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Theory versus Reality – Rights in Childbirth.

Many would argue that New Zealand women have a better deal when it cialis levitra viagra free sample comes to birthing rights and birth care than anyone else in the world. We have the right to decide where, how and with whom we give birth, and we can choose our http://www.pinneggiando.it/?p=859 midwife and have her care free-of-charge right through pregnancy, birth and up to six weeks after. These birthing rights were fought for by a community of strong, committed women who came before us. Thanks to them we are, indeed, cialis alternative very fortunate in our birthing freedoms. But despite our envied maternity care system, many women, and their midwives, are dissatisfied buylevitra with the incongruence between legislative rights and birthing realities. The pervasive medicalised birth culture infests the birth care many of us receive, https://homebirth.org.nz/magazine/cialis-line-order/ rendering our rights to informed choice and to autonomous birthing as little more than a feminist joke. While many of us in the home birth community can see through the misogynist poison that seeks to oppress birthing women and their rights, it still manages to seep into our experiences, and those of our midwives.

Home Birth Magazine

This article explores the midwife-woman partnership within the New Zealand maternity care system, and relates it to the experiences of home birth women and their midwives. It examines the challenges that women and their midwives face in exercising their rights and responsibilities, and it provides some insight into why it’s not always as simple as ‘supporting women’s choice’ when it comes to midwifery care. Suggestions are given as to how we can achieve a more positive birth culture for the generations that follow.

Jane had a traumatic first birth experience in hospital. She felt disempowered and damaged by a system of care that failed to support her most basic rights, and which coerced her to undergo unnecessary medical procedures that essentially led to the caesarean delivery of her baby.

Two years later, Jane is pregnant again. This time she is determined to avoid hospital. Her midwife had told her, when they first met, that she would support Jane to give birth at home. At 39 weeks of pregnancy, it is discovered that her baby is settled in a breech position. Jane does her research and decides that she wants to continue with her plan to birth at home. Her midwife, however, says she is uncomfortable with supporting a breech VBAC (vaginal birth after caesarean) home birth, and that if Jane chooses to birth at home, she will need to find another midwife.

 Birth Trauma

Within the New Zealand home birth community, scenarios such as the one above are not particularly uncommon. Choosing to birth at home runs counter to mainstream birthing. To have made such a choice suggests a high degree of investment in seeking a specific type of birth experience – one that upholds an holistically safe and loving family-centred journey. It also implies a greater sense of self-determination than many other birthing women possess. As New Zealanders we are in the fortunate position of having had the right to autonomous birthing won for us by past activists, but there is more at play than legislative entitlement when it comes to women’s birthing rights. The relationship between a woman and her midwife is a key aspect of how the woman’s birth unfolds.

At the core of every woman’s decision-making surrounding her birth, is the need for a safe outcome for her baby and herself. The fact is that no one can definitively determine what course of action (or inaction) will result in the safest outcomes for a mother and her baby. There is no one ‘right’ answer. Safety is a subjectively determined experience, one that involves more than just perceiving ourselves and our babies as physically safe. To be safe, we need to have our emotional, mental and spiritual selves protected from harm, too. Keeping that in mind, it is the well-informed mother who is most capable of determining the safest options for her pregnancy and birth. No one is more invested in a safe outcome than she is!

So, what may appear to the well-meaning family member, friend, midwife or doctor, as a mother making a dangerous decision regarding her birth, will almost always have an undercurrent of valid reasoning in its wake. If we use Jane’s example from the beginning of this article, the harm that was done to her through her hospital birth experience was so damaging that the risks of birthing her breech post-caesarean baby at home were less than the risks associated with birthing in hospital. However, to someone who does not know or fully understand Jane’s history, her decision to birth at home may seem unreasonable.

Since the beginning of the medicalisation of childbirth some 90 years ago, women have been coerced into believing that doctors and their tools and technology are better determinants of safe birth processes than well-informed women themselves. New Zealand, though, has enacted a maternity system that seeks to challenge such an oppressive dogma. The 1990 Nurses Amendment Act which allowed midwives to practice autonomously reflected years of political activism by women and midwives. Guilliland and Pairman (2010, p.17) note, “This shared personal and political activity gave birth to the New Zealand midwifery model of partnership.”

Recognition of birthing women’s rights and competencies in determining their birth processes is demonstrated in the philosophical and ethical underpinnings of this midwifery partnership model of care. Amongst the concepts that define this partnership are the following:

The midwife acknowledges the woman’s autonomy in her own life and respects the decisions she makes for her childbearing experience.

Midwives accept the right of each woman to control her pregnancy and birthing experience.

Midwives accept that the woman is responsible for decisions that affect herself, her baby and her family/whānau.

Midwives uphold each woman’s right to free, informed choice and consent throughout her childbirth experience. (Philosophy and code of ethics, 2014)

Such an ideology is congruent with the philosophy of home birth. In 1994 the Waikato Home Birth Association developed a comprehensive booklet for maternity consumers and workers, titled ‘Have you considered a home birth?’ The section ‘Qualities we expect in a midwife’ includes the statement, “The midwife must at all times respect a woman’s right to make informed choices over her birth. It is the woman who is in charge of her birth…and it is the woman who delivers her own baby.” (Waikato Home Birth Association Inc, 2014, p.11). As well, the Health and Disability Commission (HDC) produced legislation which states that every health care consumer has: “The right to make an informed choice and give informed consent.” (The code (full), 2014)

To further meet the needs of birthing women, as defined by women themselves, the New Zealand midwifery profession adopted a unique approach to all their organisational, regulatory, disciplinary and educational functions. The midwifery profession defines and implements each of these in partnership with women, both the woman and the midwife being recognised as expert and equal (Guilliland and Pairman, 2010).

Given that New Zealand midwifery acknowledges a woman’s right to autonomy in childbirth, why was it that Jane’s midwife (using the example provided at the start of this article) declined to support Jane’s decision to birth at home? As logical, empowering and positive as the partnership model of care appears to be, putting it into practice is occasionally a tricky balancing act, one that may find women and their midwives precariously walking a tight rope. Like any partnership, there will be instances where the needs of both parties will clash. Clearly Jane’s needs ran counter to those of her midwife. When faced with such ‘conflicts of interest,’ how well does this partnership model equate to birthing autonomy for the woman?

In this partnership of equality and shared responsibility, the woman has the right to choose where and how she gives birth, but equally, the midwife has the right to decline to continue caring for the woman. Although the midwife has a responsibility to be honest about her views and limitations regarding the care she provides, the withdrawal of care at the end of pregnancy puts home birthing women in the uneasy predicament of having to decide between three unsatisfactory options: 1) to give birth at home unassisted, 2) to give birth in the hospital, or 3) to find another midwife who will support her to birth at home, and attempt to develop a trusting rapport with her in a very limited time frame. This clearly undermines a woman’s right to determine her birth process.

Home birth midwife, Maggie Banks, views such withdrawal of care as a safety concern and says she would not discontinue care, but rather, “…continue to work with her, as birthing without professional support would, potentially, only compound any complication.” (Personal Communication, 26 May 2014). Similarly, Home Birth Aotearoa trustee, Sian Hannagan, believes that, “Having a midwife attend a risky birth is still better than a risky free birth [a birth with no midwife in attendance]” (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014).

By failing to support a woman’s choice to birth her baby at home, regardless of the midwife’s own view on the degree of safety, the midwife is feeding the patriarchal beast that seeks to subjugate all birthing women. Whether she means to or not, a midwife who drops her care of a woman late in pregnancy (or threatens to), not only sends the message that what the woman is choosing for her birth and her baby is wrong, it also coerces that woman into choosing an unsatisfactory birth option, the very thing that she was trying to avoid by taking ownership of her birth and opting for a home birth midwife in the first place.

In defense of Jane’s midwife, there was more to her decision to stop caring for Jane than just ‘feeling uncomfortable’ about the home birth option. Jane’s midwife was scared that if she supported Jane and the baby died during the birth, there would be a difficult battle to fight that she would almost inevitably lose, and that irreparable damage may be done to her career. Although the midwifery profession recognises a woman’s innate entitlement to determine her birth process, the medical community and our society in general are slow to adopt this understanding. In her protection of women’s birthing rights over the past 30 years of home birth midwifery practice, Maggie Banks has had complaints instigated against her from paediatricians, obstetricians, midwives, neonatal nurses and maternity managers, all of whom, she states, “…do not, or did not, understand that women have a right to control their own health decisions” (Personal communication, 26 May 2014).

 

Despite some advances, we continue to live in a society that bestows god-like status upon the white coats with MD affixed to their name, and crucifies women (including midwives) for being self-determining and supporting one another. In order for mutual safety to be achievable for women and the midwives who support them, each needs to support the other, especially in the event that things do not go to plan. This is no small task when faced with adversity, for even when this partnership of trust is upheld, midwives and women are still vulnerable pawns in a misogynistic society that does its best to maintain authority over women, especially those who threaten its power base. New Zealand College of Midwives (NZCOM) midwifery advisor, Norma Campbell, pointed out that a coronor investigating a baby death will find midwives at fault much more readily than when a baby dies at the hands of a doctor. “Doctors are listened to differently than midwives,” she said. (Personal Communication, 24 July 2014).

Sian Hannagan (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014), acknowledges that there is no black and white answer in solving the issue of protecting women’s rights whilst simultaneously protecting midwives careers, but believes there needs to be a more supportive environment for midwives, “…so that they don’t carry the blame if they aren’t culpable.” Despite having a maternity care policy that entitles women to retain autonomy over their birth decisions, midwives who support such policy run the very real risk of having their practice investigated and potentially thrown under the media spotlight. Midwife, Kate Rankin, points out this conflict of interest when stating, “The HDC does support [women’s choice] BUT the media and the midwifery council seem to want blood sometimes and the investigations they make can be extremely traumatic for midwives” (ibid.). Such a threat impacts the way many midwives choose to practice. Consequently, it also has an impact on the degree to which women can exercise their birthing rights.

Sadly, vulnerability for midwives who uphold women’s choices may also come in the form of judgment from their midwifery sisters. When midwife, Karen Van der Leden/Donald, supported a woman to birth her twins at home, she felt let-down and mistreated by her midwifery community. Karen has felt silenced in being able to celebrate and speak out about that special birth she was a part of, “…because of fear that no one will understand what true informed choice and consent is all about for women and their partners.” (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014). Midwives Jan Scherp and Maggie Banks wholeheartedly believe in the importance of depending on trusted midwifery colleagues – those whose practice is reflective of their own – in seeking support and guidance for the work they do (ibid.). Unfortunately, for Karen Van der Leden/Donald, there were no such midwives in her region. She was alone in her support of a woman’s right to choose her birthing circumstances.

What support exists for midwives outside of their like-minded midwifery circles? According to many of the midwives who commented on the Homebirth in Aotearoa New Zealand facebook thread (13 May 2014), very little. NZCOM midwifery advisor, Norma Campbell, disagrees. She said that the College receives calls from midwives facing practice dilemmas like those discussed here, all the time (Personal Communication, 24 July 2014). However, not all midwives appear to get the support they are seeking from such conversations. Karen Van der Leden/Donald, the midwife who attended the twin birth, had the following experience:

When I spoke to NZCOM… about my documentation etc, to make sure I was on the right track, I was told that they couldn’t advise me and that I was on my own and hopefully it wouldn’t get into the papers as another disaster. I did feel abandoned by them, as I did expect more guidance than this. (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014)

Midwife, Jan Scherp, explains why she believes trusted midwifery colleagues are a midwife’s only real support source within the midwifery profession. She says, “Midwifery Council are there to protect the public not support the midwife and NZCOM are there to support the midwifery profession but not the individual midwife” (ibid.). Perhaps the NZCOM fears being linked to the support of midwives who care for women that choose to ‘stray too far from convention.’ Appearing too radical could understandably be damaging to the reputation of the midwifery profession in the eyes of the public. But again, in what foggy undefined space does that leave home birth women like Jane and midwives like Karen?

For some midwives, as it is for Maggie Banks, support from the women they care for is another vital aspect of their home birth midwifery work. The woman relies on her midwife to offer holistic care, including honesty about her midwifery philosophy and limitations, and unbiased information to help guide decision making. And the midwife depends on the woman to communicate honestly and openly, and to maintain responsibility for the informed decisions she makes. Such co-dependence in the midwife-woman partnership necessitates mutual trust, good communication and shared responsibility in order to function effectively. For Maggie, the relationship of trust between her and her clients enables her to feel safe in supporting the choices of the women she works with, despite feeling there is a lack of professional support for midwives outside of their midwifery circles (Personal Communication, 26 May 2014).

For other midwives, though, broken trust has led to a more self-protective midwifery practice. Midwife Kate Rankin shares, “I am a midwife who supports a woman’s choice… but I have been seriously let down by women on several occasions” (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014). Such an experience could understandably lead a midwife to conclude that ‘if I can’t trust the women I work with to ‘have my back’, I’ll be less inclined to put myself in the position of needing them to.’

Counter to Maggie Banks’ personal experience, Norma Campbell revealed that, in her experience, most complaints against midwives come from the women they care for. When a baby death is involved, she said, it is “very rare” that the woman will take responsibility for whatever decisions she’d made regarding her birth. In their grief and anger, says Norma, parents are looking for someone to blame (Personal Communication, 24 July 2014). Knowing this, good clear communication throughout a woman’s pregnancy becomes glaringly vital. “Information sharing is what the partnership is all about,” says Norma (ibid.). And it’s not just about what is shared, but how it’s shared that determines its effectiveness. Norma points out the importance of midwives presenting things to women in pregnancy as their responsibility, and she acknowledges the need for the woman’s partner and support people to be a part of such discussions (ibid.).

Midwives also have an obligation to communicate the boundaries of their practice. Relating this to Jane’s story, perhaps it would have been more appropriate for her midwife to have stated her limitations around supporting Jane to birth at home at the beginning of the relationship. Instead, Jane was only made aware of this when it was essentially too late to opt to change to another midwife. Although it would be impossible to cover the total array of occurrences that could deter a midwife from supporting a woman’s home birth decision, it would surely be appropriate and helpful to ask a midwife early on: “Under what circumstances would you be unwilling to support me to birth at home?”

As was the case for Jane’s midwife, some midwives won’t attend home births due to a lack of experience and confidence with managing more complicated births. Twin birth, breech birth, and shoulder dystocia are some of the obvious examples here. One of the many worrisome consequences of our medicalised birth system is that birth practitioners are becoming less adept at managing these types of births. Women are often pushed to birth their breech babies, their twin babies, and their ‘large’ babies via caesarean section, resulting in birth workers having less opportunity to watch, learn from, and develop the skills related to, such births. Even women who are supported to give birth vaginally are frequently bullied into agreeing to various interventions, thus hindering their chances of giving birth in a physiological manner. Midwife Karen Van der Leden/Donald sums up the importance of the points being made here:

Midwives need to keep up their knowledge and skills in natural birthing practices, so that instead of making the woman feel uncomfortable with her choices for no scans, or no sonacaid, or birthing a breech or twin, a midwife is able to wholistically assess the woman’s situation and work with her instead of against her, working towards making good informed decisions based upon positive information instead of fear based processes which leave a woman detached, [and] more prone to interventions, postnatal depression, and other issues which are becoming more common these days. (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014)

Until society buys into the concept that women have the right to decide where, how and with whom they give birth, then this medicalised birth culture will continue to thrive, further eroding society’s view of birth as sacred, women as capable, and midwives as the experts in protecting normal birth. What will it take to get our society to see the light? Birthing rights are undeniably a feminist issue. In my opinion, the way we should look to begin tackling our medicalised birth culture is by strengthening our culture of womanhood. I say this because, as far as I can see, having an empowering midwifery model of care like that proposed by our home birth community and reflected in New Zealand’s Midwifery Partnership Model, is only going to achieve what it is meant to if women support and honour one another for the things that make us the strong, capable beings that we are.

At a grass roots level, I believe that more women need to share their birth stories with one another. This needs to be done in an environment which feels safe for women to be honest and open. If a woman’s birth has been hard or traumatic, she needs to be able to share her experience without fear of being judged for the choices she did (or didn’t) make, or of being told, “At least you have a healthy baby.” And women who have had a positive and empowering birth need to share how wondrous birth can be without fear of being judged for the decisions they made around their birth, or of crushing the spirits of those who didn’t get the birth they deserved. Because, unless women’s traumatic births are acknowledged as damaging and undeserved, unless women know how birth can be, and unless they hear what good midwifery support entails, they may only ever know birth as a horrid and disempowering event that they must suffer through in order to receive their much-wanted babies.

It is encouraging to see a growing number of online birth support forums which respectfully foster the sharing of women’s stories. It has been especially heartening to see global woman-to-woman support against birthing injustices (such as forced caesareans, or midwives being punished for supporting women’s birthing rights). When we roar with a united voice, we are powerful. Our sisters across the oceans are feeling our embrace, as we feel theirs, and we become empowered in our womanhood. At a national level, we have numerous support groups that honour women as mothers, and mothers as women. La Leche League and regional home birth support circles are two obvious examples. There are also a growing number of birth trauma support networks starting up. Through the learning and support gained by being a part of these groups, women will come to realise their birthing potential, and they’ll trust themselves more, both in their ability to birth their babies without medical interference, and in their ability to make wise decisions about their births.

As women, we need to support our midwives, too. We can do this by honestly sharing our needs, expectations, hopes, and fears regarding our births with our midwives, and by maintaining responsibility for the choices we make for ourselves, our births and our babies. It can be scary to make decisions that we feel unsure about, especially when we are making them on behalf of another human being, but they are our decisions to make… Welcome to motherhood. We can also support midwives in their learning and growth by inviting student midwives to attend our home births. Far too few midwifery students have witnessed even a single home birth by the time they finish their formal training. Being present at a home birth, especially after having witnessed numerous medicalised births, can be a game-changer for a student midwife who is still developing her own midwifery philosophy. Help to enlighten our future midwives by sharing your gentle and empowering birth experience with a student. And, if you’re comfortable to, you might like to consider inviting your sister, niece, or friend to share in your home birth experience, too.

Midwives, you can help strengthen our culture of womanhood by maintaining a philosophy of care which seeks to protect normal birth and be ‘with woman.’ Your home birth community (and all their yet-to-be-empowered sisters and daughters) are depending on you to enact this philosophy in the important work that you do. As well, you need to support your midwifery sisters, especially students and new graduates, to learn the range of ‘normal’ that exists amongst the pregnant and birthing population, by not interfering with Mother Nature unless there is a damn good reason to do so. Find midwifery colleagues who share your philosophy, and ensure there is opportunity created for the discussion of midwifery experiences in a non-judgmental forum, then lean on each other for support when you have doubts or fears… or when you want to celebrate another empowered new mother’s story. Midwife Karen Van der Leden/Donald notes that, “Midwives also need to know more about informed choice processes and how to practice safely when being challenged by what a woman wants, instead of making the woman fit into a box” (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014). In the current climate of medicalised birth, midwives are only too aware, and understandably protective of, their professional reputations. I’d like to pose the following questions to them: As a midwife, what do you want to be remembered for? What messages do you want to send women and the general public through the work that you do? Do you want to enforce and encourage women’s right to autonomous birthing? Or do you want to perpetuate our current medicalised birth culture which reeks of patriarchal dominance over birthing women’s minds and bodies?

Strong women fought for the birthing rights of all New Zealand women. Thanks to midwives like Joan Donley and to women like those in our historical home birth community, we now have policies in place that allow us to have much more freedom in how we choose to birth our babies. We are not lucky, we are incredibly fortunate for the hard work of the women who came before us. Let us not take for granted the foundations those committed women laid for us. As has been demonstrated in this article, we still have work to do in ensuring women and their midwives are supported to enact the principles behind the midwife-woman partnership. If you are not a member of your local home birth group, join now! If no home birth group exists in your region, start one up! Be a part of the birthing revolution that will see women and their midwives right across the globe, supported, valued, and respected.

To finish, as women and midwives we rely on each other for support and guidance. We do not always have the backing of those who are lost in the turbulent waters of patriarchal society and its medicalised birth culture, but we do have strength and wisdom amongst us. As Maggie Banks says, “We [home birth midwives] still need to look to each other for support and understanding about our culture.” And from Kate Rankin, “…and we need wonderful women (like the ones here) to love and protect us back.” (Homebirth in Aotearoa New Zealand facebook page, 13 May 2014). The power is within us to ensure that our daughters, and their daughters that follow, have a clear path to empowered birthing. As Margaret Mead so aptly said: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

 

References

Guilliland, K., & Pairman, S. (2010). The Midwifery Partnership: A model for practice. Monograph Series, Wellington 1/95 Victoria University.

Philosophy and code of ethics. (2014). Retrieved July 21, 2014, from http://www.midwife.org.nz/quality-practice/philosophy-and-code-of-ethics

The code (full). (2014). Retrieved July 21, 2014, from http://www.hdc.org.nz/the-act–code/the-code-of-rights/the-code-(full)

Waikato Home Birth Association Inc. (2014). Have you considered a home birth? (3rd ed.). Hamilton, NZ.

4 Comments

  • Reply September 9, 2014

    lisa kelly

    Great article. Totally related to this. Just keep on keeping on. Xx

  • Reply September 11, 2014

    Anna

    So the pregnant woman should have all the rights, but you want to take the rights away from the midwife and force her to care for a woman she does not feel comfortable caring for? The midwife has just as much right to choose her patients and to advise them to find another provider if the midwife does not feel comfortable with the pregnant woman’s choice. You can’t have it both ways.

  • Reply October 14, 2014

    donna fowles

    thank you to all the strong women and midwives who stood in the face of the doubters, who birthed in their homes, birthed their own stories of love and faith. Without you what would there be?
    No direct entry midwifery, no Bachelor of Health Science Midwifery, no knowledge of physiological birthing, no midwifery skills, no concept of partnership, and not my own sweet son born in the dining room in front of the fire…. there would be a heart sore me.

  • Reply January 25, 2018

    kelly

    this reflects and stirs my soul. For me, this is truth, spoken well. my 5th child was planned to be home-born, in a place of love under my own stars. instead, i laboured in a 140km car for 40mins at 2am and gave birth 1minute after arriving at the bright fulresant lights of the materty ward. Was care given? Who was kept safe in this? I am saddened, by my choice being taken from me, that when i needed a trusted educated person to make my choice safe there was no one for me. i am sad i didnt have the capacity to be brave in that moment, and surrendered.Next time my baby will be born here.

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