A Passion for Birth

by Sheila Kitzinger

  Immediately after birth many women did not criticise care, and it was not until the second half of the year after the baby was born that they reflected more critically.

  Over half the women who took part in the study had seen the same caregiver throughout their pregnancy, but in labour almost all women, whether public or private patients, had encountered midwives and sometimes doctors, students and other personnel whom they had never met before. With changing shifts they might also have met another new set of faces, and if they experienced complications or a long labour, as we have seen, they sometimes found themselves surrounded by multiple extra personnel while their partner was pushed to the back of the room. The challenge for maternity-service providers was to find ways of overcoming the current level of discontinuity and fragmentation in the way that care is provided.57

  Close on 40 per cent who attended a public clinic said they saw a different caregiver at each visit: ‘I sometimes felt that I had to remind clinic staff of tests required, for example that I had Rhesus negative blood, that I hadn’t seen a doctor when they said I would. It just seemed a bit haphazard at times. The doctor (female) was too impersonal.’58

  What women wanted most was the recognition that someone was listening. The Chinese ideogram for ‘listening’ is composed from the four signs for ear, eyes, heart and undivided attention. ‘Such listening enfolds us in a silence in which at last we begin to hear what we are meant to be.’ (Lao-Tze, Tao Te Ching).

  Jo Garcia summarised women’s comments on studies in the UK as thick with ‘recurrent images … of cattle markets and conveyor belts’.59

  But the evidence is that change does not come, or does not come fast enough, when an expectant mother has a quiet talk with an obstetrician – only when there is open and public protest. There is a place for quiet talks, but we need more than that if our culture of birth is to see any radical transformation. The task calls for knowledge and understanding, the courage to question assumptions, and the energy to work together to create a way of birth in which women are recognised as adults and active birth-givers.

  It is understandable that a woman on her own feels she cannot make any effective protest. But there’s more to it than that. New mothers often tell me they don’t like to write complaining in case someone at the hospital ‘takes it out’ on them or the baby next time. Anyway, they are grateful to have the baby and pre-occupied with the new challenges and 24-hour work of being a mother. There may even be an element of Stockholm Syndrome. That’s what happens when a kidnap victim living right through the 24-hours with her captors, identifies – or even falls in love – with them. It’s often only much later that a woman looks back at her labour and realises that she was robbed of any right to make decisions about her own body and her baby, and was treated like a naughty little girl – and feels helpless anger.

  On the other hand, we cannot close our eyes to the epidemic of Caesarean sections throughout the Western world. In the United States one woman in five has a Caesarean. This is happening partly because of clock-watched labour – each patient is forced to conform to a time norm. It is also because doctors often no longer know how to deliver a breech baby vaginally, and because of unnecessary obstetric interference – induction, for example, when the uterus wasn’t ready to contract, so there has to be surgery to get the baby born.

  It’s more difficult, too, for any woman in a high-tech hospital – even one with a simple, normal labour if she exceeds the time allotted – to avoid being festooned with tubes and wires and connected to boxes with flashing lights and reels of paper. Caregivers may assume that a patient’s wishes are identical to their own management plan. When one woman said she did not agree to have her labour induced the midwife protested, ‘Oh, but you wouldn’t want to have your baby in the middle of the night, would you?’

  Women themselves may be convinced that the medical team have got it all streamlined. One mother told me, ‘Induction is the only civilised way.’ The technological take-over of birth could be justified only if randomised research showed clearly that it saved babies’ lives. No proof of this kind exists for routine electronic fetal monitoring, induction, and many other interventions in labour.

  But when I feel most disheartened I look at what we have gained. In hospitals all over the country women are no longer given drugs for pain relief without being consulted first. Doctors and midwives now usually hand the newborn baby straight to the mother and parents have some time alone with their baby. In most hospitals nurseries for babies who are not labeled ‘at risk’ have been eradicated. Rows of newborns yelling their heads off in boxes are a thing of the past. Instead mothers have their babies with them and with any luck can cuddle them close and feed them when they’re hungry.

  Yet we must face up to it. Many doctors are so star-struck with high-tech ways of controlling the uterus and detecting what is going on inside it that they don’t watch and learn from what a woman can tell them. When technology fails, that’s a recipe for disaster. ‘Even God cannot sink this ship’, announced the Captain of the Titanic.

  The Place of Birth, published in 1979 by Oxford University Press, stimulated research in the United States too. Writing to me from The Boston Women’s Health Book Collective conference, Norma Swenson said that Iain Chalmers waved a copy of the book at the audience: ‘Has a book ever been so much and so reverently handled … in three days? He would scarce let it out of his sight, so we all contented ourselves with fondling it.’

  She went on to prepare me for a NAPSAC conference in Atlanta: ‘A feminist controversy has arisen about participating in the meetings, which derives from the fact that Georgia is a state which has not ratified the ERA (Equal Rights Amendment, a constitutional amendment guaranteeing that women may not be discriminated against because of their sex). Several groups of feminists, notably NOW (the National Organisation for Women, the largest and most popular of the groups) decided to apply an economic boycott against all states which have failed to ratify the ERA, by persuading national organisations to relocate expensive, revenue producing conventions to other states.’ She described it as ‘a strange turf where left meet right, and feminists meet anti-feminists, but where the leading edge of change in childbirth in America is today.’

  More About Birth Plans

  When I was thinking through the idea of constructing birth plans, I asked myself: how do you plan for a whirlwind? And does a woman get an entirely false sense of control over a force that is often unpredictable, elemental and passionate if she has made a plan? Plans can twist the birth experience into a juridical and confrontational mind-set.

  A birth activist and one of my closest colleagues, Penny Simkin, lives thousands of miles away, in Seattle. We both believed that it was vital to discover women’s experiences and to record them in their own words. Listening to women was the basis for research that led to understanding how to improve the environment for birth and help them afterwards.

  In spite of being a physical therapist and incorporating Lamaze techniques, Penny focused on birth as an experience rather than an energetic physical activity or an ordeal to be faced. She modified Lamaze teaching and founded the Childbirth Education Association of Seattle.60

  For each of us the Quaker spiritual ethos of making space for listening and learning was the basis of our work. She focused on birth as a life transition, not just a process that must be survived with exercises for breathing and neuro-muscular co-ordination.

  When she introduced the birth plan in the United States, she did so in a way to avoid antagonism between a woman and her caregivers and ‘enhance co-operation and trust’. I introduced it in the UK following this, so that women could work out what they wanted, make it clear to their caregivers, and also make choices if birth was not straightforward. I designed it as a basis for discussion during pregnancy to which caregivers should refer when a woman went into labour. For both of us the birth plan included conclusions about procedures such as shave and enema – routine in the 60s and early 70s – drugs fo
r pain relief, drugs to stimulate the uterus, time-limits on different phases of labour, mobility in labour up to and including the second stage, pelvic exams, intravenous hydration, monitoring of the baby’s heart, directed or spontaneous pushing, episiotomy, assisted vaginal delivery (forceps or vacuum suction) and the management of Caesarean birth, cutting the cord, rooming in with the baby or having it put in the nursery, care of the baby, breast or bottle feeding, and whether feeding should be timed or responsive to the baby’s behaviour. At that time babies were still being routinely removed to the nursery. Another important element was the father’s role. Was he to be there? An onlooker, or actively involved?

  Birth plans came in for a lot of criticism from some midwives who complained that women were presenting them like ‘laundry lists’ and with ultimatums that were unrealistic. They claimed that they ignored or undervalued midwifery skills. I made the point that making decisions about birth in advance was a bit like going out on a picnic in English weather when it might rain or snow. Plans had to be realistic with a section for choices if birth did not turn out just as a woman would like it to be.

  Later, like me, Penny founded a doula movement, Doulas of North America, so that women could have support from another woman through childbirth, and worked to educate midwives and reinforce their contribution to birth in a culture where obstetricians were professionally dominant over midwives. I went to speak at the Seattle Midwifery School, which opened in 1973, and became one of its patrons.

  My survey of 1,795 women about their experiences of episiotomy was published by the NCT in 1981 and in 1984 Penny started her own small publishing firm and issued a book I had edited, Episiotomy and the Second Stage of Labour, revising it for the American market because practice was so different. For one thing, midwives had been more or less eradicated through North America and mid-line episiotomy was a standard part of normal birth, whereas in the UK episiotomy was less standard, and when it was performed it was done in a hockey-stick shape rather than mid-line straight down to the anus. The book sold well and rapidly went into new editions. She also published my book of batik paintings and poems, A Celebration of Birth. The International Childbirth Education Association (ICEA) bought the rights to this and produced cards of the pictures.

  Penny introduced birth plans with some colleagues of hers in the mid-eighties, and I did the same in the UK a couple of years later. Plans turned up in different guises, and often made caregivers anxious. It is claimed that a pregnant woman arrived at an American hospital with a list of demands she’d signed with a lawyer. They started: ‘I, Doris Smith, being of sound mind …’ and she signed it in his presence. ‘That’s why birth plans make me anxious,’ one midwife told me.

  On the other hand, there were still women who relied on professionals to make all the decisions, saying ‘I leave it to you Doctor. You are the expert. Whatever you say!’ Some obstetricians preferred women to think through what they want and make choices.

  Others took it for granted that women are ignorant. Ann Oakley records an interchange between a doctor and patient:

  ‘DOCTOR (reading case notes): Ah, I see you’ve got a boy and a girl.

  PATIENT: No, two girls.

  DOCTOR: Really, are you sure? I thought it said … (checks in case notes) oh no, you’re quite right, two girls.’61

  Doctors and midwives do not have to be burdened with patients’ total reverence. I was starting to meet some who realised that when women got utterly dependent on them it could be more threatening than open confrontation, for when things go wrong and a baby is damaged or dies, total faith may turn to litigation.

  In the United States, where obstetricians may offer a woman everything she wants if she will trust them completely, insurance malpractice premiums are sky-high and some doctors are going out of business because it is all too costly. It is almost invariably those who put unquestioning trust in the doctor who sue for malpractice – not women who accept responsibility, weigh up the pros and cons of different kinds of care and make decisions themselves.

  The paradox is that in the United States where midwifery was not recognised, and midwives were working outside the law, they were far less concerned about prosecution than obstetricians who had all the power of the establishment behind them.

  Birth plans are a way for a woman to work out the kind of setting in which she wants to have her baby – teaching hospital or GP unit for example – and the general style of birth she prefers – high-tech and an epidural or drug-free and moving about.

  Home birth is one option. Perinatal mortality statistics for planned (as distinct from accidental) home births in Britain are among the lowest in the world.62 With a home birth a woman herself controls the setting for birth and doctors and midwives are her guests.

  The sort of requests women make are: ‘Please consult me beforehand about everything that is done to me and my baby’; ‘I should welcome the midwife’s support to give birth actively, moving about and changing position in whichever way I am comfortable’; ‘I should appreciate help with the relaxation and breathing I’ve learnt in National Childbirth Trust classes’, and ‘I’d prefer a second stage with no commanded pushing’.

  Those opposed to birth plans often urge women to be nice to their doctors to get what they want. Being nice is not enough. The kind of doctor who brushes aside a request saying, ‘Of course you can give birth naturally. All birth is natural’, and who tells the woman: ‘You can hang from a chandelier as far as I’m concerned’, is likely to be induction-happy, hooked on electronic fetal monitoring, and possibly knife-happy too.

  Many doctors feel threatened by birth plans. I have heard an obstetrician dismiss them because, he says, he ‘can’t stand backseat drivers’. Birth plans are not set in tablets of stone. At best, a birth plan is part of a good working relationship.

  There are hospitals where women feel physically and psychologically assaulted in childbirth. In these hospitals, I hoped that a reminder that a birth plan was in the notes would give a signal that the woman was not prepared to acquiesce to conveyor-belt obstetrics, and knew what she wanted.

  The challenge is to use them so that they become part of a developing dialogue between each pregnant woman and the people caring for her.

  CHAPTER TWELVE

  LENTILS TO DUBROVNIK

  Lurid pictures of Dubrovnik in flames at night had been on the front pages. The beautiful port was besieged by land and sea. The areas around it were overrun by the Yugoslav National Army and gangs of irregulars. The city itself and the Dalmatian islands near it were flooded with refugees. Uwe kept his boat in a small fishing harbour on Korčula and had close friends there, and the local Caritas and Red Cross faxed us a plea for help: ‘Last night the only remaining bakery in Dubrovnik was blown up. There is no bread, no flour, no lentils …’

  We appealed to the big charities – Oxfam, Save the Children and others – but they were already too busy in other parts of the world, especially Africa, and the Balkans were not their primary concern.

  So we decided to do what we could as a family and start a relief agency from our home. I drew on what I knew as an anthropologist about Balkan cultures to work out what supplies would be most useful. One food we could send would be lentils, since they were familiar, nutritious and cheap, could be stored easily, combined with other protein and herbs and spices, and, when mashed, fed to small children and used as a weaning food. We started Lentils for Dubrovnik, long before any of the existing relief agencies were ready to make a contribution, on 6 November 1991. Our first load with nine tonnes of lentils, 50 kilos of chocolate, clothing and blankets arrived by lorry two weeks later.

  Though ‘Lentils’ was the name, it wasn’t just about lentils. We added many other foods, together with toilet, sanitary and cleaning materials. We wanted to supply the basic needs of women and children, and in January 1992 introduced gift boxes, woman-to-woman, baby-to-baby, child-to-child, and even island-to-island. Our daughter Tess took on the task of being Planning and T
ransport Manager and was very skilled at this. Uwe managed the political end of it and sought help from big-wigs. He reckoned his talent was lunches! We found patrons in the Chancellor of Oxford University, the Bishop of Oxford and the Lord Mayor of Oxford.

  I undertook publicity and contacted firms that produced food and everything else the refugees needed. Firms often approached others on our behalf when they knew the quantity of goods available. For example, a company that manufactured labels for clothing sought help from firms which used their labels and as a result we had a bulk supply of tracksuits by Alexon, trousers, t-shirts and other garments.

  Transport was vital. In the 15 months that followed we sent 33 loads, 500 or 600 tonnes in 43ft lorries, and some in shipping containers on Croatian merchant ships. We used volunteer drivers and lorries that were either lent to us or, if necessary, hired for the occasion. The first lorry was ferried to the Continent by P&O free of charge. Covering all administrative costs ourselves, we sent our supplies by reliable routes to the twin Korčula charities Caritas and Red Cross. They were run from a tiny office by friends with whom we were in almost daily contact by fax or phone. They set out their precise needs. Our friends distributed the supplies with a multi-ethnic team of volunteers, helping people in every religious and ethnic group. (Father Josip distributed woman-to-woman parcels in Ston oblivious of the condoms thoughtful British women had included in their boxes. But then, he was the sort who would have laughed if he had learned about it afterwards.)

  All that winter and spring Dubrovnik was completely cut off by road and basic supplies got into the city by sea at night. Around 85 per cent of the buildings suffered damage by shells or fire. Living mainly on bread and pasta, people were hungry and their currency almost worthless. Often no clean water was available because pipes had been blown up, so the only way to get fresh water was to put buckets out in the street and hope it rained. Eye infections were common. I was able to get water purification tablets from one company. It was cold at night and I managed to obtain thousands of blankets, too, and sent them out there fast. It was tremendously exciting when news came in from a firm giving something we really needed.