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Birth Top Trumps - who holds the winning card?

As ambivalent as I am about social media, I’m a Twitter lurker. I enjoy the access it gives me to ideas & perspectives I might otherwise not hear. This week was a perfect example of that.

Ed Prosser Snelling, Consultant Gynaecologist & Obstretician, posted this graph and asked ‘Somebody remind me about the argument against routine induction of labour at 39 weeks? National Maternity Ambition. Patient Safety’. It’s a bloody shocker, and you don’t need to be a clinician to see that curve sweep up. Even someone as numerically challenged as me can see there’s something there.

I’ve followed Ed for some time now, and while I only know him through Twitters superficial veil, he seems like a decent, kind, ethically minded chap. But there’s something in his Tweet that ricocheted me back 9 years to my first pregnancy. It returned the shameful fear I hear echoed time and again in conversations with otherwise bright, capable, successful women; how can I keep my baby safe without compromising myself? Must I 'hand myself over' to have a healthy baby?

Ed’s Tweet was delivered with the airy confidence of the powerful. It sums up in one sentence the dynamic many pregnant women experience; the medic who knows they are right, and doesn’t need to prove it vs. a women who can only bring her feelings and intuition to the conversation. Ultimately, medics see this as the boundary line; the risk of the death of a child trumps every other factor.

Around 9 families a day become parents to a still born baby

Here are some facts about still birth, courtesy of Tommy’s;

· In 2017 1 in every 225 births ended in a still birth.

· For every 1,000 babies born, 4.2 were stillborn.

· That means that around 9 families every day become parents to a still born baby.

· Croatia, Poland and Czech Republic all have better stillbirth rates than UK.

· 2017 had the lowest stillbirth rate in the UK since recording began.

The sorrow the death of a baby brings runs far deeper than grief. Many families are never able to know why their baby died, which introduces anxiety & uncertainty to future pregnancies. The intensely personal experience becomes searingly public, as family members, colleagues, friends and the wider community absorb the news. There are the practical complexities of paternal leave, funerals, what to do with clothes, buggies & other items belonging to your lost child. And for the mother, the physical reminders or her pregnancy linger. It’s a loss that is rare, and there are few places & people to provide support in what can already be an isolating world. There's no minimising the impact of the loss of a child.

It’s more complicated than life and death, though.

What this Tweet didn’t take into account, though, is that while every single pregnant women I have ever met worries about still birth to some degree (depending on her experience & context), this is not the ONLY thing women fear about birth.

That’s the sensation I was viscerally reminded of when I read Ed’s Tweet. My novice’s inability to balance the fear of something awful happening to my baby, and the risk of something awful happening to me. I feared that in order to keep my baby safe I would have to expose myself to harm.

I speak to many, many women about birth. Superficially, they talk about pain, and the danger of birth ‘going wrong’. Speak to them carefully, though, give them time to form their thoughts (and women need time, because pregnancy is actually rather short, and women have a lot to learn in those short weeks) and the space to express them, and I find that what they actually fear is the loss of themselves. Women are scared of being lost to the process. Of losing the ability to self-determine. Of being bodies on the conveyor belt of a busy maternity unit, where decisions are made by coolly made by protocol, rather than with care and compassion.

Every woman I have ever spoken to about birth is acutely aware of that birth may require medical intervention (far more aware of the potential for this then the potential for birth to augment them). They are also aware, though, of their relative ignorance about birth, and how this makes them reliant on people they do not know. They know that sometimes birth requires invasive procedures to be carried out on the most intimate and private parts of their bodies, and that the side-effects may be felt for months & years. They understand that hospitals are institutions, designed for ease of process, rather than the comfort of the individual.

What women really fear is being harmed by birth. It’s a real and reasonable fear, because women are harmed by birth, physically & emotionally, everyday. I speak to too many women who carry physical, emotional and psychological damage. Often this damage is not reported at all, or if it is, it's directed to a mental health services, plastic surgery & women's physiotherapy, and I wonder if the implication of this is that those at the front line of maternity services remain unaware of the number of women who are discharged with healthy babies but very unhealthy minds & bodies. These women often blame themselves - they feel that either their body or their character failed, and they carry the result with guilt and shame. We don't have a facility to counter that, to reassure them that they weren't the only person in the room, that everyone played their part in how that birth played out. So these women are hit with a triple whammy; feeling undermined & out-gunned prior to birth, experiencing a damaging birth, and then left to pick up the pieces alone, and without support.

So the claim ‘we do this to reduce the risk of your baby dying’ doesn’t sound at all reassuring. It sounds coercive because it is. It is a way of getting women to comply to something they know might be harmful to them, without recognising that their fears are well founded.

How can we share our common purpose?

The point – the one that Ed’s Tweet missed – is that birth is more than a medical event. Birth is an all-encompassing human experience. Sure, it’s about life and death and risk. But it’s also about hormones, intensity, strength, fear, hope & resilience. It’s very personal and ignites issues like self-esteem, trust, vulnerability, sex, guilt, shame & identity. It’s more than personal, because it’s about faith & hope, rites and the culture we identify with. It’s about extended family relationships, and the stories our mothers, aunts, sisters, grandmothers & friends share and hold. Birth is about trust, vulnerability, compassion, power, nuance & complexity.

Ed’s Tweet highlights, better than I’ve seen in a while, that the medical claim to hold the Birth Top Trump doesn't hold true. Birth is not one thing. So suggesting that the view from one face of the prism (the medical) is pre-eminent to those from another (the holistic) throws the whole conversation out of balance.

For clarity, that is not to say that research like this should be ignored. Maternity, birth, matresence is truly the bed-rock of everything that follows, and I want more research, more widely shared, please.

The death of a baby is certainly the worst outcome. I don’t agree that it’s an argument for a race to the bottom, through, to sweep aside all the other factors inherent in birth and focus solely on how medicine can ‘solve’ this issue on behalf of (and separate to) women.

My ambition for improvements in maternity services is for experienced, compassionate, ambitious, enthusiastic medics like Ed Prosser Snelling to continue their research and their drive to improve maternity services for all women. I also want pregnancy to be recognised as a pivotal human experience, rich & complex & vital. I want it to be recognised that all women are not the same, that one size does not fit all.

More than this, I would dearly like us all to share a comprehensive view of what happens for women while they are pregnant. This current division of medical vs. holistic only serves to drive an increasingly unhealthy dialogue around birth - and in turn damaging women who have no choice but to nail their colours to one mast or another. What we are doing now is limiting women's choice, rather than augmenting it.


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