Physiologically and culturally, women are programmed and supported to provide an optimum environment for their unborn baby. Animal studies suggest that raised levels of progesterone during pregnancy provide a natural anti-depressant (Molina-Hernández and Téllez-Alcántara, 2001); its calming effect promotes a slower pace of life, and underpins the nesting instinct that inclines mothers-to-be to stay close to home and to people they know and places they perceive as safe, such as the maternity hospital. Pregnancy rituals found in every culture are driven by a desire, both at the level of the individual and society, to keep the pregnant woman and her unborn child, safe. What constitutes ‘risk’ is defined culturally and according to how advanced a particular society is in relation to its access to technology and the sophistication of its health care services.
Superstition is rife in pregnancy, but its basis is evolutionary. For example, native American women may be ‘taken to the water’ at the start of their pregnancy to bathe in waters imbued with herbs that protect the child against harm; special blessings may be bestowed on African women of certain tribes to protect them and their unborn children against malevolent spirits (Vincent Priya, 1992). While such rituals may seem unusual, many cultures in advanced societies have their own practices and superstitions driven by the primeval need to minimise risk and promote the safety of the mother and baby. In the UK, some women have been known to not eat strawberries during pregnancy to avoid their baby having a birth mark. Furthermore, women and men in antenatal classes may express a wish not to talk about caesareans because doing so may increase their likelihood of having one. Superstition represents the commitment of the community to the survival of the race, and the commitment of the mother to the survival of her child. It is part of what the psychologist, Donald Winnicott (1958), described as, ‘primary maternal preoccupation’.
The instinct to provide a safe environment and to therefore avoid risk to the unborn child is strong in the pregnancy and childbirth continuum. Around the world, special provision has been made by tribes, small communities and advanced societies, to ensure that the labouring woman is protected while she is giving birth. In the heart of Australia, aboriginal women in labour go to a hollow in Uluru accompanied by other women, while her husband, supported by his male friends, stands guard in an adjacent hollow (Uluru Ranger, personal communication, 2011). The ‘informed choices’ that western women make in relation to place of birth are also made with the intention of giving their baby the best chance of being born alive. Some women will frame that ‘best chance’ in terms of having ‘everything on offer’ that contemporary obstetric practice can provide; they choose to put themselves in the hands of midwives and doctors because they consider that these professionals ‘know best’. Other women will choose a labour that is ‘as natural as possible’ because it is their perception that not interfering is the best way of enabling nature to achieve her mission of birthing a live baby. All of these women are driven by the same primal need to secure a safe birth and a live baby. Assessment of risk has therefore been undertaken by childbearing women long before it became the bedrock of 20th and 21st century maternity services.
‘In a risk-averse western culture, and in a period when the maternity services continue to operate a medical model of birth, normal birth is, ironically, seen as ‘risky’
The fear of dying in childbirth is still common (Hofberg and Ward, 2003), despite maternal mortality rates in the developed world being at an all-time low. Maternal deaths in the UK, for example, have decreased from 11 per 100 000 women giving birth in 2006-8, to 10 per 100 000 women giving birth in 2009-12 (MBRRACE-UK, 2014). This fear of death is, in part, a fear of leaving the baby without his or her primary protector. Alongside the drive to keep herself physically safe, the pregnant woman also recognises the need to have a birth that will leave her untraumatised, emotionally untroubled and therefore able to care for her baby effectively. Psychologists refer to the need for new mothers to be ‘mind-minded’, that is to be able to reflect on their babies' likely thoughts and feelings, a capacity that appears to relate to babies' security of attachment (Arnott and Meins, 2007). Women who have had frightening experiences of childbirth may manifest ‘FR’ behaviour (Main and Hesse, 1990)—frightened and frightening behaviour—in relation to their infants, disrupting the attachment relationship. Similarly, women who are depressed following birth may create a damaging environment around their baby—not offering eye contact, not smiling or chatting to their baby or showing spontaneous affection even when the physical care they provide is satisfactory (Grace et al, 2003).
Women's choices around childbirth may, therefore, be logical from an evolutionary perspective. The woman who wrote the following poem did not perceive her first labour in hospital as ‘safe’ and wanted to stay at home for her next labour because she could not risk a repeat of the psychological damage that she had incurred during her first:
Suddenly urgent Harsh tones and panic like slaps rouse me Strangers in and out and around me, Needles and stirrups, Chattering onlookers, Writhing, unstoppable agony Supine on the slab, I am irrelevant. I am sliced and entered barbarically Dripping blood onto the floor, My baby is born, Sucked out of me gracelessly.
Discourses around risk
While women's assessment of risk may sometimes, appear misguided, the ‘scientific’ assessment of risk may be equally obscure and removed from the ‘evidence-base’. In the UK, despite publication of the Birthplace study in 2011 (Birthplace in England Collaborative Group, 2011), which concluded that giving birth in England for low-risk women was very safe wherever they chose to have their babies, the home birth rate has remained resistant to change; in 2013, only 2.3% of births were homebirths, the same as the previous year (Office for National Statistics, 2014). In the Netherlands, in 2013, the homebirth rate was 20% (De Jonge et al 2013), and 0.9% in Australia in 2010 (Li et al, 2012). It is clear that a shared evidence-base cannot underpin these widely varying rates in countries with similar well-educated populations and adequate resources for health care. The rate of interventions across the world may serve as a proxy for various maternity services' perception of the need to intervene in order to prevent harm. For example, the episiotomy rate in Italy is 43.6% (Lauria et al, 2012), and in the UK, it is 19.4% (Health and Social Care Information Centre, 2011), again suggesting that medical hegemony and cultural discourses around risk, rather than evidence, are the driving forces.
Fear of contravening policy may inform health professionals' encounters with women more than they would wish it to, or perhaps are aware of. A mother who challenged the advice given to her regarding her post-term pregnancy, reported the following discussion:
‘They told me on day 9 that I would have to be induced on day 10. I asked for the medical reason and they said it was their policy. I saw three different consultants who tried to get me to be induced. And none of them could give me a reason other than it was their policy. So then I asked, “If your policy is 10 days, why is the policy at the hospital down the road 14 days?” They couldn't answer; they just said it was – policy.’
Fear of censure if women in their care make unusual choices or refuse routine procedures may drive professionals to make statements that they know are untrue. The story told by this woman depicts considerable desperation on the part of the midwife to obtain compliance:
‘The community midwife told me that I needed to have blood tests and one of these was HIV. I said I didn't need that one because I had had all the blood tests with my first pregnancy and they had been absolutely fine, so she could test for anaemia and things like that, but I told her she didn't need to test for HIV because I hadn't got it. She said, “Well, we still have to test anyway,” and I said, “But you don't need to because I haven't got it; I didn't have it last time”. And she said, “Well, things change” and insinuated that my partner might have been having an affair. I reassured her that he hadn't and then she told me that I might have caught HIV on holiday from a swimming pool!’
Intimidation and coercion may be closely linked to attitudes which see patients as not being the equals of their professional carers and their beliefs as lacking the ontological status of medical knowledge. Such attitudes would not be espoused by the majority of health professionals and, indeed, new campaigns driven partly by financial necessity, but also by a genuine desire to halt the onslaught of unnecessary interventions, may assist the democratisation of maternity care in terms of respect for women's choices. ‘Choosing Wisely’ (choosingwisely.org) is a Canadian campaign to prevent doctors from ‘over-treating’ patients and ‘to spur conversation about what is appropriate and necessary treatment’. It has been taken up by the Royal Colleges of Medicine in the UK who are currently drawing up a list of procedures that expert opinion now suggests should not be used routinely.
How can channels of communication be opened up with women who make what professionals see as risky choices? In the first instance, it is important to reassure women that meetings with midwives and doctors are encounters between equals, in which all present share their expertise openly and genuinely. The conversation flows around sharing and agreeing plans for the labour and birth and, where there are concerns, all parties engage in ‘negotiation of disagreement’. Areas of compromise are identified; lines are drawn in the sand; promises are made that whatever is agreed will be adhered to by all parties. This kind of partnership working aims to protect the dignity and self-esteem of everyone involved, with the ultimate aim of ensuring the physical and emotional survival of the baby and mother.
‘Risking’ normal birth
In the UK, while fear of interfered-with birth may force women labelled as ‘high risk’ to take unusual responsibility for their labours and births, other women's fear of normal birth may make it difficult for them to choose a straightforward labour. The definition of normal birth is controversial and is easier to define by what it is not, rather than what it is. Using the criteria established by the Maternity Care Working Party (2007), normal birth does not involve induction, epidural, spinal or general anaesthetic, forceps or Ventouse, caesarean section or episiotomy. In 2008, among the 4.2 million births in the US, the majority (94.1%) listed some type of complicating condition (Elixhauser and Wier, 2011). In 2010–2011, the normal birth rate in the UK was 38.7% (BirthChoice UK, 2011). Normal birth would therefore appear to be under threat in these two countries. It might be argued that this rate of perceived complication reflects women's lack of interest in normal birth rather than doctors' over-enthusiasm to practise their skills. Anecdotally, however, I would challenge this. In my experience, women's response to a question about what kind of birth they would like to have is generally, ‘I would love to be able to do it all on my own’. A senior midwife approached me following a conference at which I put forward this idea and said how strongly she agreed with me that women did want normal birth, but were unsure how to achieve it and whether, indeed, it was possible or ‘allowed’ in hospital. Women are fearful of wanting normality and frequently tell stories of friends who had similarly hoped for a normal birth and been disappointed.
It may be that in a risk-averse western culture, and in a period when the maternity services continue to operate a medical model of birth, normal birth is, ironically, seen as ‘risky’. In 1932, Aldous Huxley's ‘Brave New World’, imagined a human race where natural reproduction had been abolished and only women outlawed from society and described as ‘savages’ continued to give birth vaginally. Huxley explicitly linked state control over birth in his imaginary dystopia with active discouragement of critical thinking. It is worthwhile considering whether, nearly a hundred years later, the high caesarean section rates across the world (i.e. 50% in China in 2012 (Hellerstein et al, 2015); 33% in the US in 2013 (Centers for Disease Control and Prevention, 2013); 46% in Brazil in 2008 (Gibbons et al, 2010) might be seen as reality catching up with fiction.
Controlling women
The fact that reproductive decisions are increasingly politicised is concerning and demands a robust response on the part of both women and maternity services to support women's decision-making. The case where a local authority took a woman to court in order to seek compensation for her 7-year-old daughter who was born with fetal alcohol syndrome is a worrying one. The lawyers argued that the mother's heavy drinking in pregnancy amounted to ‘attempted manslaughter’ (Bowcott, 2014). Finally, the Court of Appeal ruled that the mother had not committed a criminal offence. The possibility that the woman might have received a criminal record as a result of her pregnancy behaviour raises the question of where, in the future, the attempt to control pregnant women might lead. In Hungary, a mother's choice to have her baby at home with an independent midwife had to be pursued as far as the European Court of Human Rights (Ternovszky v Hungary, 2010) in order to gain a ruling that women have the right to choose where their baby is born and that actively frustrating this choice is an abuse of their human rights.
Maternity services have long struggled to understand to what extent they are the defender of women's autonomy, and to what extent it is professionals who should decide what kind of care and treatment is ‘in the best interests of the woman and her baby’. Logically, it is difficult to defend attacks on women's right to choose. Women may make wrong decisions but so do obstetricians and midwives as numerous ‘critical incidents’ and ‘near miss’ records testify. In her autobiography, published just weeks after her death, Sheila Kitzinger (2015: 10) reminds us of the destructive effects on human beings ‘of treating women as if they were containers to be opened and relieved of their contents’. Birth is about the survival of humanity. Everyone has the baby's welfare in their sights, but no-one has a more holistic understanding of what that means than the mother herself.