Dear Mr Anaesthetist
On Wednesday night I made a new friend on twitter. Whilst broadcasting both of our, rather different, thoughts on the Channel 4 documentary One Born Every Minute, an anaesthetist and I collided across our respective wi-fi’s. You can read our discussion here (look out for @welsh_gas_doc).
I’ve had similar conversations before in the real world. They generally start off a bit less confrontational when you are face-to-face, but I’ve had to count to ten more than once to prevent myself from exploding with rage at medical professionals in my social circle when discussing issues around childbirth, safety and pain.
Here on the internet I feel less inhibited, but twitter’s 140 characters don’t lend themselves to reasoned argument. So, @welsh_gas_doc, here’s my open letter to you. Consider this cc’d to several of your twitter colleagues and a few of my own acquaintances. I’d love you to read it all the way through.
Dear Mr Anaesthetist,
as we established the other night you probably weren’t looking for a reasoned debate when you introduced yourself to me. I get it. Your twitter stream was pretty funny and the ‘lentil weaving banshee bashing’ that you hoped to engage in would indeed have made it funnier. Full credit to you for dropping that plan swiftly and realising that we aren’t so poles apart in our aspirations if not our methods.
Yet the catch-all unifying slogan of ‘it’s all about informed maternal choice so we’re on the same side really’ doesn’t really get to the heart of how I feel when I read your comments and listen to the face-to-face conversations I’ve had with others in your profession. So I’m writing you this letter in the hopes I can explain myself properly and give you some insight in to my world.
First I’d like to tell you how grateful I am that:
– you and your profession exist. Without you there would be no life-saving caesarean sections, no relief for mothers at the end of their tethers, no respite for someone during a long induction of labour, no chance to sleep and rest and recuperate.
– so many of you that I encounter professionally are gentle, calming, kind and go to great lengths to treat mothers as individuals.
– you often subtly reinforce the message that choosing pain relief isn’t failure and can be a positive choice for a woman and her baby.
– you almost always let me stay in the room while you put in an epidural, recognising the support I can give not only to the mother but her (often frightened or squeamish) partner and the help I can be to you as a trusted and well-known voice who knows the ropes.
– you sometimes let me come in to theatre if a change of plan becomes necessary, presumably knowing that it is at this time that my support is often at its most valuable.
But I’d also like you to try and understand that:
– when we meet mid-labour we are at very different points in our journey with this woman. I will have been getting to know her, earning her trust, hearing her deepest fears and hopes, laughing and crying with her often since the first trimester of her pregnancy. I will have been with her for hours, sometimes days throughout her labour. I know this woman, I care deeply about this woman and I am emotionally invested in her.
– my job is not to obstruct you, it’s not to spout propaganda, it’s not to laminate a birth plan that states that pain relief is for unwomanly wimps, it’s not to wave mystic crystals and scents and it certainly isn’t to question the judgement of highly qualified medical professionals.
– maybe you don’t know much about what I do?
So, let me try and summarise for you that as a doula I:
– never advise my clients, only signpost them to resources, remind them they have choices and encourage them to ask questions. So that they never look back and say ‘I don’t really know how that happened’ or ‘why was that done to me?’
– am frequently the only ‘continuity’ person involved in this woman’s pregnancy and birth.
– do most of my work before the birth building a strong relationship, getting to know the woman and her partner, understanding what she wants and needs, encouraging her to think through her fears and hopes, building confidence in her body.
– may have worked with her on dealing with a previous traumatic birth or helped her come up with a plan to handle the impact previous sexual abuse or a phobia may have on her labour.
– have no agenda other than supporting a woman to have the most positive pregnancy, birth and postnatal period that she can. If what she needs is an early epidural, let’s see how we can make that happen. If she needs a home water birth after a previous caesarean let’s put her in touch with the Supervisor of Midwives and see what we can get agreed.
– will be supporting this woman for weeks, sometimes months after she has the baby. Providing a listening ear, feeding support, signposting her to resources, helping her process the birth – particularly if it didn’t go to plan. I will know in no uncertain terms how she felt about her care, what helped, what made her feel strong and what made her feel weak, what she regrets and what makes her proud, what helps her set off on her journey in to motherhood and what hangs like a millstone around her neck. I will know this and I will take this knowledge through to future births.
Because I try to tune in to others as part of my job, I’ve thought about the fact that we have such different experiences of birth:
– I’d guess you only (or almost only) see women at a point in their labour where they can’t manage the pain. The only thing that helps is what you can provide. You watch someone who is sometimes screaming in pain gradually relax and finally sleep peacefully. All is well again. I understand why you’d want all women to have access to this.
– I, more often, see women who never get to that point. They aren’t ‘enduring pain’ or being brave, or following an ideal to the letter because of their principles or ill-informed antenatal teachers. They are simply ok. Sometimes (like with my labour) it just isn’t really painful. I chose my positions, was well supported, it wasn’t too long, I used water, I felt relaxed, my body did its thing and you couldn’t have paid me to have sat still and had a catheter inserted in to my epidural space. I’m a wimp, terrified of needles, it would have been awful. Sometimes it’s tougher, women need lots more coping strategies, especially when they get tired. And yet for a myriad of well-thought out reasons and in the moment instincts they don’t want pain relief when it is offered and are glad afterwards that they didn’t.
– I see birth in many different settings: home, hospital, birth centre. I know the difference that a home environment makes to women’s perceptions of labour as painful. I imagine that while you’ve experienced many more labouring women that me you have only encountered them in an obstetric setting.
– I also see the difference that home can make to the management of a woman’s labour with time and space for a woman to progress in the way her body sees fit, rather than the way hospital protocol dictates. NHS homebirth midwives often agree that – even though a mother and baby never showed any signs of distress – the homebirth with no interventions, no tears, no episiotomy that we just witnessed would have been an augmentation of labour with all the additional stress that brings in a hospital setting.
– I see birth as a year-long journey. I get involved in the planning, the anticipation, the birth from first twinge to delivery of the placenta and the beginnings of new parenthood. I imagine you see women mainly during the first stage of labour and rarely during pregnancy or much beyond the birth.
And because of that we’ve formed different opinions around the same event. I believe firmly that:
– unmedicated birth is something to strive to protect. Not for everyone is it safe, appropriate or desired and that is fine. But in the context of our maternity services where statistics show it is getting harder to achieve, there need to be people committed to keeping women informed about the benefits of normal birth. All the while ensuring they respected a woman’s right to choose and never to be made to feel guilty about her decisions.
– there are benefits to normal birth. Like everything birth-related there are risks and benefits which must be weighed up in relation to a the individual mother and baby, but benefits there are. While you are keen to assert that the causal link between epidurals and intervention isn’t proven the strong statistical association between the two can’t be denied. For a woman who doesn’t want intervention there is a strong motivation to avoid an epidural. And interventions increase the various risks for mother and baby – the aftermath of a forceps delivery on a woman’s perineum, bladder, pelvic floor, mental health (not to mention physical trauma to the baby) spring swiftly to mind.
– there are plenty of (albeit not enough) studies which demonstrate the relationship between a more medicalised birth (especially opiate analgesia) and breastfeeding issues. So women who want to breastfeed and to experience the profound health benefits to themselves and their babies that this confers also have a motivation to avoid a medicalised birth.
– normal birth, without anaesthesia or analgesics, is more often achievable if a woman has the kind of continuous support during labour that I provide. This support doesn’t seek to ensure women don’t use pain relief but makes it possible for them to have a positive experience without it should they want to. The support of a doula (or of another person not associated with the hospital or a member of the woman’s social or family circle) has been shown to not only decrease the need for pain relief, but improve maternal satisfaction, improve baby’s APGARs and decrease the risk of interventions like forceps or caesarean sections. You can read more about the Cochrane review I’m refering to here.
To be 100% clear about this I do want you to imprint on your mind that this very large review of studies concluded that the group of women who had this kind of labour support had less pain relief and were happier with their experiences.
So it does make me angry when you say things like:
– “homebirths are unnecessarily dangerous”
– “Nothing makes my heart sink more than the presence of a laminated birth plan and a doula in the room!”
Because those kind of blanket statements (seemingly born only from personal experience, opinion, agenda and a willful disregard for some very concrete evidence to the contrary as well as a lack of understanding of what is outside your sphere of comfort and knowledge) cause exactly the kind of problems, issues and divides that you bemoan.
Medical professionals, especially those who work in a field connected with childbirth, should be careful about expressing such negative and divisive opinions about choices. People listen to you, they take your advice, they believe you therefore you have to accept some responsibility when it comes to your publicly shared views on these choices. Especially choices like homebirth which have just been demonstrated to be safe and lower the risk of an unwanted intervention by over 30%. Especially choices like having a doula which further lower that intervention rate and improve maternal satisfaction (whether the birth goes to plan or takes a different turn). Especially when someone feels so fearful that her medical caregivers will disregard her wishes that she goes as far as laminating her birth plan.
And while maybe I was a little faecitious with my use of the word ‘friend’ at the start of this piece, I’d actually like to build bridges between our different thoughts and opinions. Because I do agree that women are unkind to women and can often be viscious about different parenting and birthing choices to those they made themselves. I concur wholeheartedly that a woman should never suffer something she can’t bear or doesn’t want to bear in childbirth. A woman should never be deprived of something she needs, or made to feel like a failure for changing her mind and taking a different option.
I’d just like you to look through my eyes and the eyes of a woman I’m supporting and ask yourself not ‘how can I save her from enduring this pain’ but ‘how can I help her make a positive, informed choice so that she is never enduring anything but simply making a series of her own good decisions that she can look back on and be proud of – whatever they are.’