Wednesday, November 25, 2009

Medical dominance in birth

Society and cultural beliefs may not always agree with or understand the ‘promotion of normal birth’ which is, by definition, the duty of every midwife (ICM 2005). Many midwives who may have only practised under medical supervision, may not understand or have any skill in the promotion of normal birth. Regardless of the fashion of the day, and a midwife who does not possess skill in promoting normal birth should be challenged and supported in achieving competence, in the same way as a midwife is required to have competence in newborn resuscitation or any other basic midwifery skill.

In a discussion on ‘Birth Territory: a theory for midwifery practice’ (Fahy and Parratt 2006) the authors postulate that “when midwives create and maintain ideal environmental conditions maximum support is provided to the woman and fetus in labour and birth which results in an increased likelihood that the woman will give birth under her own power, be more satisfied with the experience and adapt with ease in the post-birth period.” (p49)

Are midwives really able to create and maintain ideal environmental conditions for good births? If so, should midwives accept responsiblity, at least in part, for the inability of women in our society to give birth in a spontaneous, physiological way, and to make the adjustments to mothering successfully?

It is not fashionable for midwives to take responsibility for the high caesarean rate in Australia. After all, that's the doctors' domain. Yet surely the national caesarean rate of approximately 30% (and growing) points as much to poor midwifery as it does to interventionist, knife-happy obstetrics.

Midwives who practise as independent primary carers demonstrate excellent outcomes, both locally and internationally. The woman's own home is uniquely suitable for her to engage in a sensitive and demanding physiological process, and the midwife is uniquely skilled at enabling that process.

In commenting on conflicts and tensions between midwifery and obstetric professional groups, Karen Lane (2005) presents the argument that midwives need to “resist the terms of their own professional subordination. In other words, the complexity of midwifery identities will variously position each midwife to accept, resist or just remain ambivalent about the causes and forms of their own oppression.” (p2)

In its submission to the Maternity Services Review (2008), the National Association of Specialist Obstetricians and Gynaecologists (NASOG) state that it “believes that it is preferable that a single individual carer take overall responsibility for care of a woman in labour and the obstetrician is the most appropriate choice for such a role.” (p5) It is clear from this and several other obstetric submissions that the concept of the midwife as the primary or leading professional carer is not understood by the writers of the submissions. NASOG asserts “That current excellent obstetric outcomes are due to a high quality overall maternity service which has historically been medically led.” (p6), and strongly discourages the government from making the reforms foreshadowed in the review’s Discussion Paper.

It can be argued that medical dominance in birth, and devaluing of normal birth in western societies falls within ‘Modernity’ – “a narrow canal through which the vast majority of contemporary cultures have passed or are passing. … Thus in modernising societies, traditional systems of healing, including midwifery, have become increasingly regarded by members of the growing middle and upper classes as ‘pre-modern vestiges’ of a more backward time that must necessarily vanish as modernisation/biomedicalisation progresses.” (Davis-Floyd, 2005 p32)

While it makes sense to class the midwife as a traditional system of healing in a society that understands birth within a medical mindset, it may not be helpful. The modern authentic midwife is not a therapist, not one of the myriad of ‘healing’ modalities that have little evidence and require amazing faith: simply because birth is not an illness, so there is essentially nothing to be healed or ‘therapied’. The midwife’s role is to work in harmony with, and to support and protect the individual woman’s own ability to give birth.

While pre-modern midwives were confronted with the full spectrum of the woman’s challenges in reproduction, the modern midwife is not a one-stop-shop when complications arise. The midwife of today is able to detect “complications in mother and child” and access “medical care or other appropriate assistance” (ICM 2005). The midwife primary carer is able to fulfil this role, with the woman-baby dyad at the centre of care, and effective collaboration that seeks to protect the wellness of mother and child.

Melbourne academic Kerreen Reiger (2006) considers that “In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system.” (p331) The current Victorian policy states that “Ensuring continuity of carer and providing choice thus underpin the new framework for maternity services.” (DHS 2004, p1) These two elements, ‘continuity of carer’ and ‘choice’ would appear to ensure a strong future for caseload midwifery in Victoria. As time passes we will be more able to judge whether ‘ensuring continuity of carer and providing choice’ are indeed established in maternity services.

As the maternity reform process that was ushered in by the Maternity Services Review (2008) has progressed, the reality of medical dominance in birth has become progressively more foreboding. The hope for changes based on evidence coming into mainstream maternity care has been replaced by an unprecedented level of medical control that is being systematically written into the laws of this country. Even the level of access to private midwifery care that women 'enjoy' at present will expire 30 June next year.

It appears to me that Australia's socialist government's efforts to reform public hospital maternity care have entrenched a two-tier health system, reducing the public system to a processing line, while protecting the pockets and privilege of the obstetric/medical class. The small degree of choice that has been provided by private midwives who have carefully worked to "create and maintain ideal environmental conditions" for physiological birth and adaptation to mothering, is being extinguished.

[Note: References have not been given in full. That would encourage students to copy! jj]

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