Assembly-line delivery

Maternity departments are often run like an assembly line.

dr walsh 298.88 (photo credit: Judy Siegel)
dr walsh 298.88
(photo credit: Judy Siegel)
Women have been doing it since Adam and Eve produced Cain and Abel, but much is still unknown about childbirth. Many of the world's modern medical centers have turned birth into an assembly-line aimed at keeping a maximum number of beds filled for a minimum amount of time. To mark its 25th anniversary, the Israel Childbirth Education Center (ICEC) recently held a day-long conference called "Humanizing Birth" in Jerusalem attended by about 400 women - Jewish and Arab, religious and secular. They were midwives, childbirth educators, doulas, breastfeeding counselors, doctors, and mothers interested in the subject. Unlike some of Israel's hospitals, the majestic YMCA auditorium where it was held was decidedly baby friendly, and participants who brought infants nursed them in an adjacent breastfeeding room. The event, organized with Great Shape/YMCA specialists in perinatal health, began with a greeting from Wendy Blumfield, president and co-founder with Marion Silman of the Haifa-based ICEC. She has spent the past 35 years promoting breastfeeding. Although she studied psychology and worked in British journalism before her aliya in 1974, she took a personal interest in breastfeeding and was certified by England's National Childbirth Trust. Blumfield and Silman encountered a serious lack of information and support for women who preferred natural childbirth and breastfeeding, so they established their center (which now has over 100 childbirth educators around the country) despite a complete absence of outside funding. "Remembering all the difficulties we had in bringing change to the maternity scene in Israel, it amazes me that we are actually celebrating our 25th birthday," she told the audience. "Many of the counselors trained by us over the years have themselves entered midwifery and public health nursing, and in this way made great improvements in the system." But Blumfield added there there is still a long way to go until women have totally free choice of birth place, until every hospital is baby friendly, until the medicalization of birth is reserved only for high-risk cases. "We have to make sure the World Health Organization's recommendations are implemented: Reduce the cesarean rate to an acceptable 12%, remove central nurseries in maternity departments, and make sure babies are with their mothers at all times, ban the marketing of formula in health institutions and make sure that every new mother receives breastfeeding counseling. And we need to support the protocols of the home birth movement so this is a safe choice." While the program included several speakers from Israel and abroad, the lion's share - four hours - was given to an Australian-born British midwife, Dr. Denis Walsh. One of only 100 male midwives in England, Walsh has delivered about 400 babies (but not his own two daughters). Working as a male nurse in Leicester, UK, he decided to train as a midwife in the mid-1980s because he wanted to deal in something happy. Walsh, whose Leicester hospital delivers 6,000 babies a year, is also an independent midwifery consultant and a researcher at the University of Central Lancashire. His doctorate on the "birth center" model has aroused interest, and he developed an evidence-based course for normal labor and birth, teaching more than 2,000 midwives throughout the UK, Ireland and Australia in the past five years. He has also published widely in journals such as the British Journal of Midwifery. WALSH BEGAN by saying that although he had worked as a volunteer in a northern kibbutz, he was not aware of new developments in Israeli birthing. But after being briefed by ICEC activists, he was encouraged to hear of the trend toward reduced medicalization and the greater empowerment of women. The shift from home births to hospital deliveries surged in the 1920s in the US, and only in the 1960s in the UK. In Israel, the Health Ministry has encouraged near-100% hospital birthing because of higher infant and maternal deaths in the Arab (especially Beduin) communities, and the hospitals - which receive NIS 6,000 per delivery from the National Insurance Institute - view it as a money-making enterprise. While an advocate of home births for women who want it and are at low risk, Walsh said he knew most babies will be born in hospital, or at least in special birth centers. But these institutions can train their staff to treat every woman as a healthy individual who has the right to state her preferences. Due to the widespread assembly-line approach to obstetrics, many hospitals regard 12 hours in labor as "too long" and "dangerous" to women and babies, he said. But, Walsh insisted, even 24 hours of labor is not too long if the baby is not endangered and its mother wants no undue intervention. "Until 60 years ago or so, there was an entirely different view of things. Today, there is a preoccupation with the length of labor. But every woman has her own pace," he said. "Can men poo on cue?" Walsh told of a center in Ireland where a single midwife does only vaginal examinations for women who arrive in labor, like a car factory where each worker assembles only one part. In the UK, some delivery wards assign a different room to each phase of labor, moving women from one to another to keep "production" moving. This depersonalizes the birthing process and disconnects midwives from their patients. The preoccupation with the "progress" of labor led to very frequent vaginal examinations by midwives and/or obstetricians, who insert gloved fingers to determine the size of the cervical opening. Some insist that for labor to be normal, it must "progress" at one centimeter an hour. "But people have begun to question this orthodoxy," he added. Periodic vaginal examinations during labor is unpleasant, and studies of women who suffered post-traumatic stress showed that many bitterly recalled the indignity. "Research has found no therapeutic value from repeated vaginal exams," said Walsh, and hospitals that have minimized them to even one in 12 hours observed no harm to baby or mother. In any case, the exam is unreliable, as one midwife or doctor can register a different opening size than someone who does it immediately after, he said. Obstetricians, he said, tend to lose patience if they are brought in for the early stages. They want it over with quickly, as their time is valuable, so they may initiate medical interventions prematurely or when they are not necessary. Midwives generally have more patience. "A midwife I know told me the most valuable skill she had in the delivery room was to knit." About one quarter of births in the UK - end with cesarean sections (and about 20% in Israel, compared to the WHO recommendation of 12%). Cesareans may be required in some situations, such as multiple births and if the fetus is feet down or in distress, but they should be avoided if possible, as they involve complications for the mother. In the US, where obstetricians - rather than midwives - are responsible for delivering infants, the cesarean rate is much higher. Creative ways of determining cervical openings should be considered, suggested Walsh, who presented two amazing observations among midwives in various parts of the world. In Peru, for example, it has been noticed that when the baby is about to emerge, a ridge forms on the mother's forehead from the top of her nose to her hairline. Others have observed that at this key moment, a "purple line" forms between the mother's anus and the top of her buttocks. While this is merely anecdotal, Walsh said, these signs should be considered and their accuracy studied. The delivery room should also be as comfortable as possible, with little noise, soft lights, and with as few intruders as possible. One study found that as many as 18 people can wander in during labor and delivery. Having one's husband or partner alongside until the baby cries has become de rigeur, but some recent studies have shown that the father is not necessarily the best person to be present. Some may feel sick, faint or be unable to provide support, Walsh said. The woman's own mother, sister, friend or a paid doula may be more helpful. Today, many midwives don't puncture the amniotic sac if it has not happened naturally; amniotomy has frequently been performed in delivery rooms to speed up labor, insert an internal electronic fetal monitor, take fetal blood samples or determine if there are fetal bowel movements, which are considered a sign of fetal distress. "No one claims there is no room for medical intervention if it is needed. When labor is not going well, it has to have a place, but you need clear justification," Walsh concluded.