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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Essential Midwifery Practice
- Sprache: Englisch
Intrapartum care has undergone profound changes over the past fifty years. Essential Midwifery Practice: Intrapartum Care takes a broad sweep to examine these changes and their intersection with midwifery, in particular their impact on the midwife’s role during labour and birth. It is an invaluable guide for all midwives.
Essential Midwifery Practice: Intrapartum Care addresses a wide range of topics including the evolution of intrapartum care, debates about knowledge, and childbirth education. It looks at birth environments, labour rhythms, working with pain, normal birth, unusual labours, and complementary therapies. Written by key experts and providing guidance on best practice, this unique and diverse text will bring readers up-to-date with the latest research and reflection in their specialist fields.
- Written by key experts in their respective fields coming together for the first time
- Provides comprehensive examination of normal birth practice
- Evidence-based, bringing you up-to-date with the latest research
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Seitenzahl: 614
Veröffentlichungsjahr: 2013
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Contents
Contributors
Introduction
Chapter 1 Evolution of Current Systems of Intrapartum Care
Medicalisation of childbirth
Backlash
Models of childbirth
Place of birth debate
Contemporary challenges
Conclusion
Chapter 2 Debates about Knowledge and Intrapartum Care
Introduction
Ways of seeing childbirth
Framing of childbirth as a religious duty
Movement towards (and away from) scientific medicine
Positivist science in the ascendancy
The challenge from interpretivists and constructionists
Bringing it all together
Alternative explanations for childbirth processes, including complexity theory
Knowledge from narratives and personal histories
Conclusion: towards an ontology for childbirth in the 21st century
Chapter 3 Childbirth Education: Politics, Equality and Relevance
Introduction: towards a political and social ideology of childbirth education
Antenatal education and adult education: learning in small groups
Antenatal education: the realism agenda
Conclusion: creating a critical mass through maternal health literacy
Chapter 4 Birth Environment
Introduction
Labour and interpersonal relationships
Attitudes and beliefs
Redefining safety – human nesting
Components of nesting
‘Mother-like’ care
Sketching matrescence
Conclusion
Chapter 5 Labour Rhythms
Introduction
Origins of the progress paradigm
Organisational factors
An emergent critique
Rhythms in early labour
Rhythms in mid labour
Alternative skills for assessing labour
‘Being with’, not ‘doing to’ labouring women
Definition of second stage
Time and fetal health
Early pushing
Attitudes and philosophy
Conclusion
Chapter 6 Evidence for Neonatal Transition and the First Hour of Life
Introduction
Birth practices
Early post-partum practices
Conclusion
Appendix A
Acknowledgments
Chapter 7 Midwifery Presence: Philosophy, Science and Art
Introduction
A philosophical view of midwifery presence
The scientific evidence for midwifery presence
The art of midwifery presence
Conclusion
Notes
Chapter 8 Skills for Working with (the Woman in) Pain
Introduction
Models of pain
Pain as transformatory
Support at the birth
Skills and other aspects of working with pain in labour
Conclusion
Chapter 9 Complementary Therapies in Labour: A Woman-Centred Approach
Introduction
Key evidence
Implications for midwifery practice
Implications for midwifery education
Implications for strategic policy
Conclusion
Glossary
Further resources
Chapter 10 Midwifery Skills for Normalising Unusual Labours
Introduction
Understanding labour physiology
The laws of physiology in labour
Midwifery skills for unusual normal labour
Conclusion
Chapter 11 Psychology and Labour Experience: Birth as a Peak Experience
Introduction
Study method
Study findings
Discussion
Conclusions
Chapter 12 Sexuality in Labour and Birth: An Intimate Perspective
Introduction
Rediscovering the parallels
Sexual liberation and birth
Sexual birth in the 21st century
Orgasmic birth
Sexuality in the labour ward
Birth as rape
Birth as agony and ecstasy
The ecstatic hormones
Conclusions
Chapter 13 Spirituality and Labour Care
Introduction
Women’s views
Birth environment
Connection and relationship
Coping with labour
Complicated labour and birth
Third stage of labour
Spirituality of the unborn
Implications
Conclusion
Chapter 14 How Midwives Should Organise to Provide Intrapartum Care
Introduction
What are women’s views of hospital birth?
How is intrapartum care currently organised in hospitals?
Evidence on reform
Political, managerial and leadership skills
Conclusion
Notes
Chapter 15 Feminisms and Intrapartum Care
Introduction
Feminisms
A feminist critique of contemporary birth
Biomedicine as a form of surveillance
Woman-centred care and the trap of matriarchy
Conclusion
Notes
Further reading
Chapter 16 Towards Salutogenic Birth in the 21st Century
Working with salutogenic connectivity: physiology, evidence and politics
Respectful inter-professional collaboration
Conclusion: a vision for the 21st century – changing the world, one birth at a time
Index
This edition first published 2010
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Library of Congress Cataloging-in-Publication Data
Intrapartum care / edited by Denis Walsh, Soo Downe.
p.; cm. – (Essential midwifery practice)
Includes bibliographical references and index.
ISBN 978-1-4051-7698-9 (pbk.: alk. paper) 1. Midwifery. I. Walsh, Denis, 1955- II. Downe, Soo.
[DNLM: 1. Delivery, Obstetric – methods. 2. Labor, Obstetric. 3. Midwifery – methods.
WQ 415 E78 2010]
RG950.A2I+ 2010
618.2 – dc22
2009024487
A catalogue record for this book is available from the British Library.
1 2010
Contributors
Tricia Anderson (1961–2007)
Former Senior Lecturer in Midwifery
Bournemouth University
Independent Midwife Practitioner
(all-round brilliant person who sadly died during the gestation of this book)
Sarah Buckley
Author and General Practitioner
Email: [email protected]
Soo Downe
Professor of Midwifery Studies
Midwifery Studies Research Unit
University of Central Lancashire
Email: [email protected]
Debra Erikson-Owens
Doctoral Student
University of Rhode Island College of Nursing Kingston
Email: [email protected]
Jenny Hall
Senior Lecturer in Midwifery
Faculty of Health & Social Care
University of the West of England
Email: [email protected]
Nicky Leap
Professor of Midwifery Practice Development & Research
Centre of Midwifery, Child & Family Health
University of Technology Sydney
Email: [email protected]
Rosemary Mander
Professor of Midwifery
School of Health
University of Edinburgh
Email: [email protected]
Chris McCourt
Professor of Anthropology and Women’s Health
Centre of Research in Midwifery & Childbirth
Faculty of Health & Human Sciences
Thames Valley University
Email: [email protected]
Judith Mercer
Clinical Professor
College of Nursing
University of Rhode Island
Email: [email protected]
Mary Nolan
Professor in Perinatal Education
The University of Worcester,
Email: [email protected]
Holly Powell Kennedy
Professor of Midwifery Yale School of Nursing
Yale University
Email: [email protected]
Verena Schmid
Midwife, Founder of Donna e Donna-Il Giornale delle Ostetriche
Florence
Email: [email protected]
Mary Stewart
Research Midwife
National Perinatal Epidemiology Unit
University of Oxford
Email: [email protected]
Gill Thompson
Research Assistant
University of Central Lancashire
Email: [email protected]
Denise Tiran
Director, Expectancy Ltd
London
Email: [email protected]
Denis Walsh
Associate Professor in Midwifery
University of Nottingham
Email: [email protected]
Introduction
Denis Walsh
This book is an attempt to bring together experts in their respective fields to place in one volume, for the first time, a comprehensive examination of normal birth practice. A glance through the Contents pages will reveal the variety of perspectives included here. Soo and I wanted to capture, as far as we could, a holistic overview of the current state of knowledge and skills in the wonderful complexity of labour and birthing. At the risk of overstating the significance of this particular era of childbirth practice, we both feel a sense of crisis confronting advocates of physiological birth. All over the planet, there appears to be an exorable drift towards a technocratic model of birthing (Davis-Floyd 1992) and a marginalisation of the low-tech, non-hospital birth.
These chapters are intended to feed the soul of women, midwives and other childbirth activists who still champion the experience of drug-free, normal labour and vaginal birth.
In Chapter 1, I give an overview of the recent history and trends in intrapartum practice and the philosophical models they are predicated on. Soo Downe then examines the historical legacy of these models in greater depth by explicating the struggle over ‘ways of knowing’ in childbirth. She contextualises the debate around childbirth in broader theories of complexity and constructionist influences of the postmodern era we live in.
In Chapter 3, Mary Nolan brings us up to date with the challenges facing childbirth education. Adult learning styles must be adopted if education is to be effective. The challenge of preparing childbearing women realistically for the institutional birth environment most will encounter is elaborated on before Nolan concludes by championing education as a tool for change.
Change is a central focus to the next two chapters on birth environment and labour rhythms. Both are undergoing reform, though mostly in birth centres and home-birth settings. These still only represent around 5% of births in the Western world, but their usage is increasing slowly as policy makers strive to address soaring Caesarean sections rates. Getting the birth environment right so that women can reconnect with an ancient nesting instinct and accepting that normal labour rhythms vary from woman to woman may reduce rates.
Judith Mercer and Debra Erikson-Owens discuss the exciting new developments around the third and fourth stage of labour, highlighting the significance of the intact cord after birth and the conditions necessary for early post-natal bonding.
Against these clinical and environmental factors, Holly Powell Kennedy, Nicky Leap and the late Tricia Anderson stress the importance of attitude to the birth process in their inspiring thoughts on midwifery presence. Linked to this is a need to view labour pain in a new way as Rosemary Mander discusses in Chapter 8. She concludes that labour pain can be transformatory.
Denise Tiran, the UK midwifery expert on complementary therapies takes us through their relevance and application to labour care in the next chapter before Verena Schmidt and Soo Downe in Chapter 10 overview unusual labours that are usually classed as abnormal. They believe that many such births can be normalised with the appropriate skills.
Gill Thompson, a psychologist, shares her important research with women who experienced traumatic births followed by healing births and tries to tease out the key elements that enable some women to refer to birth as a ‘peak experience’. This is followed by one of the international authorities on childbirth hormones, Sarah Buckley, who addresses the rarely examined area of labour and sexuality.
Jenny Hall has had a long-standing interest in the spirituality of birth and brings her wisdom in this area in Chapter 13. In another under-researched area, Jenny discusses the relevance of the spirituality to contemporary childbirth.
Midwifery organisational models for intrapartum care is the specialist field of Chris McCourt, one of the original researchers on the One-to-One Midwifery Model at Queen Charlottes in London. She brings her depth of knowledge to this vexed field with a clarity and vision. Mary Stewart edited the visionary book on feminist perspectives on childbirth (Stewart 2004) and brings aspects of this thinking up to date in the penultimate chapter.
Soo Downe gathers up the interconnecting and overlapping threads of all chapters in an articulation of a vision for birth in the 21st century in the final chapter. Utilising her well-known application of salutogenesis, she makes a clarion call for all stakeholders in maternity care to work together to transform how birthing is done on our planet for the benefit of mothers, babies and families.
Soo and I hope this book becomes an important contribution to knowledge around intrapartum care and a source of inspiration and challenge for those who read it. As Suzanne Arms, the long-term childbirth advocate from the United States reminds us,
How we care for women and babies in the hours around birth makes a difference for the rest of their lives…
References
Davis-Floyd R (1992) Birth as an American Rite of Passage. London, University of California Press.
Stewart M (2004) Pregnancy, Birth and Maternity Care: Feminist Perspectives. London, Elsevier Science.
Chapter 1
Evolution of Current Systems of Intrapartum Care
Denis Walsh
This chapter provides a brief overview of the recent history of labour care and the predominant influences that have impacted on it. It includes a discussion of different models and approaches, reflected in trends around the place of birth and the evidence underpinning this. The roles of maternity-care professionals and of birth technologies are seminal in intrapartum care’s recent history and will be critically reviewed. The chapter closes with speculation on what the future influences are likely to be.
Introduction and history
It may seem a little far-fetched to link ancient Greek philosophy to current labour care practices but the legacy of Greek thought around the understanding of the mind and body is relevant to these deliberations. Plato is credited with originating the dualism of mind–body split which posited the mind as superior (Rauchenstein 2008). This legacy in western thought has resulted in a suspicion of bodily processes as liable to error and breakdown. The mind needs to govern the body to prevent this from happening. Reproduction has suffered under this belief for millennia, both in relation to sexual behaviour and childbirth (Christiaens & Bracke 2007). Both have been cast as base and potentially errant behaviours and experiences. In the context of labour, the unfolding of physical expression should therefore be subject to rational planning and ongoing monitoring and regulation. It is easy to see how the body physiology becomes reduced to mechanical functioning within this paradigm.
The suspicion of parturition has been aided and abetted by another historical-cultural belief deeply embedded in western societies that can again be traced backed to Greek and Roman times – patriarchy (Longman 2006). This holds that social structures and especially power in the public sphere privileges men. Patriarchal beliefs and values, it could be argued, preceded mind–body dualism as it was men who propagated such ideas. In fact the history of western philosophy could be recast as a ‘male only’ mediated history (Zergan 2005). Patriarchy imposes control of men over women, especially in the public sphere and this has been played out in the recent history of childbirth where man midwives and subsequently male obstetricians oversaw many of the trends in the medicalisation of childbirth and the evolution and regulation of the midwifery profession (Donnison 1988).
Both patriarchy and dualism largely ignored childbirth until the Enlightenment period commenced in the 17th century when both the ideas and practices around childbirth began to migrate from the private, domestic sphere and enter the public domain (Fahy 1998). The Enlightenment saw an explosion in scientific advances, including the understanding of the human body. The accompanying rapid industrialisation saw the emergence of a wealthy middle class with disposable income. The emerging profession of man midwives saw an opportunity to profit from this wealth by offering childbirth services (Donnison 1988).
Prior to this, lay midwives and traditional birth attendants had provided support in childbirth, probably since the beginning of human evolution (Rosenberg & Trevathan 2002). Socrates’ mother was a midwife and midwives are mentioned a number of times in ancient texts like the Bible. In the 17th century in the West, they continued to offer care to a huge majority of poor women but began to be excluded from the wealthy as male midwifery spread (Donnison 1988).
With the advent of inventions like the forceps by the Chamberlain family and pain-relieving drugs, and the rise of state provision for health care, childbirth was rapidly being viewed as belonging in the public sphere, overseen by accredited professionals. This heralded a drawn out battle for midwifery to be recognised as a profession in its own right with each country writing its own history of this struggle (Donnison 1988; Rhodes 1995).
Medicalisation of childbirth
Childbirth practitioners in the Western world in the 21st century are inevitably influenced by the conditions of practice we are exposed to and the kind of education and training we have had. For the vast majority of midwives that means a ‘surveillance’ orientation to care in labour. Surveillance is premised, as Foucault argued, on a dominant discourse of what should happen so that the one doing the surveying, is judging whether what is under observation complies with a preordained order (Foucault 1979). Foucault argued powerfully that dominant discourses regulate public behaviours by imposing a particular reading (knowledge) of what should happen. One such discourse is the medicalisation of childbirth (Van Teijlingen et al. 2000). An illustration of the power of this discourse is the fact that labour is divided into three stages that entirely reflect a professional nomenclature (Walsh 2007). Each is required to be framed in chronological time that may bear little resemblance to narrative accounts by women. The pervasiveness of labour stages and their timing is illustrated by the ubiquity of the partograms in maternal labour records across most of the world.
By far the most potent marker of medicalisation is the ever-increasing rates of Caesarean section, especially over the last decade (Johanson et al. 2002). The rises have not been accompanied by improving maternal and perinatal mortality, which begs the question of whether the Caesareans were necessary. The normalisation of Caesarean birthing has reached a point where, in the United States, an active debate exists as to whether Caesarean delivery should be a choice for women (Maier et al. 2000). The Caesarean issue raises another consequence of medicalisation – the attendant morbidities for mother and babies. Both Johanson et al. (2002) in Britain and Barros et al. (2005) in Brazil have raised concerns in this area. In Brazil, the ‘modernisation’ of maternity services has resulted in such high rates of intervention that a counter movement (REHUNA, Movement for the Humanisation of Birth 2008) has arisen to humanise birthing practices.
Backlash
Across the western world a backlash against the discourse of medicalisation is gathering momentum. This is being led by an alliance of consumer groups, midwives and other childbirth professionals challenging orthodoxies like hospital birth for all and the routine application of technologies like continuous fetal monitoring (Goer 2004). They have been successful in some countries in reducing episiotomy and artificial rupture of membrane rates but not in lowering Caesarean rates. Arguably, they have been more successful in addressing infrastructure and policy issues in maternity services such as the development of a vibrant midwifery profession and installing a woman-centred ethos to maternity care policy (Hirst 2005; DH 2007).
A woman-centred ethos is fleshed out with recurrent themes of choice, information and continuity appearing in policy documents on maternity services across the western world over the past 25 years (DH 1993; Declerq et al. 2002; Roberts et al. 2002). These themes have prompted the exploration of different midwifery models of working like teams, caseloads and group practices in addition to redressing the bias to acute services in maternity services (Page 1995). Continuity schemes like these are generally based in primary care. Consumer action has also stimulated more social science research and from the late 1980s onwards, alternative models of care began being hypothesised (Kirkham 2004).
Models of childbirth
Jordan (1983) was the first to suggest that cultural determinants constructed birth in contrasting ways in different settings but it was left to Davis-Floyd (1992) to conceptualise these variations as models of childbirth. She framed the medicalisation of birth as a technocratic model and a midwifery approach as holistic model. She delineated a number of values and beliefs which she believed typified attitudes and practices within each model and these have become a useful heuristic device in much of the literature since (Wagner 2001; Walsh & Newburn 2002). The debate around models is explicit in the midwifery and sociological childbirth literature but almost entirely absent from medical journals, though it is known that obstetricians and midwives conflict over what each considers to be the appropriate care of labouring women (Reime et al. 2004). There is still clearly a need for greater dialogue between the two professional groups, challenging though that is likely to be, given the historical imbalance of power between them.
The literature around models of birth runs a significant risk of essentialising the characteristics of contrasting beliefs when interrelationships and practices in context do not reflect this. There are plenty of exceptions to the rule where obstetricians endorse normality and midwives favour intervention. Recent literature on the meaning of natural or normal birth demonstrates that neither is a self-evident state, which is revealed when all trappings of medicalisation are stripped away (Mansfield 2008). Instead, Mansfield argues that each is accomplished by enacting particular social practices which she suggests are related to activity during birth, preparation before birth and social support.
No one would argue that either a medical or social model of birth could be applied with consistency to every birth, depending on which model was favoured by the principal actors. Purists on both sides would agree that there may be a place for elements of each in certain births. Even the elective Caesarean choice can be undertaken in a women-centred, holistic way and, from time to time, natural labours require medical interventions. Davis-Floyd et al. (2001) argues for a postmodern midwife who can seamlessly traverse between social and technocratic models but that transition often requires a geographical movement between home or birth centre and hospital. Does working and birthing in different settings hinder or help the provision of intrapartum care? The next section examines this issue.
Place of birth debate
Nowhere has the divide over place of birth been more evident than in the United Kingdom. Against a backdrop of a long history of home-birth provision by midwives, recent wholesale hospitalisation of birth has prompted argument and counter-argument around the interpretation of evidence (Gyte & Dodwell 2007; Steer 2008). Though epidemiological research is very reassuring about the safety of home birth, when the National Institute for Health and Clinical Excellence (NICE) intrapartum guideline was being formulated in 2007, different members of the guideline group could not agree on the weighting of evidence around home-birth transfers (Gyte & Dodwell 2007). One of the consumer representatives resigned in protest at the way some of the professionals on the group had admitted evidence that was clearly not robust enough. It was as though their deeply held beliefs about the risks of home birth won out over a dispassionate consideration of the evidence.
It is now acknowledged by the most influential sources of evidence that there is no risk-based justification for requiring the birth of all women in hospital and, furthermore, that women should be offered an explicit choice when they become pregnant over where they want to have their baby (Enkin et al. 2000). Tew (1998) argues that the perinatal mortality rate for planned home birth is actually better at home than in hospital, though she is reliant on retrospective analysis of data. Nevertheless, her scholarship has been in-depth and meticulous. Most experts agree that it would be almost impossible to undertake a prospective randomised controlled trial in this area because of the large numbers required to establish statistical significance on perinatal mortality and because it is a topic that most women are not neutral about (Devane et al. 2004; Fullerton & Young 2007). In other words, they may be reluctant to be randomised to either hospital or home.
Apart from the recent NICE Intrapartum Guideline (NICE 2007), the most comprehensive recent review of the home-birth research literature was undertaken by Fullerton and Young (2007) and included 26 studies from many parts of the developed world. The conclusions were that the ‘studies demonstrate remarkably consistency in the generally favourable results of maternal and neonatal outcomes, both over time and among diverse population groups.’ (p. 323) The outcomes were also favourable when viewed in comparison to various reference groups (birth centre births, planned hospital births).
It is important to note that randomised controlled trials have demonstrated clear benefit in a number of associated elements of the home-birth ‘package of care’. These include continuity of care during labour and birth (Hodnett et al. 2007) and midwife-led care (Hatem et al. 2008), both of which are probably universal aspects of home-birth provision.
Though official UK-government policy up to the present is to offer women a choice about the place of birth, the national home-birth rate is still only about 2% compared with 25% in the early 1960s (The Information Centre 2006). Despite the rhetoric of choice, there are plenty of anecdotal stories of women being discouraged from choosing the home-birth option.
Home birth has been described by Cheyney (2008) as ‘systems-challenging praxis’ because it is such a countercultural choice in the western world. Both women and midwives have to challenge powerful discourses of safety, authoritative obstetric knowledge and professional hegemony to secure their choice of home birth. What was exciting about her findings of women choosing home birth in the United States was the narrative of personal empowerment that was a consequence of their choice. Many spoke of inhabiting the metaphysical place of ‘labourland’ where they uncovered and experienced the power of birth that left them in awe.
There are no randomised controlled trials and generally a paucity of good quality research on free-standing birth centres or midwifery-led units. Walsh and Downe’s (2004) structured review found these environments lowered childbirth interventions but methodological weaknesses in all studies made conclusions tentative at best. Stewart et al.’s (2005) commissioned review reached similar conclusions. However, this model has still been endorsed by the Department of Health (2007) in the Maternity Matters Report and this may reflect policy thinking that free-standing birth centres would be unlikely to have worse outcomes than home birth as a similar profile of women use both.
Regarding integrated birth centres or alongside midwifery-led units, evaluations have shown no statistical difference in perinatal mortality and encouraging results regarding the reduction in some labour interventions (Hodnett et al. 2005). Debate has continued to rage over the noted non-significant trend in some of the studies of higher perinatal mortality for first-time mothers (Fahy 2005; Tracy et al. 2007). This is unlikely to be resolved until contextual studies exploring the interface at transfer or clinical governance arrangements or the impact of contrasting philosophies is examined in depth.
All of which underlines the need for robust, prospective, multi-method studies which separate out modes of care from types of birthing centre and this is now being addressed by the birthplace study being conducted by the National Perinatal Epidemiology Unit (NPEU 2008).
Qualitative literature on home birth and free-standing birth centres highlight two other aspects of care in these settings. These are to do with how temporality is enacted and how smallness of scale impacts on the ethos and ambience of care. The regulatory effect of clock time is much less in evidence both at home and in birth centres. Labour rhythms rather than labour progress tend to be emphasised by staff and there is usually greater flexibility with the application of partograms. Part of the reason for this lies in the absence of an organisational imperative to ‘get women through the system’ (Walsh 2006a). Small numbers of women birthing mean less stress on organisational processes and a more relaxed ambience in the setting. This appears to suit women and staff well. It also appears to be attuned to labour physiology, which inherently manifests biological rhythms based on hormonal pulses of activity, rather than regular clock-time rhythms (Adams 1995).
Home birth and birth centres have enormous potential to expand as currently they provide 4% or less of all births across the western world (Walsh 2007a). This represents a tiny proportion of all suitable births. Estimates of what proportion of women might take up this option vary from 15% (Wagner 2006) to 80% (Arms 1999). Within the United Kingdom, there is evidence that long-standing integrated birth centres birth around 25% of all births from their catchment areas (Walsh 2006b).
Contemporary challenges
Current issues for intrapartum care are divergent depending on whether one is considering the Western world or the developing world. For the latter, the spectre of unacceptable perinatal and maternal mortality continues to dominate the agenda. Yet even here, strategies to address the problem have to be more than replicating high-tech Western-style maternity hospitals. Arguable poverty is the greatest killer of all in these contexts, but as Ronsmans and Graham (2006) comment, the statistics defy simplistic analysis and the identification of linear cause and effect. Multiple interventions are required to address a complex phenomenon, including the provision of midwifery care to remote areas.
In the west, morbidity rates are on the rise in some countries, primarily related to private provision of maternity care where financial incentives reward intervention (Block 2007). Governments are vexed by the problem of how to incentivise non-intervention as the Payment by Results formulae in England illustrates (O’Sullivan & Tyler 2007). As one would expect intuitively, midwifery-led care of low-risk women is cheap (Tracy & Tracy 2003) with clear reductions in consumables. It is likely that the imperative to provide one-to-one care in labour will drive alternative service provision as this is always more complex to address in large maternity hospitals. What is emerging in the western world is the rationalisation of perinatal services by the creation of tertiary centres of excellence forming a hub for local midwifery-led units or birth centre and home birth (Maternity & Newborn Working Party 2007). This model is likely to increase the numbers of birth centres and midwifery-led units and will be welcomed by service users and midwives.
This will contribute positively to addressing the trend to increasing medicalisation of birth but this phenomenon is fed by a number of powerful discourses including the techno-rationalist age, risk and professional power (Walsh 2006b). Techno-rationalism proffers that science is progressive and altruistic, and holds an optimistic view of technology (Lauritzen & Sachs 2001). It is challenging for an anthropological approach to childbirth to have credibility, competing for women’s hearts and minds, when up against such a ubiquitous and pervasive alternative. In what other context of our lives would we embrace pain as part of ‘rites of passage’ transition? In what other context would we reject the use of technology in favour of traditional skills? This is why preserving the anthropological alternative in out-of-hospital birth settings is so crucial. It is unlikely that these frontiers will ever be rolled back in hospital where professional vested interest in maintaining them is strong. In the hospital context, technologies application in treating pathology is appropriate and beneficial but in childbirth its attendant iatrogenic effects have undermined this intent. In addition, the integration of technologies with labour care in the context of institutional hospitals has tended to dehumanise the birth experience (Kitzinger 2006).
Sensitivity to the user voice in maternity care is also driving reform, especially around choice and options for birth. As in broader health, the rise and rise of what are now called ‘experts by experience’ (Preston-Shoot 2007), is requiring service providers to move beyond tokenism in user consultation to planning services and evaluations with them. This is beginning to challenge professional and managerial power as a number of stories of resisting closures of birth centres illustrate (Walsh 2006a).
Conclusion
The future is uncertain regarding trends in intrapartum care. The postmodern era that we are moving into is characterised by choice, eclecticism and a suspicion of grand narratives that propose to answer all the questions (Walsh 2007b). Both technocratic birth and natural birth are childbirth versions of a grand narrative. Neither can claim complete jurisdiction over the vagaries of the childbirth experience, though both have an appropriate context of application. There will continue to be ongoing tension over their respective claim on the care and practices in childbirth.
References
Adams B (1995) Timewatch: The Social Analysis of Time. Cambridge, Polity Press.
Arms S (1999) Birthing the Future, available from http://www.suzannearms.com/OurStore/ (accessed 02/08).
Barros F, Victoria C, Barros D et al. (2005) The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004. Lancet 365: 847–54.
Block J (2007) Pushed: The Painful Truth about Childbirth and Modern Maternity Care. Los Angeles, De Capo Life Long Books.
Cheyney M (2008) Homebirth as systems-challenging praxis: knowledge, power, and intimacy in the birthplace. Qualitative Health Research 18(2): 254–67.
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Chapter 2
Debates about Knowledge and Intrapartum Care
Soo Downe
Introduction
The following exchange between Humpty Dumpty and Alice may, at first glance, just seem to be a childish nonsense:
‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone,‘it means just what I choose it to mean – neither more nor less.’‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’‘The question is,’ said Humpty Dumpty, ‘which is to be master – that’s all.’
(Carroll 1994)
However, beyond the children’s story, Lewis Carroll was raising important issues about what words mean and, therefore, about the kind of knowledge that counts, and the way the world is perceived and understood, by both societies and individuals. As Humpty Dumpty so insightfully noted, the most important thing to know in trying to understand a society and how it operates is ‘which is to be master’. In Jordan’s terms, this is determined by whose knowledge is authoritative:
the power of authoritative knowledge is not that it is correct, but that it counts
(Jordan 1997, p. 58)
This chapter explores the changing nature of authoritative knowledge in childbirth, and the way this might impact on service delivery and decision-making.
Ways of seeing childbirth
As Jordan has noted elsewhere ‘Birth is everywhere socially marked and shaped’ (Jordan 1993). Most cultures and individuals appear to recognise that childbirth is a transforming event, both for an individual, and for a society. In many communities across the world, the events of pregnancy and birth are still marked by formal rites of passage (Grimes 2000). These rites note that first birth, in particular, changes the mother (and father) fundamentally, both in terms of the social role they adopt, and in their physical, emotional and psychological outlook on life. Also for birth, formal rites of passage operate in life-changing events such as coming of age, marriage (or pair bonding) and death. They tend to separate the individual from their cultural norms, and to expose them to dangerous or frightening events. This causes the individual to have to draw on inner resources they did not know they had, as they do battle with unknown forces and deal with difficult or dangerous situations they have never encountered before, in a so-called liminal, or ‘betwixt and between’ state of being. If the individual triumphs, they complete the rite of passage, and re-enter the community in their new role.
Most high-resource societies in which midwives work no longer have these formal rites of passage. However, birth is an undeniably life-changing event. Even without a formal way of framing it, women who are actively experiencing childbirth usually encounter stages of fear, liminality, hard and painful work, and triumph. Some of the positive consequences of this are explored further in other chapters in this book. In post-industrial late modern societies, childbirth is governed by institutional ritual and expectations, which define the way it should be conducted, who should be present, and even the type of physical experiences the women (and their partners) should undergo (Kitzinger 1987). For example, since the 1970s, childbirth activists have claimed that the rituals of removing women’s clothes, forcing them to shower, undertaking perineal shaves, and administering enemas were all processes designed to strip women of their autonomy, making them ready to receive the administrations of the maternity care system at the time (Arms 1975; Kitzinger 1987; Gaskin 1990). This can be seen as a classic rite of passage process, even if the formal biomedical justification (at the time) was the reduction of infection for mother and baby.
The underpinning rationale used for these rites of passage events demonstrated the prevailing epistemology and ontology of the time and the culture in which they apply. Epistemology refers to the nature of knowledge – how we (choose to) know what we know. Ontology refers to the nature of reality: what we perceive things to be. The next section addresses some of the epistemological and ontological systems that have been in operation in the maternity services in many countries of the world in recent history.
Framing of childbirth as a religious duty
Until the early 20th century, much of the formal history we have on childbirth comes from medical practitioners, and not from women or midwives. Between the late 19th and early 20th centuries in most of the Western word, philosophical ideas were beginning to migrate from a largely religious (usually Christian) ideology, that saw pain in labour as a God-given trial that should be endured, towards a biological process that could be understood through the science of observation and deduction from the natural world. An example of this difference in ontological understanding is provided by the debate in the United Kingdom and the United States about pain relief in labour at this time in history, when pharmacological methods were just beginning to be developed.
An article published in 1846 in the Boston Surgical and Medical Journal (Bigelow 1846) reports on a demonstration of the efficacy of inhaled ether by William Morton, a dentist. Bigelow reported that ether had been used orally since the beginning of the 19th century, but that the inhalation method had been viewed with some suspicion, despite accounts of its successful use in animals as early as 1816. Dr Crawford Long, reporting in the Southern Medical Journal in 1849, claims its first use in a surgical operation in 1842, and backs this up with an affidavit from the patient involved (Long 1849). However, despite the increasing acceptance of ether as an anaesthetic in the surgical field, the use of pharmacological pain relief in maternity care was slow to develop. A number of authors have examined the initial resistance to, and gradual acceptance of, pharmacological agents for the relief of pain in childbirth (Caton 1970; Farr 1980; Zuck 1991). These authors suggest that resistance to the introduction of such analgesia was based on three grounds: religious opposition to interference with ‘God-given’ pain; moral objections to the presumed effects of ether in rousing women’s sexual passions; and medical concerns, both that pain is therapeutic in indicating excessive interference, and in causing improved healing, and that the use of narcotic agents caused morbidity and mortality to mother and fetus. It certainly seems to be likely that the general reluctance amid the emerging profession of obstetrics to chloroform and ether was rooted in society’s attitude to the pain of childbirth, which was that it was a natural trial that should be borne as part of the lot of women. Connor and Conner quote the following which illustrates this point:
No female for whom I have any regard shall, with my consent, inhale chloroform. I look upon its exhibition as pandering to the weakness of humanity, especially the weaker sex.
(Connor & Connor 1996)
Movement towards (and away from) scientific medicine
However, the simple division between God and nature, doctor and patient, and men and women that is suggested by the analysis above is misleading. From the early 1900s, discoveries such as penicillin and acceptance of the importance of hygiene began to change maternal and infant mortality rates, but women were still desperate for improvements in their experience of childbirth. The foundation of the National Birthday Trust in 1928 was prompted by concerns of influential women about the lack of access of working class women to obstetric care, and to pain relief in labour. The Trust lobbied successfully to increase such access, and their intervention popularised, and made accessible, the minnitt apparatus for delivering nitrous oxide and oxygen to labouring women, both at home and in hospital (Beinart 1990; Caton 1996). The pressure group, the Association for Improvements in Maternity Services (AIMS), was formed in 1960, initially to increase access for women to hospital beds (Durward & Evans 1990). This continued some of the work that had been undertaken by the Women’s Co-operative Guild maternity campaign (Lewis 1990). Paradoxically, 4 years earlier, the National Childbirth Trust was formed, to promote ‘natural’ ways of approaching childbirth, following the work of the obstetricians Dick Read and Lamaze (Kitzinger 1990). There was, therefore, an interesting dichotomy prevailing – some activists were seeking an increase in access to the perceived advantages of a medicalised hospital environment, while others were attempting to minimise the use of drugs in labour.
The development of pain relief in labour was simultaneously championed and opposed both by doctors, and women of all classes. Happlin (1997) concurs with Leavitts’ (1986) analysis of the potential for women to set the childbirth agenda, and states that
many leaders of the twilight-sleep movement were suffragists and women’s rights leaders. Twilight-sleep represented women’s control over birth decisions.
However, most of the agents available at that time did not have specific analgesic properties beyond their amnesic effect, and there was an increasing recognition in the obstetric literature that they had harmful side-effects, particularly relating to haemorrhage and the effect on respiration for the baby. Elam (1943) noted that the Royal College of Obstetrics and Gynaecology, in a report in 1936, had not approved the use of either paraldehyde or chloroform. This left very few agents, none of which had any specific anaesthetic effect. As John Elam goes on to claim:
… anaesthesia and analgesia in obstetrics is not only a medical problem, but a sociological one.
Within 25 years of this statement, views about the meaning of childbirth pain had changed radically. Most hospitals administered inhalation analgesia, many used narcotics and opiates, and the consensus of opinion was swinging towards the development of techniques such as epidural analgesia. The prevailing ontology of childbirth had changed in a generation, and, to use Kuhn’s term, the post-industrial ‘normal science’ (Kuhn 1970) of observation, measurement and objective enquiry began to form the basis of formal, institutional maternity care provision in many parts of the world.
Positivist science in the ascendancy
The concept of (logical) positivism, or objectivism, began to be developed by the so-called ‘Vienna Circle’ in the 1920s (Crotty 1998). The philosophy spread widely over the next few decades. Its basic epistemology was that knowledge about the world can only be developed by observational evidence of what things are, and how they work, and that this evidence can best be obtained by mathematical deduction and theorising. Some of the principles of the theory were challenged as it dispersed. Most notably for this chapter, Karl Popper disputed the (ontological) assumption that, if we look hard enough and long enough, we will eventually gather enough information to verify how the world is, once and for all. Popper proposed that we can only ever get close to this truth, and that the way to do this was to propose a hypothesis, then try to falsify it (Popper 1959). As each theory is found to have flaws, a better and more precise theory can be proposed. This is the basic philosophy of basic biological science, and of the randomised controlled trial (RCT), both of which are dominant (but by no means universal) ways of finding out about pregnancy and childbirth in late modern societies.
Once established as a profession, the authority of medical practitioners to dictate the application of new clinical techniques was largely unquestioned by external agencies. There is, however, convincing evidence that internal challenges relating to particular techniques have always been prevalent, as examples in maternity care have demonstrated (Arney 1982; Tew 1990; Loudon 1992; Chamberlain et al. 1993; Graham 1997). Practice usually developed through trial and error, anecdotes and sharing of case studies (Bromley 1986). However, even influential individuals, such as the American obstetrician DeLee, were called upon by colleagues to provide objective, positivist evidence for more radical claims (Graham 1997, p. 49). The development of the RCT as applied to health care issues was a consequence of this increasing concern to find out if health care practices were really effective at the level of populations (Meinert 1986). The RCT was a revolution in the design, collection and analysis of data. It was borrowed from the design of experiments undertaken by agriculturists. It is based on the logic that if you rule out anything that might affect an outcome, then introduce the one element that you want to test for some of those in the experiment, but not for others, you will find out if the new element works or not. Any other element that is introduced (such as culture, gender, the state of mind of the participants, or the beliefs of the practitioners about the intervention) is seen as ‘noise’ that gets in the way of finding the true answer to the question under investigation. Randomising people to either the intervention or the control group allows both known and unknown ‘noise’ to be controlled for. To those who believed that universal truths were there to be discovered, this new technique promised answers to the vexed problem of what works in health care.
The challenge from interpretivists and constructionists
The argument against logical positivism as the sole epistemology for health care is that it over-simplifies human experience. Humans are influenced by society and culture, and not just by the biological and physical elements around them. At the same time as positivist positions were gaining dominance in the science of health, those studying the social world of human culture were drawing on alternative positions, such as constructionism and interpretivism (Crotty 1998). These researchers held that people make sense of the world through social interaction and language, and not just by observing and relating to objects and events in the physical world. In this way of seeing, the same physical things and events are interpreted very differently by different individuals, depending on their cultural and social history. Anthropologists and sociologists were early adopters in this field of largely qualitative research. These groups developed methodological approaches like ethnography (focused on culture), grounded theory (focused on the generation of new theories to understand social situations) and approaches based in the philosophy of phenomenology (focused on the meaning-making of individuals). Their methods included interviews, focus groups, and observational fieldwork.
The difference between so-called objective (positivist) and subjective (interpretivist/constructionist) positions is more than methodological. For some, it was deeply political. For example, feminists and ethnic activists were quick to appreciate the value of the phenomenological approach (Phoenix 1990; Fisher & Embree l999). Their critique was that the so-called objectivity of ‘normal’ (positivist) science was in fact a creation of the dominant Western (white, middle class, male, heterosexual, Christian) society. Attention to the cultural and personal dimensions of knowing allowed those outside this culture to finally make their voices heard (Phoenix 1990, pp. 92–3). Other marginalised groups have also seized on qualitative research as a way of gaining a voice. These include midwives and childbearing women (Kitzinger 1976; Kirkham 1987; Hunt & Symonds 1995).
For some philosophers and researchers, the two ontological positions described above are impossible to reconcile: either there is a truth waiting to be found, or there is not (Lincoln & Guba 1985). However, over the last couple of decades, there has been something of reconciliation between these two positions.
Bringing it all together
Since the early 1980s philosophers and researchers have begun to focus on the potential combination of positivist and more constructed positions, and on both qualitative and quantitative research ways of seeing. Bryman (1988) noted that different problems may need different methods:
Rather than the somewhat doctrinaire posturing of a great deal of the literature dealing with the epistemological leanings of quantitative and qualitative research, there should be a greater recognition in discussions of the …need to generate good research … The critical issue is to be aware of the appropriateness of particular methods (or combinations of methods) for particular issues
(Bryman 1988, p. 173)
Acceptance of the value of mixed methods has become increasingly evident (Daly & McDonald 1992). Proposals have come from researchers in fields as diverse as occupational therapy (Short-DeGraff & Fisher 1993) and maternity care (Oakley 1992). More recently, there has been a move to so-called ‘realist research’ that seeks to find out ‘what works, for who, in what circumstances’ (Pawson et al. 2005). This is a clear move towards the particular needs of individuals in their cultural, social and historical environments, and away from knowledge that is developed with large populations, and then applied in clinical practice to all individuals, regardless of their particular circumstances. Indeed, even the architects of evidence-based medicine held that
Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient value … when these three elements are integrated, clinicians and patients form (an)… alliance which optimises clinical outcomes and quality of life …
(Sackett et al. 2002)
Despite the continuing dominance of health care protocols and guidelines based on randomised trial data, there is some evidence that the more relative approach to knowledge for health care is becoming more mainstream (Wilson et al. 2001). The recent National Institute for Health and Clinical Excellence (NICE) guidelines for ante- and post-natal mental health use individual stories alongside more formal studies, to illustrate the fact that each person must be treated in their particular social and culture context, with an understanding of their personal life history (NICE 2007).
Oakley (1992) in reviewing the theoretical, philosophical and procedural basis of the Social Support and Mothering trial, offers a good example of a way forward. She illustrates the false dichotomy implicit in rejection of one or other technique, as she states:
Science and knowledge are socially produced: that is, they are subject to the very influence of social processes and practicalities that their common-sense representations would dismiss as quite beyond their frames of references.
(Oakley 1992, p. 335)
In an earlier paper relating to the same study (Oakley 1989) she succinctly argued the case for a common, value-free conceptualisation of the fundamental philosophy of research (and, by extension, of the kind of formal knowledge that should be used in health care). She claims that the tension between techniques such as randomisation and informed consent, or attention to protocol and clinical need, can be overcome, and the essential value of the RCT as a replicable, sound piece of evidence in guiding care can be matched with a participant-centred approach to the running of the trial. Oakley’s study illustrates her hypothesis that the methodological debates are not mutually exclusive. She suggests the following factors in creating a ‘non-dichotomous discourse of knowledge’:
(Oakley 1989, p. 344–5)
Alternative explanations for childbirth processes, including complexity theory
In 1972, Archie Cochrane, then director of the Medical Research Council Epidemiology Unit, published a seminal book, entitled ‘Effectiveness and Efficiency’ (Cochrane 1972). This put forward the apparently simple view that ‘all effective treatment must be free’ (my emphasis). Its implication was revolutionary in that it proposed by default that ineffective treatment should not be free. This agenda has become central to governmental thinking over the last decade. The problem arises in trying to define what is effective. This is not merely a matter of asking ‘does it work’, but, fundamentally, of deciding what should be evaluated, how this should be done, and how the results should be interpreted. More recently, Murray Enkin, one of the architects of the Cochrane Collaboration has confessed:
This paper … was conceived during an era of medical authoritarianism, born in a time of nascent … family-centered maternity care, matured in a period of enthusiastic (but not unquestioning) homage to evidence-based obstetrics, and culminated in a reluctant but comforting acceptance of uncertainty … it is, to use an ancient word I only recently learned, a clinamen, a swerve, a point of intellectual revision …
(Enkin et al. 2006)
There are echoes here of Ralph Pawson’s Realist Research position mentioned (Pawson et al
