March 18, 2003

Second guessing birth outcomes

It is Leicester today and another Active Birth workshop. Once again I am meeting midwives from a variety of maternity services, but most are either from the Leicester General Hospital or the Leicester Royal Infirmary.

At the General they are planning to open a Birth Centre and the at the Royal moves are afoot to re-establish the midwifery led programs that had were recently disbanded. This unit, with its various teams (the famous BUMPS team was a named centre of excellence in the “Changing Childbirth” report of 1991) had been a model for other units around the country and had achieved some enviable outcomes.

I well remember presenting a series of workshops for all its midwives (facilitated by Denis Walsh) many years ago now. The outcome of the workshop was audited, and they were able to increase their rate of women giving birth in upright positions from 18% to 43% in 12 months, once most of the midwives had attended the workshop. I was very pleased to have this kind of feedback on my work and chuffed that they were so keen to put it into practice.

Sadly, administration decided that due to shortages of staff all these teams would be disbanded and the whole unit revert to more traditional care. Now, the midwives are once again setting up more woman friendly options. Pregnant women will be graded as being low, medium or high risk and then cared for by a dedicated team assigned to each group. Whilst this is a step in the right direction, the need to categorise women at the outset with a risk factor is a shame, because it will lock women into a designated mode of care with little option for swapping. How can anyone foresee how a labour will develop, or whether a particular risk will become a reality? Women wanting a vaginal birth after previous caesarean, for example should really be seen by the midwifery team, but I suspect they will be banished to the high risk team and will therefore be more likely to end up with another caesarean.

I am against classifying or labelling women during pregnancy. I much prefer the approach of “wait and see” especially for place of birth. This is the big challenge for those trying to normalise birth: avoiding the making of assumptions about women’s abilities around labour and birth. As soon as we label a woman we set her up for a self fulfilling prophecy. No one will be surprised that a woman described as “high risk” has a complicated birth or a caesarean. What will be most unexpected is if she defies the outcome pre-determined for her and gives birth without trouble. I suspect that her only hope of this outcome is to avoid the whole system entirely and chose a home birth.

I hope that the midwives in Leicester are able to get their midwifery unit operating as well. I suspect that the need to second guess a woman’s birth prospects in advance will work well for those who are deemed to be of low risk, but will mean a lack of choice for those who don’t meet the rigid guidelines the midwifery service will be required to work under. This is a sad indictment of a health service that espouses “informed choice”. It will be the caregivers that get the choice and the women who will have to live with it - again.

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