by Jo Marchant
I remember bright lights and Tom Jones (the surgeon’s choice); a tall, blue screen across my chest; and talking to my partner about the first thing that came into my head—ice cream, as it turned out—to distract myself from the odd, rummaging sensations coming from inside my abdomen. Then a baby girl, drenched in blood, was lifted high above the screen.
It was August 2009. Days earlier, heavily pregnant with my first child, I hadn’t been too worried about the birth. I was fit and healthy and had attended all my pre-natal classes. My local hospital had a midwife-led center with birthing balls and water pools. I was excited about feeling the first contractions, and planned to sail through the delivery with some relaxing massages and deep breaths.
It didn’t happen that way. For several days of early labor I felt no recognizable contractions, just a searing pain in my pelvis that left me unable to eat or sleep. Things just didn’t feel right, and by the time I got to the hospital—high blood pressure meant I was ineligible for the birthing center, so I ended up on the obstetrics ward—I was exhausted and scared.
A midwife promptly broke my waters, wired me up to a fetal heart monitor, and administered artificial oxytocin to boost my contractions. That’s when I realized that the searing sensation I’d felt before had been mere discomfort. Now the dial jumped to ten—my pelvis was surely breaking, something must be wrong. Overwhelmed by fear and pain, I started to panic.
The midwife seemed frustrated. In her view I was still in relatively early labor, and should have been coping better. I’ve climbed mountains, I wanted to protest. I’ve dived with sharks (well, reef sharks at least). I have a black belt in jiu jitsu! I’m not a wimp with no willpower or tolerance for pain. But it’s hard to talk when your awareness is dissolving into screaming white noise. This was all perfectly normal, the midwife insisted between contractions. Her words made me feel alone. Either she had no idea what I was experiencing, or I was a complete and utter failure at childbirth.
I found out much later that my baby was in a difficult position, facing forwards instead of backwards, which meant that instead of fitting smoothly into the birth canal, her skull jutted awkwardly against it. Given time, babies in this position sometimes turn. But when the midwife broke my waters and administered oxytocin, the fluid cushioning the baby’s progress was gone, and my contracting uterus forced her skull inexorably downwards, bone grating against bone.
I requested an epidural, and the disappearance of the pain was magical. As sometimes happens after an epidural, however, my contractions slowed. I spent the next 24 hours flat on my back surrounded by wires, drips and monitors. With the first midwife long gone, a series of others came and went. They checked graphs and upped doses, carried out internal exams to check on my progress, and poked a needle into my baby’s scalp to check on hers. Eventually, a doctor informed me that she was stuck and I would need an emergency caesarean section.
I didn’t hold the baby at first; I was nauseous and shivering violently after the surgery, and no one thought it was a good idea. Without that initial contact, my daughter subsequently struggled to breastfeed. She started her life crying and hungry in a Perspex-walled cot (she lost over 10% of her body weight in her first week), while I was scolded day and night for her condition by a further carousel of midwives and health visitors.
One of them made me spend hours expressing drops of precious colostrum into tiny syringes (tricky in the dark when the only lamp is on the wall behind your head), then the next would come on shift and chide me for having left my baby in her cot. Another repeatedly folded my breast into my daughter’s mouth as if she were stuffing a chicken. I wondered how long it is possible for a person to go without sleep.
Four days and several panic attacks later, I was allowed home. I was overwhelmingly grateful to have a healthy child, but I was left wondering whether there might have been another way.
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IN OTHER words, it was a typical birth. Thanks to modern medical care, childbirth is now extremely safe. In the U.K., only around 0.7% of babies are stillborn or die shortly after birth.1 The proportion of women who die is even lower. And we have ready access to pain relief. Yet despite all that, labor is often a distressing experience. In one survey, nearly half of women interviewed two days after the birth of their babies said that it was the worst pain imaginable, even though 91% of them had received pain-relieving drugs.2
And many women are left with mixed feelings about the birth of their babies. Around a third of women feel traumatized after giving birth, while 2–6% of women suffer from full-blown post-traumatic stress disorder (with women who have experienced instrumental deliveries or emergency C-sections at increased risk).3
Meanwhile more than half of births in developed countries such as the U.K. and U.S. are “assisted,” which means they are either induced or involve the use of instruments or surgery.4 Such outcomes can have long-term health implications for mother and child. Take C-sections, for example. Particularly when surgery is carried out as an emergency, potential complications range from bladder damage and infection to life-threatening hemorrhages and blood clots.
Women who deliver by C-section also risk complications in future pregnancies, including uterine rupture and problems with the placenta. They are less likely to breastfeed (which protects babies against infection) and may be at greater risk for depression and post-traumatic stress (which affects how they care for their babies). With all the advances of Western medicine, is this really the best we can do?
Ellen Hodnett, a professor of perinatal nursing research at the University of Toronto in Canada argues that we should take a different approach. It turns out, she says, that there is something that reliably reduces pain, distress and the risk of complications and interventions during labor. But it isn’t a drug, a scan or a surgical procedure. It isn’t a fancy birthing position, or even a state-of-the-art hospital wing. It’s having the same caregiver stay with you throughout a birth.
In 2012, Hodnett analyzed 22 randomized controlled trials involving over 15,000 women in 16 countries, and found that women who have one-to-one continuous support through labor are less likely to need a C-section or instrumental birth, and are less likely to use painkilling drugs.5 Their labors are shorter, and their babies are born in better shape. “It’s the only intervention I’m aware of that actually reduces the likelihood of a caesarean birth,” she says.6
When used appropriately, C-sections save lives, and all things considered are extremely safe. But they are still major surgery; not something to go through without good reason. The World Health Organization warned in 2010 that although very low C-section rates are dangerous, so are unnecessarily high ones.7 Studies across different countries suggest that the ideal C-section rate is around 5–10%; rates below 1% and above 15% tend to signify worse outcomes for mothers and babies. The C-section rate in England, where I live, is 26%. In the U.S. it is 33%.8
But why should being accompanied by one caregiver—rather than having intermittent support from different midwives who go on and off shift, say—influence whether a woman needs surgery? Hodnett suggests that perhaps those who receive continuous care are more likely to be helped into physical positions that aid labor. Emotional support from a single, trusted person may also reduce women’s fear and stress and help them to feel more in control. This can reduce the pain they feel during labor, meaning they need fewer painkilling drugs, which in itself can reduce complications and cut the need for further interventions. Easing anxiety can also influence the physical progress of labor directly. Hormones released into the bloodstream when we’re stressed or scared, particularly in the early stages of labor, act to slow contractions down.9
The benefits of continuous care are strongest in developing countries, particularly in situations where women are frightened or uneducated about labor, and tend to give birth in poorly equipped hospitals, without the support of a partner or family member. In a study of 7,000 women across the U.S. and Canada, by contrast, continuous care didn’t reduce t
he rate of interventions at all.10 Perhaps here medical care is so good they don’t need the extra support?
Not so, says Hodnett. She argues instead that an aggressive approach to intervention in these countries trumps any influence of continuous care. “Everything is ruled by the clock,” she says. “You’ve got to have your baby within a certain amount of time or there’s a problem. That’s not evidence-based, but everybody relies on the clock.” If things don’t go to schedule—a labor not starting on time, progressing too slowly, or a woman taking too long to push her baby out—staff step in with drugs, scissors, forceps or surgery.
“You’re in an environment in which two thirds of women are getting artificial oxytocin in labor, they’re all getting continuous fetal monitoring, so they’re confined to bed. They’ve got IVs, they’ve got powerful drugs, at least two thirds are getting continuous epidural analgesia in labor.” Women attempting to give birth in such circumstances inevitably end up requiring high rates of drugs and surgery, argues Hodnett, whether they have a supportive caregiver or not.
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SO WHAT happens when women give birth outside of that high-tech environment—for example at home? It’s a choice made by about 3% of women in the U.K., and just 1% in the U.S. When women labor at home, the same midwives generally stay with them throughout the birth, while most drugs and medical interventions aren’t available without a transfer to a hospital.
Randomized trials comparing planned home and hospital births are almost impossible to do, because it’s not practical or ethical to force women to give birth in a particular place. But there are plenty of large, observational trials, including a 2011 study that followed nearly 65,000 women with low-risk pregnancies.11 These studies compare women who choose hospital birth with those who try to deliver at home (regardless of whether they have their babies there or end up transferring to hospital for pain relief or medical intervention). It turns out that simply by choosing home birth, women are less likely to require drugs to induce or speed up labor or relieve pain; less likely to be cut open or to tear; and less likely to need a C-section or instrumental delivery. Their babies are born in better shape and are more likely to breastfeed.
A similar picture comes from U.K. trials of independent midwives, who work outside the National Health Service. They avoid medical interventions unless there is a clear reason for them, with many of their deliveries taking place at home, and the same midwife cares for a woman throughout her pregnancy, as well as during and after birth. A 2009 study of nearly 9,000 women found that 78% of those in the independent midwife group had unassisted deliveries compared to 54% of those who received conventional care.12 Their babies were around half as likely to have a low birth weight or to be admitted to intensive care, and breastfeeding rates were much higher.
Perhaps some of these benefits aren’t surprising, but aren’t the extra interventions carried out during conventional hospital births necessary to save babies’ lives when things go wrong? It turns out that in many cases, the answer is no. For low-risk pregnancies in women who have given birth before, laboring at home is just as safe, with exactly the same rate of neonatal death and injury. The authors of a 2012 Cochrane review (the medical profession’s gold standard analysis) on home versus hospital births blamed the higher complication rate in hospital on “impatience and easy access to many medical procedures.”13 In 2014, the NHS released new guidelines saying that such women are better off outside the obstetrics ward and should be encouraged to give birth either in a midwife-led unit or at home.14
It seems that when you replace easy access to technology with caring for a woman’s emotional state, she and her baby fare much better—not just mentally but physically too.
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WHEN I went into labor for the second time, late one October evening, my partner and I called the (independent) midwives and transferred not to hospital but to an inflatable pool on our living room floor.15
Jacqui Tomkins arrived first—efficient, expert and the essence of calm. The pain built faster than I expected, every contraction an agonizing, all-consuming embrace, each one stronger than the last. And while I had gone into my first delivery naively confident, this time I knew how difficult things might turn out to be. “I don’t think I can do this,” I said to Jacqui. “Of course you can,” came the no-nonsense reply, like a mother reassuring her child on the first day of school. I’d got to know and trust Jacqui through my pregnancy, so whereas the assurances of constantly rotating midwives during my first delivery only isolated me, this time her words struck home. This was pain but with the fear taken out—nothing like the overwhelming, drowning chaos I’d felt before. Eventually I got into a rhythm: feel it rise, relax, close your eyes, breathe out. Like ducking under a wave into the still water instead of struggling through the crashing surf.
After six hours or so, I heard a noise. It was a guttural roar, that seemed to have come from me. “What’s happening?” I asked in alarm. Jacqui smiled. “You’re pushing your baby out.” This, I discovered, was a different pain, like being ripped and torn from the inside. But it was too late for second thoughts now. And thankfully this final phase is usually short; delivery could be just minutes away. My second midwife arrived, ready for the big moment. Elke Heckel is a large, warm German woman who dresses in bright colors and likes Earl Grey tea. She had heard the noise too. “Not long now,” she said cozily, and settled herself onto the sofa.
Her arrival was comforting, another thread in the safety net that Jacqui had woven around me. Unfortunately this baby too found an awkward position, with his elbow jammed against his head, and his progress down the birth canal was scrapingly slow. Two hours later, the sun was peeping through the shutters, and London commuters crunched past among autumn leaves. But there was no baby. I was exhausted, and once again starting to panic.
I had been pushing for longer than guidelines for conventional care allow. At this point, NHS midwives would have ambulanced me to the hospital for an obstetrician to extract the baby, using scissors, forceps or most likely (because of my previous history) another C-section. This would guarantee a timely delivery. But emergency surgery would bring its own risks, including potential difficulties persuading my newborn to breastfeed. The hospital stay and longer recovery time would also leave me less able to care for my three-year-old at this sensitive time in her life.
Instead, Jacqui and Elke continued to monitor the baby, and assured me that with all looking well, there was no need to intervene. “You’re doing great,” they said. “He’ll come in his own time.” And that was it. That was the moment the statistics changed; the moment an emergency C-section became a complication-free birth. Played out on my living room floor, it was a demonstration of what trials show holds true across tens of thousands of women: that the reassurance of someone we trust is not a trivial luxury. The right words can be powerful enough to replace aggressive medical intervention and transform physical outcomes.
A few minutes later my son slid into the water. Jacqui fished for him in the dim light and guided him into my arms: pale, puffy-eyed, perfect. I was feeding him on the sofa with a mug of tea in my free hand, just in time for my daughter, who had slept through the whole thing, to come downstairs and say hello.
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OF COURSE, home birth isn’t the answer for all—or even most—women. Many women have no wish to give birth at home, and the trials mentioned above suggest that first-time mothers may be safer not to; when they give birth in a hospital compared to at home, slightly fewer babies die or are seriously injured. (The same is almost certainly true for high-risk pregnancies such as breech birth or twins, although virtually no studies have been done on this because so few of these women attempt home birth.)16
What the contrasting births of my children taught me, however, was how crucial emotional support can be wherever women have their babies. We respond very differently to care delivered by someone we know and trust rather than by a series of strangers, and this affects not just psychological outco
mes but physical ones too. Unfortunately, our medical system generally asks women to choose between two extremes: they can have either holistic care at home, but without immediate access to life-saving medical technology, or interventionist, impersonal care in the hospital.
Hodnett argues that we should aspire instead to the best of both worlds: a supportive hospital environment with midwives who stay with women throughout their labor—with access to pain relief and medical technology when they are needed, but only then. This is partly the philosophy behind midwife-led birthing centers in the U.K., but these still don’t guarantee continuous care, and they cater only to women with low-risk pregnancies (about 45% of cases)17 who are willing to forgo the most potent forms of pain relief. What about everyone else, though? Wouldn’t all women—including those on the obstetrics ward—benefit from more supportive, less aggressive care?
“The common response in North America is we can’t afford to have continuous one-to-one support in labor,” says Hodnett. She argues that it doesn’t necessarily cost more, however: in a trial of nearly 7,000 women in 13 hospitals across North America she provided continuous care simply by changing how nurses and midwives were deployed, without increasing the number of staff working at any particular time.18 And of course reducing the number of interventions required would ultimately be cheaper, not more expensive. The average amount charged by U.S. hospitals for maternity care (pregnancy, labor and newborn care) is around $50,000 for women who have a C-section, compared to around $30,000 for those who have a vaginal birth.19
If her studies had shown that women should get an expensive new drug during labor, Hodnett says, “everyone would have gotten it the next day.” Introducing new drugs fits easily into the existing model of medical care. Changing instead how women are looked after wouldn’t necessarily be more expensive but it would take wider changes in how hospital departments are organized, and according to Hodnett, there is little appetite for tackling the problem. “It requires a shift in attitudes and behaviors of the physicians, nurses, midwives and hospital administrators that just hasn’t happened.”
