes told it was the rule that they should be in the second stage no longer than one hour, and otherwise it would be a forceps or ventouse delivery. Occasionally time was restricted to 45 minutes. The disadvantages of this commanded pushing and prolonged breath-holding were demonstrated by Roberto Caldeyro-Barcia and his colleagues. The Valsalva manoeuvre can lead to cardio-vascular malfunction and pronounced dips in the fetal heart.
By the mid 80s in a handful of hospitals there were no restrictions on the duration of the second stage provided the mother and baby were in good condition. Sometimes women described second stages lasting two or three hours, or longer. A woman who gave birth in the Royal Maternity Hospital, Glasgow, told me,’ My cervix was completely dilated, but I had no strong urge to push. Sister said, “Just take things easy. The baby has plenty of room, so don’t push unnecessarily”.’ One woman, at Dulwich Hospital, described a second stage which lasted seven hours, a record for that particular hospital, and said, ‘I never felt scared or out of my depth. The attitude was, “It’s your birth. We’re here if you need or want us”. They kept telling my husband that he was doing a good job, too.’ They often laboured upright, squatting, kneeling and standing positions, and sometimes on birth chairs.
A typical description of the second stage was, ‘The lighting was dimmed. I had one midwife. My husband sat on the bed at my side and the midwife sat on the end of the bed. Throughout, she maintained a relaxed, calm, almost casual atmosphere, and gave me immense confidence in myself and in my ability to give birth.’ Another woman said, ‘As soon as the head was born the midwife placed my hands on his head and with the next contraction I lifted him out onto my tummy myself.’
There had been a striking decrease in the rate of episiotomies, and more women had an intact perineum after birth. This came because of pressure by women and their anger at this ritual mutilation. In the 70s episiotomy statistics were not kept in many hospitals. Episiotomy was to be expected. In 1981 the National Childbirth Trust published the results of my research on women’s experiences of routine episiotomy which revealed that it often caused unnecessary pain at birth and in the weeks after. It used to be claimed that it prevented a tear, that ‘a nice, straight cut’ was better than ‘a jagged tear’, and that it saved pelvic musculature from trauma. None of these claims were true. It does not avoid laceration, or improve the condition of the perineum or pelvic floor, may intrude on the mother’s relationship with her baby, adversely affect the start of breastfeeding, and result in dispareunia and stress in a couple’s relationship for many months afterwards.
When I did research for the first edition of that book I found that protocols were produced by consultants who insisted on episiotomy for every primigravida after 30 minutes in the second stage. This was often interpreted as the half hour following full dilatation of the cervix, and some women hadn’t even started to push spontaneously at all. Postnatal wards were filled with women sitting uncomfortably on episiotomy wounds and trying to breastfeed their babies while shifting in acute pain from one buttock to the other.
Following media focus, practice started to change immediately in many hospitals – especially teaching hospitals – and episiotomy rates were often halved within a matter of months. Research projects were initiated in several maternity units, and as soon as questions started to be raised about routine episiotomy, its incidence decreased, even before the results of randomised controlled trials were published. In the Royal Berkshire Hospital, Reading, for example, research was started, but the researcher told me that the rate was reduced by between half and two thirds even among women in the control group in whom the routine practice of doing an episiotomy to avoid a tear, however small that tear might be, was supposed to be continued. By the 80s women having second and third babies often described how everyone was walking about normally on postnatal wards and could feed the
ir babies without getting into contortions.
I realised that I must have made a mark when at the British Congress of Gynaecologists in 1989 James Owen Drife, then a Senior Lecturer in Obstetrics at Leicester University and later Professor of Obstetrics and Gynaecology at Leeds and a witty columnist in the British Medical Journal put on a sketch with Walter Nimmo, the Director of Medical Research in Edinburgh at the piano, which was a parody of my Good Birth Guide – the Good Patient Guide.
The duo had made their name as young doctors at the Edinburgh Fringe, where they introduced the Fallopian Tuba with their student band, Unbelievable Brass. According to the Sunday Times the Good Patient Guide left the members of the Congress laughing so much that they were ‘fighting for breath’.
Each patient was identified by symbols in the margin; a black square, for example, signified that the woman had to be delivered in total darkness, a fur coat, that she was an accountant’s wife, a stethoscope, a doctor’s wife, half a stethoscope, a psychiatrist’s wife. Capital ‘O’ obese. ‘OO’ she intends to breastfeed, ‘OO7’ she wants to bond. Thumbs up, member of BUPA, oil well gushing, a sheik’s wife, oil well gushing down a sheikh’s wife who is a member of BUPA, a notebook, a journalist, and a little notebook with a black hat, a journalist from the Guardian Woman’s Page. ‘Difficult patients’, Drife told his audience, ‘explained why so many intelligent, middle-class obstetricians were forming self-help groups and practising “natural obstetrics”. This was a method of doing without patients altogether (loud applause) … now being pioneered by a London teaching hospital (more loud applause).’
Repercussions In Australia
The publication in 1979 of The Good Birth Guide stimulated research and enquiries into health services and birth rights. In 1989, Health Ministers in New South Wales, Western Australia and Victoria commissioned reviews that included consultations with women who used the services as well as those who provided them. Women were sent questionnaires six to eight months after they had given birth.
A Passion for Birth Page 32