Everyone hates women

A few weeks ago, this excerpt from Adam Kay’s memoir This is Going to Hurt was doing the rounds on Twitter. Kay’s book recounts his experiences as a junior doctor working in obstetrics, and this particular excerpt caused a lot of disapproving comment:

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(I actually enjoyed Kay’s book and mostly he comes across as a human and decent individual. Still, he wrote this passage, so one assumes he stands by it.)

More recently, Amy Tuteur, who blogs as the Skeptical Ob, attacked an article by Justine Van der Leun about her difficult pregnancy. Van der Leun complained about the language used by the medical professionals treating her, using terminology such as “incompetent cervix” and “blighted ovum”.

Tuteur’s regards Van der Leun as “self-absorbed” and writes:

“Oh, grow up! It’s hard to imagine anything more immature than facing a life and death situation and whining about the language that doctors used to describe it.”

And now we have an obstetrician called Aoife Mullally express her views on women’s expectations of birth. According to an article in the Irish Times,

“Dr Mullally said everyone would ‘know the women because we’ve all had them’ who “think they are the only woman who’s ever given birth and they certainly think they are the only woman giving birth in the labour ward that day”.

She also said:

“For many women the birth experience has acquired a similar status to one’s wedding day – over privileged, over-anxious middle-class ‘birthzillas’ harassing well-meaning hospital staff with unrealistic birth plans, all the while egged on by ill-informed, overpaid midwives and doulas.”

(The Irish Times claims here that she is quoting Tuteur, but in fact it seems to be a quote from Victoria Smith paraphrasing Tuteur’s views in the New Statesman.)

Dr Mullally also apparently asked whether it was feminist to revere “effortlessly fertile, blissfully pregnant women who find affirmation in the excruciating”.

Sneering at women: the best sport of all

Women, eh? What are they like, with their ridiculous expectations of wanting to be treated as autonomous human beings? Middle-class women are the worst, as we all know: spoilt, entitled, privileged (words that are hardly ever applied to men). Even women seem to think of other women in this way.

There is a debate to be had – and is indeed being had – about how much medical intervention there should be in childbirth. Is medical intervention in childbirth frequently unnecessary, something that detracts from women’s ability to give birth normally? Is it a consequence of medics’ over-zealous desire to interfere in a process that would proceed quite smoothly if women were just left to get on with it? Or is medical intervention absolutely essential, something that has saved the lives of countless women and their babies?

The point is that it should be possible to have this debate without attacking women, either for being foolishly and self-indulgently wedded to the idea of a normal birth, or, on the other hand, for being too cowed, too frightened, too in thrall to medical science to attempt a normal birth. This is a debate that should be carried out between medical professionals: they, after all, are the ones who have a fundamental disagreement about how to manage childbirth. Argue it out amongst yourselves, but please don’t start blaming women for your disagreements. (Incidentally, is there any other area of medicine where professionals are so at war with each other over the best approach to patient care? It hardly inspires confidence.)

But women are an easy target. People seem to relish attacking women for their “privilege”, even though giving birth rarely feels privileged, and more often feels painful, exhausting and traumatic. It doesn’t feel privileged to be left permanently incontinent, or in chronic pain, though such women are usually told to be grateful that they and their baby are alive.

When men go into hospital to have, say, an appendectomy or heart surgery, no-one attacks them for their unreasonable expectation that they will be given the appropriate amount of anaesthetic, or that their stiches won’t be infected, or that they will be given pain relief when they ask for it. No-one calls them “spoilt” or “entitled” or reminds them how lucky they are to live in an age when medical intervention saves lives. No-one tells them to just shut up and be grateful.

As Victoria Smith puts it:

“The sneering dismissal of women having inner lives as some pointless middle-class indulgence has worked very successfully to undermine the authority of far too many feminist voices. The implication is that, if you care whether or not women are treated like complete human beings, with experiences of their own, you are focusing on some added extra: the icing on the cake of women’s liberation, as opposed to the most basic principle of all.”

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Are women too frightened of childbirth?

In today’s Mail, a former antenatal teacher forcefully expresses the view that horror stories in the media, and programmes such as Call the Midwife,  are responsible for peddling the idea that childbirth is frightening and dangerous. Reading or seeing horror stories, her argument goes, makes women feel frightened, and the fear itself increases the risk of a difficult labour and worse outcomes.

It’s a view I’ve heard expressed a lot recently – including last week, at a training day for midwives on mental health, at which I was also speaking. I couldn’t help recalling a talk I’d given a year ago, at the end of which an obstetrician expressed the view that the two most dangerous days of a woman’s life are the day she’s born and the day she gives birth. She went on to say that one of the reasons women felt traumatised by a difficult birth was that women these days were going into birth with expectations that were too high: they assumed that they would be able to give birth normally, with help from breathing exercises and a birthing ball, and were bitterly disappointed to discover that giving birth is much harder than they’d imagined.

So there you have it. In one view, women these days are too frightened of birth, which leads to them having a traumatic birth; in the other, women are too blasé, which leads to them being traumatised by birth.

What strikes me now, however, is that both views – that women should be either more positive, or more wary ­–­ are mistaken. Whether a woman has a good experience or a bad experience of birth has little, in reality, to do with how she feels about it beforehand, and a great deal more to do with how she is looked after by the people responsible for helping her birth her baby. Some things, of course, are out of everybody’s control: physiological problems that result in a long or particularly painful labour, or lead to a postpartum haemorrhage, are hard to predict and avoid.

But what we can do something about is how well the woman is treated. Is she being cared for on a one-to-one basis, or is her midwife, as a result of staff shortages, having to dash between multiple labouring women? Will the midwife ask the woman’s consent before carrying out an internal examination or breaking her waters? If the woman is in a great deal of pain, and asks for pain relief, will that request be taken seriously, or ignored or even belittled? If the woman feels the urge to push, will there be a check to see that she’s in second stage labour, or will it be assumed that she can’t possibly be that far along, as she hasn’t been in labour long enough? If something goes badly wrong, such as the baby getting stuck in the birth canal, or the woman haemorrhages after labour, will that emergency be dealt with not only quickly and efficiently but with kindness? Will someone explain to the woman what is being done and why? If she is feeling distressed, will someone take the time to hold her hand and comfort her?

All these things, as new research has confirmed, make a difference as to whether a woman finds her birth traumatic or not. It’s possible to have a potentially frightening experience, such as a shoulder dystocia delivery or a huge postpartum haemorrhage, without feeling traumatised, as long as the woman feels confident that the people looking after her are both capable and caring. Ultimately, whether the woman goes into labour feeling serene, or absolutely terrified, should make no difference, because if she is well looked after, then there is every reason to expect that she will come out of her birth experience feeling relieved and happy.

Should we think of birth as normal, or as dangerous?

 

A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.

 

 

 

 

Traumatic births: women tell their stories

It can be hard for women to speak out about their traumatic birth experiences. There’s a widespread perception that all that matters is a healthy baby, and that women should be grateful for a modern system of medical care that means they are unlikely to die in childbirth.

Of course, it’s great that most of us don’t die in childbirth any more. But not dying is setting the bar pretty low for our expectations for medical care. If we go into hospital for surgery, for example, we do usually expect a bit more from the care we receive than simply “not dying”.

So I welcome it when women are prepared to talk about what happened to them in childbirth and to highlight some of the poor practice that still exists. A new photo series called Exposing the Silence gives a voice to women who have experienced shockingly bad care.

The women in the photos speak of having procedures such as episiotomies or membrane sweeps performed without their consent or of being able to feel themselves being cut during caesarean-sections. A lot of the women speak of the trauma they felt after having their preferences ignored or dismissed.

These stories come from the US, but I’ve heard similar experiences in the UK. The story recounted by one of the women is not, sadly, uncommon:

“‘Do you understand you are doing this without my consent?’ As they are putting needles into my arm, I’m telling them, ‘You are doing this against my will.’ Their response, even as my strong contractions grew faster and I was in active labor, was, ‘I can’t wait all night, and we are doing this now.’ Less than an hour later, he was born, taken from me before I could hold him longer than a minute or two, and not returned until almost three hours later, even though he had no complications. I cried every minute and couldn’t stop thinking, this isn’t supposed to be like this.”

Is it a good idea to reduce the caesarean rate?

Caesarean section rates in western countries have been rising for a long time – but the rate varies widely between different countries. In Sweden, for example, it’s 17%, while in Cyprus it’s 52%.

It’s not at all clear why rates differ so much. Reasons often cited for high caesarean rates include: the increase in older first-time mothers (for whom pregnancy and labour is riskier); the increase in overweight mothers (ditto); the fact that babies are getting bigger; a trend for women to request a planned caesarean section; increased medical management of labour, which sets labour on a path culminating in emergency caesareans; and a cautious approach by doctors who fear litigation.

This is informed speculation, however: the only way to know for sure would be to record and collate the reason for every caesarean section, and that doesn’t seem to happen. I am slightly sceptical of the idea that the increase is down to women requesting the procedure. It provides a handy narrative and another pejorative term for women (“too posh to push”) but the truth is that the majority of caesarean sections are performed as an emergency procedure, and there are often medical reasons for planned sections (breech presentation, placenta praevia).

Does it matter?

This is the interesting question. In Australia, one in three babies is born by caesarean, one of the highest rates in the world. There is pressure to reduce the rate: caesareans, it is argued, pose an increased risk to the mother and baby. An article in the Sydney Morning Herald quotes Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women in New South Wales:

“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery. I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”

In New South Wales, a policy to reduce the c-section rate and increase the “normal” birth rate has been unsuccessful, with c-section rates remaining fairly static. According to the Herald article, there has even been an increase in the number of women having induced labour and forceps deliveries. More women “are having major haemorrhages after they give birth.”

One obstetrician, Professor Hans Dietz, argues that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours”. He says:

“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six. It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”

The article goes on:

“He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.”

Dietz is also sceptical about the oft-cited dangers of caesareans:

“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says.

So, is the drive to push down the caesarean rate misguided?

The short answer is: I don’t know. I suspect that nobody else does either. The Herald article demonstrates that people who work in maternity services have vastly differing views on the subject.

For women, it’s bewildering. Few, I imagine, are delighted at the prospect of surgery to deliver their baby; but even fewer want what Dietz describes as the potential consequences of a difficult vaginal birth: “urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”

What we need is more data: why caesareans are performed; the health consequences for women (and their babies) who deliver this way; whether reducing the caesarean rate results in better outcomes for women and their babies; the particular factors that lead to an assisted delivery; the physical and mental health consequences for women and their babies who have an assisted delivery; the correlation between factors such as age, weight and social class and method of birth.

Until we have that data, women will continue to be the unwitting victims of an argument that rages between professionals without coming to a satisfactory conclusion.