Dot writes: ignorance may not be bliss, but reading can produce discontentment. I mentioned a few posts ago that I’ve started to find my steps mysteriously straying towards the midwifery section again. A bit over a week ago they strayed towards a book called Birthing Autonomy: Women’s Experiences of Planning Homebirth by Nadine Pilley Edwards (Abingdon: Routledge, 2005). I’ve found it illuminating, but it has wakened doubts about the care I’m receiving in this pregnancy that perhaps were better not wakened, given there’s not too much I can do about it now.
The book talks about how homebirth services can ‘bring the hospital into the home’ by importing a mechanistic, protocol-governed approach and a preoccupation with risk into a setting that is meant to promote personalised care and confidence in birth. It points out that women don’t get continuity of care from community midwife teams but instead meet different midwives at every visit, so there is little opportunity for a midwife to gain a sense of a woman’s particular needs and strengths or for the woman to become confident that this is someone she can trust to help her rather than to impose procedures she doesn’t want. A common reaction is to play the good patient and avoid mentioning anything that might challenge the norms, for fear of losing the support of one’s caregiver.
I’m afraid I recognise all of this. We are planning a homebirth for Sprout, so I leapt at the chance to sign up with the (highly regarded) community midwife team based in the National Maternity Hospital. So far I have been impressed with the kindliness, lack of rush and willingness to listen of all the midwives I have met, but I’ve been playing my part of the birthing star – the quick labourer who gave birth first time round with only her husband and a beanbag to help, but who has now signed a consent form detailing a pretty formidable list of circumstances under which Sprout’s birth will be transferred back to the hospital. I was keen to show my knowledge of what all these eventualities were and why transfer was recommended, but I didn’t mention any of the reading I’d done on how some risk factors might in fact be adequately or better dealt with at home. (For example, high blood-pressure: given a stressful atmosphere can raise blood-pressure, if the reading doesn’t point to something truly frightening would it not be better to concentrate on keeping the woman in a relaxing environment? And isn’t there evidence that meconium in the waters is only sometimes a sign of foetal distress, and that a heavily monitored labour with all its concomitants of reduced mobility, more reliance on pharmacological pain relief etc etc might end up itself placing stress on the baby?)
Nadine Pilley Edwards remarks on how ‘obstetric ideology’ devalues women’s own knowledge of their bodies and respects only the knowledge produced by its own methods: for example, a woman might know when she conceived, but the doctor would only want to know her last menstrual date. Again, I identify with this one because I don’t have a textbook cycle and in both my pregnancies the LMP has given a due date that I knew from the first was wrong. (In fact my GP, infuriatingly, is still using that wrong EDD, even though she referred me for a dating scan that confirmed the date Ken and I had calculated.) But this question of knowledge leads me to an aspect of the book I find rather frustrating. The opening, theoretically orientated section discusses how experience is not an irreducible and stable authority but is itself mediated and affected by various discourses. In this context we can see that women’s knowledge is not in diametrical opposition to obstetric thinking: to various degrees women read up on birth using books that draw on the last couple of centuries of medical research, and they are also affected by the talk surrounding birth in their communities and popular culture. Particularly in a first pregnancy, the sensations one encounters are unfamiliar and one goes to a health professional for help in learning to read them. One doesn’t have an authoritative body-knowledge decisively separate from that produced by obstetrics. And there are times when observations such as blood-pressure readings or listening to the foetal heart will genuinely indicate a problem the woman would otherwise have been completely unaware of. So the challenge is to find a way of integrating the knowledge of the professional and the knowledge of the woman in a way that will make for a safe and happy birth and a peaceful entry into a family for the baby; but the ‘Where Now?’ chapter at the end of the book, which should be answering this question, is rather short and imprecise. I’m convinced by the suggestion that ‘for midwives to enhance women’s autonomy, much needs to be done to enhance autonomy within midwifery itself’ (p. 256), but I get a bit lost when she writes things like ‘Is the way forward socializing birth, so that technology can be used to support women and babies, and midwifery practices when necessary, instead of further technocratizing it and using social practices to humanize it?’ (p. 258) What does that actually mean? As far as I can tell, it means (in Pilley Edwards’s view) locally-based caseload midwifery. But it probably also means much deeper cultural change to reduce the prevailing sense that birth is a madly dangerous thing we only get involved with because of our hopeless subjection to our hormones.
As for me, I will stick with the Holles St team and make the best of it. But the fact is, I am really far less worried in this pregnancy than I was in the first. I know that every birth is different and Sprout’s arrival will not follow the blueprint of Hugh’s, but I know now that my body can do it, and oddly enough that makes me much more relaxed about the possible prospect of a hospital transfer and all the bells and whistles, should that be deemed necessary. It doubtless would be nice to have one midwife through the whole process, but midwives have families too and I’m getting the services of these pleasant, extremely experienced women for free. I also feel much happier with the attitude of the community midwives than I did with the semi-private clinic at the Rotunda. Last time round, my consultant seemed to see it as his mission to talk me out of my birth plan; this time, the midwives seem very sure of my ability to give birth, and that in itself makes me feel good about myself and about them.