One of the issues I thought a great deal about during my time in Malawi is the issue of interventions in pregnancy and birth. Are interventions a bad thing? Are they good? As with many things in life, it all depends….
In the UK it has become widely accepted (and much debated) that hospital-based practice around birth tends to include lots of interventions. There is certainly a strong message from some birth educators that women (& their partners) need to be prepared to push back against suggestion of interventions. Indeed, many potential clients contact me because they feel it is inevitable that they will need professional support to avoid interventions. So are interventions a bad thing? Why are interventions suggested if they are always bad? It makes me very sad that so many people I talk to feel that bad things will inevitably be done to them by healthcare staff unless they “fight the system”. If an intervention is offered along with justification which makes sense to you, do you need to start by saying no? I think part of the problematic issue here is a privileged, industrialised world view of birth which says that natural = normal = best.
One of my naive expectations when going to Malawi was that I would inevitably see a great deal of physiologically normal and uninterrupted labour and birth. I certainly saw (and was involved in) a great many vaginal births. The majority of these were seen by the local staff to be “normal” births, but many routine interventions are simply accepted and have become almost invisible to them. This included women coming to hospital (and often waiting for days in the guardian shelter for labour to start); the expectation that women would lie down as soon as they arrived into the delivery ward; vaginal examination being “required” even if it was clear that birth was imminent; and an expectation of the speed of progress based on findings over an initial vaginal examination. There was a big mismatch between my definition of “normal” and theirs. Are interventions a bad thing when they are part of what is seen as an inevitable part of pregnancy and birth? How do we define bad? I found the lack of privacy, respect and lack of informed consent really problematic and disturbing, but came to realise that for many of the women this mirrors their general life experience. The healthcare staff were doing they had been taught was right, with the primary motivation being to identify serious life threatening issues. Sometimes, this enabled an appropriate intervention . Sadly, in many situations issues were suspected or obvious, but the facilities to intervene to help the mother or baby simply did not exist there. In a developing country with minimal healthcare resources “natural” birth, without interventions can often lead to a poor outcomes.
In my experience, most interventions are a response to healthcare providers wanting to achieve “the best” for a client. Unfortunately we do not always share our knowledge, assumptions or beliefs about what best is, or check that we agree on these definitions. Sometimes our perspective of the risk (or chance) relating to a particular situation doesn’t match with your perspective. Sometimes healthcare staff overlook the emotional and physical cost to you of proposed interventions, not stopping to ask if the potential “risk” justifies the cost. Complex decisions require a great deal of information and time to process it. Shared decision making requires honesty and trust.
In our part of the world, where the majority of mothers and babies can be expected to survive birth, there is a sense that a less than perfect outcome must be someone’s fault. Much healthcare practice in the industrialised world is defensive – interventions are recommended to avoid possible problems- but clarity is needed to differentiate between theoretical, possible problems and real, immediate and specific issues. This is very much the case with interventions such as a recommendation to expedite birth (by induction of labour or c section). Many people receive advice based on population based data – because of your age or your skin colour you may be advised that an intervention is advised. The important question to ask is “for me and my baby, right now, what is the justification for this intervention”? Just because some people “like you” get appendicitis do we tell you you must have your appendix removed?
The World Health Organisation have calculated that a rate of 10-15% of births by c section are likely to be directly associated with improved outcomes for mother and baby https://www.who.int/publications/i/item/WHO-RHR-15.02. Nature isn’t fundamentally kind towards an individual, and within any species deaths and serious injury can occur during labour and birth. Realistically, all that nature needs is for the majority to survive. The skill comes in being able to judge an evolving situation appropriately. Are interventions a bad thing if they save lives? Sometimes there is a clear and immediate need for intervention to save a life (such as placental abruption). Sometimes the condition of mother or baby is worsening at a speed that means waiting for labour to start/progress poses a threat (infection or worsening pre-eclampsia) . Sometimes we don’t know how to judge the situation (for example an unusual but not obviously pathological change in baby’s heart rate). Data from the NHS shows a rate of 34% of births by c section across the UK in 2022. In many areas it is much higher . https://digital.nhs.uk/data-and-information/publications/statistical/maternity-services-monthly-statistics/january-2022-experimental-statistics. The rate varies across the UK. One Trust local to me recently reported almost 50% of births occurring by c section. That’s a significant proportion of births where maybe intervention happened when it really wasn’t needed. The reasons are complex and varied.
I don’t have absolute answers any more than other healthcare workers do. Sometimes the balance of evidence seems to us to justify an intervention, sometimes it is a very difficult judgement. Sadly, I didn’t get a crystal ball when I graduated as a midwife. I don’t have absolute answers any more than other healthcare workers do. What I do have is time, information and a willingness to really listen to you. I have time to talk through various possible situations with clients in advance. Time to focus on one client and their baby at a time. Time to explore the facts about your particular situation and your feelings. Time to explain and explore with you. I also believe that you have the right o make choices that I may not agree with. Sadly not every healthcare worker feels able to do that. In the very rare situation that a very urgent decision is needed my clients have consistently told me that they felt confident that my advice in that moment was advice they could trust, even when it wasn’t what they wanted to hear. If they decide not to take my advice, I will continue to support them.
If you would like time rich, personalised, midwifery care in Sussex please do get in touch to discuss what might be good for you. I offer single consultations as well as packages of care https://yourmidwife.org.uk/birth-choices-consultation/