In this chapter, the phrase ‘promoting physiological birth’¹ is used deliberately as an alternative to the commonly heard phrase ‘the midwifery art of keeping birth normal’. As Holly Kennedy (2004) has suggested, the notion of ‘normal’ is hardly in keeping with the midwifery philosophy of embracing the concept of each woman’s birth being viewed by her as essentially ‘special’. However, women and most maternity care providers are unlikely to use the term ‘physiological’, and the word ‘normal’ is embedded in the documentation and discourses that shape and reflect contemporary maternity service provision. Importantly, the term ‘normal’ is used to identify the primary domain of the midwife, a sphere of practice that is clearly defined as separate from the technological or medical interventions associated with complications, identified here by the World Health Organization (WHO):

The midwife appears to be the most appropriate and cost effective type of care provider to be assigned to the care of normal pregnancy and birth, including risk assessment and the recognition of complications. (WHO 1996, p 6)

Fulfilling this role is not as straightforward as it might seem. Midwives in Western countries often work in hospitals where computerised summaries identifying ‘normal birth’ do not necessarily reflect physiological processes or the efforts of practitioners to promote physiological birth. This was identified in an important epidemiological study of 1464 births in five consultant maternity units in the United Kingdom (Downe et al 2001). Once women who had artificial rupture of membranes, induction and acceleration of labour, epidural anaesthesia or episiotomy were removed from the equation, only 16.9% of women having their first baby and 30.1% of women having a second or subsequent baby could be classified as having a ‘normal’ birth. This study shrinks the domain of midwives as ‘guardians of the normal’ and raises questions as to whether we are ‘failing’ in this role (Beech 1997). Furthermore, there are mounting concerns about the limited learning opportunities for practitioners where the promotion of physiological birth is limited by ‘technocratic’ approaches in institutions (Davis-Floyd 2001; Kitzinger 2000; Leap 2002).

In suggesting strategies to promote physiological birth, this author is mindful of the fact that the majority of midwives are working in institutions where ‘normal’ birth is not the most common experience for women. The underlying power dynamics in these situations can subvert the efforts of midwives to promote physiological birth and practise according to their full role and scope of practice. Addressing these issues starts with an understanding of how these dynamics have evolved over recent centuries.

THE MIDWIFE AS ‘GUARDIAN OF THE NORMAL’

A long history of interprofessional rivalry lies behind the 1996 WHO statement quoted above and the contemporary rhetorical notion of the midwife as ‘guardian of the normal’. Before men entered the birthing arena, most women in European countries were attended at home by women they knew, one of whom might well be referred to as ‘the midwife’ due to her acknowledged role and expertise (Wilson 1995). If problems occurred, it was not unusual for a more experienced midwife to be called to help out. As described in the diaries of Catherine Schrader, a 17th century midwife who was called to complicated births in Holland, this often involved internal podalic version and bringing the baby out by its feet (Marland 1987).

A core professionalising strategy used by midwives in Western countries in the 18th and 19th centuries was the relinquishing of complicated (and lucrative) birth practice to the medical profession in return for the domain of ‘normal childbirth’ (Donnison 1977; Leap & Hunter 1993). This strategy responded to, and set up, a dynamic that has had far-reaching consequences in terms of gender and class inequalities and the collective psychological effects of subordination (Witz 1992). Pathology was the pivotal factor for role division, and doctors were presented as the superior professionals, educated at a higher level than midwives in order to carry out rescuing manoeuvres associated with the complications of childbirth. In comparison, the midwife’s role was shrunk to that of ‘caring’ for women who did not need interventions, and to recognising problems and calling for a doctor to ‘correct’ the situation and intervene in a timely fashion.

The fraught negotiations that led to the role delineation between midwives and doctors have given way to a situation with its own set of interprofessional tensions. While fulfilling the imperative to adopt good collaborative relationships with obstetricians in the interests of women and safe practice, the midwife often defines the boundaries of ‘normal’ in situations that are intricate and unclear. She ² engages with women and makes decisions in a culture dominated by the ideologies of authoritative medical science and its quest for certainty. Evidence-based protocols and policies often do not ‘fit’ with the complexity of individual women’s psychological and social situations and the impact of the environment. This has led to a childbirth culture in which it is increasingly difficult to find consensus on what constitutes ‘normal birth’ other than an absence of technical intervention (Downe & McCourt 2008).

THE RATIONALE FOR PROMOTING PHYSIOLOGICAL BIRTH

The boundaries of what is considered ‘normal’ are at the heart of the passionate discussions that happen whenever midwives get together. In recent years, midwives have been addressing these issues by identifying the complexity of their role in being ‘with woman’ and promoting physiological birth. This is often explained in terms of the potentially self-transformative nature of birth and the profound long-term consequences of empowerment for women, their families and society (Leap 2004; Leap & Anderson 2008). The promotion of physiology begins in early pregnancy and is about far more than aiming for an uncomplicated birth. It is concerned with a journey to motherhood that will have profound consequences

SCENARIO

The birth of Jack Taylor at St Average Hospital

This is an everyday story about the birth of a baby at St Average Hospital, in Australia. It’s the story of the birth of Jack Taylor, first child of Michelle and Daniel Taylor. Michelle is a receptionist in a hotel and continued working up until she was 34 weeks pregnant. She has not had any problems in her pregnancy and has been coming to the antenatal clinic regularly, where, after waiting for over an hour, she has seen a different person at each visit for a 15-minute check-up. She attended antenatal classes at the hospital but could not persuade Daniel to come with her to these. Daniel is a motor mechanic. He’s a shy man who doesn’t like hospitals. Secretly he’s very worried about being with Michelle when she’s in labour. He’s scared that he’ll faint, and is worried about seeing Michelle in pain. He didn’t want to go to the classes in case they showed a video that might make him pass out or want to vomit. He has heard stories from his mates at work that make him shudder. Michelle found the classes useful. They reinforced her idea that she would ‘try for a normal birth’, but it is comforting to know that the epidural is there if she can’t cope.

One Sunday evening, a week past her due date, Michelle starts having some low, period-type pains. She thinks her waters may have broken. She is very scared, and so is Daniel, who rings the hospital. The midwife on the phone asks him a lot of questions: ‘How often are the contractions?’, ‘How long do they last?’, ‘What colour is the water?’, ‘Is the baby moving?’. The midwife suggests that it might be early days yet but to come in if they’re worried. They are worried. They go in to St Average.

When Michelle and Daniel get to the ‘delivery suite’ at St Average, they are assigned to the care of midwife Sally, in Room 11. Sally is friendly and efficient, asks Michelle lots of questions, including whether she has been to classes and what her choices are for pain relief. Michelle says she’s not sure how she’ll cope, as she has a low pain threshold and already these pains are severe. The midwife says, ‘We’ll take it one step at a time, shall we? You’re coping well at the moment.’ She talks Michelle and Daniel through all the ‘natural’ methods of pain relief, and then explains that if Michelle can’t cope with the pain, there are other things to help—she explains the pros and cons of gas, pethidine and epidurals.

Sally the midwife gives Michelle a hospital gown and carries out a series of tests—takes Michelle’s temperature, pulse and blood pressure, tests her urine, and palpates her abdomen. She places Michelle on the monitor and explains the trace to Daniel, who is fascinated and remains glued to every variation in the lines. Sally reassures Michelle that the baby’s heartbeat looks really good. She explains that she is looking after someone in the room next door, and that she’ll come back in 10 minutes. She gives them a bell to ring if they need her.

It will be a while before Sally can get back to Michelle. Next door, Sophie’s contractions are suddenly very strong. She is having her second baby, and in order to have continuity of care with someone she trusts, Sophie has booked with a private obstetrician, Edward Richman. Sally helps her get down onto all fours on a mattress on the floor. Sophie is bellowing. Sally asks someone to phone Dr Richman to come. He arrives 10 minutes later as the baby’s head is crowning. Edward insists that Sophie get up onto the bed, cuts an episiotomy and hands her a healthy baby girl, who will be called Anna. Sophie and her partner thank Edward profusely. There is much jubilation all round.

Meanwhile, back in Room 11, Michelle and Daniel are still anxiously watching their baby’s heartbeat on the monitor. Eventually Sally asks Rita, another midwife, to go and check on Michelle. They all look at the trace and admire its reassuring variations. According to the machine, Michelle is having what Rita interprets as ‘irregular tightenings’. Michelle says that they are quite painful and Rita responds gently by telling Michelle that she’s doing really well and that ‘Bub’s happy’ but it looks as though it’s early days yet. She asks Michelle what she has decided she’d like for pain relief if she needs it later. She reiterates what is on offer and tells Michelle that, as her waters may have broken, the doctor will come and examine her and have a look at her cervix using a sterile speculum.

Alexandria, the new resident, examines Michelle. She is kind and gentle but Michelle finds the examination painful. Alexandria asks Michelle what choices she has made for pain relief. She reassures her by saying, ‘It’s great if you can manage the pain but you don’t have to be a martyr. If you’re going to have an epidural don’t wait until it’s really bad before getting it inserted’.

It seems that Michelle’s waters have broken but her cervix is still long and firm. She is offered the choice of going home and waiting for the contractions to establish, with daily review at the hospital, or having a ‘bit of help to get things going’. She is too scared to contemplate going home and the thought of ‘getting things going’ is appealing. Michelle has some prostaglandins to help soften her cervix. She is given some sedatives to help her get some sleep, and Daniel goes home to get some rest.

The ensuing chain of events over the next day is familiar to all who have worked in large maternity units. For Michelle these events will remain embedded in her memory until the day she dies. She was very grateful to have an epidural to help her cope with the fierce contractions induced by a Syntocinon infusion. The pethidine she had had earlier hadn’t touched the pain. She had a kind midwife called Sandra with her for most of the labour. Sandra was a mature woman whom Daniel would later describe as ‘really knowing her stuff’.

Little Jack Taylor is pulled into the world with the aid of a ventouse after the monitor showed signs that he really would be ‘better off out than in’. He is a fine, healthy baby, albeit a little confused about how to find his way around Michelle’s breast. He is taken to the nursery for a few hours to be observed because he is ‘breathing up a bit’.

Daniel didn’t faint. He is in awe of Michelle and thanks God for the ‘life-saving wonders of modern medicine’. Michelle and Daniel are very grateful to the staff of St Average and give them a huge box of chocolates when they go home with Jack four days after his birth.

Michelle is given the name of a child health clinic she can go to, to get Jack weighed and where she can access advice about breastfeeding. She is pleased about this because Jack still seems a bit confused about how to latch on and her nipples are very sore. Her mum, Jenny, is coming to stay for a couple of weeks, but Jenny is very unsure about how to support Michelle in breastfeeding Jack. Jenny’s own experience left her thinking she was ‘unable to make enough milk’ and that formula was the only option in these circumstances.

Thus begins the new life of Michelle and Daniel as proud parents of little Jack Taylor …

for each individual woman in terms of how she feels about herself, her body and her capabilities (Thompson 2004). Whether or not she eventually gives birth without intervention, a woman who feels powerful is in a good situation to take on becoming a new mother.

Birth is not only about making babies. Birth is also about making mothers—strong, competent, capable mothers who trust themselves and know their inner strength. (Katz Rothman 1996, pp 253–254)

Sadly, the opposite is also true—women can end up feeling disempowered and emotionally fragile as a result of an experience of childbirth that rendered them passive in the face of intervention (Kitzinger 2000). This chapter explores some of these issues, relating them to the practicalities of midwifery practice and initiatives that optimise women’s potential to feel good about their experiences of pregnancy, giving birth and nurturing a new baby. Some strategies are suggested that might help to promote physiology, even in situations where midwives are ‘swimming against the tide’ of interventionist thinking. The word ‘interventionist’ rather than ‘medicalised’ is used in an attempt to acknowledge that it is not only doctors who can hinder physiological birth.

The imaginary story in the scenario boxes will be used to tease out some of these issues. Within the culture of maternity care in industrialised countries, where healthcare professionals who are strangers to the woman often provide fragmented care in busy, under-staffed maternity units, this is a familiar story.

This story describes well-meaning midwives and doctors struggling to provide a safe, kind service under conditions hampered by fragmented care, staff shortages, public expectations, medical dominance and all the other components of the stresses associated with maternity service provision in large tertiary maternity units. At every stage of the story, these well-meaning members of staff reinforce Michelle and Daniel’s belief that Michelle will need some form of pain relief. In the spiralling cascade of intervention, Michelle is rendered passive and dependent on the expertise of strangers.

As this is not a ‘real’ story, there is the opportunity to wind back the clock and explore how the experience might have been different for Michelle, Daniel and their baby, Jack, had circumstances been otherwise. The re-telling of this story enables scrutiny of a range of changes to practice, some of which are within the grasp of the practitioner and others that would require significant changes to systems. The evidence for these strategies will be woven throughout the process of looking at how we might reconstruct the ‘everyday story’ of the birth of Jack Taylor.

PROMOTING PHYSIOLOGICAL BIRTH

Access to midwifery care

From the scenario, some might question the usefulness of midwife-led care, given that Michelle and Daniel appear grateful and happy about the birth of their son, Jack. Although the members of staff at St Average were all strangers to Michelle and Daniel, they were friendly, kind and competent, which is what women say is important to them (Green et al 1998; Lee 1997).

Such challenges raise complex questions about how to evaluate women’s experiences of birth in terms of their ‘satisfaction’ and how midwifery and the promotion of physiological birth might be implicated. It can be argued that women have a vested interest in evaluating their experience positively in the postnatal period and that, in many situations, it is impossible for women to know how their experience might have been otherwise. For example, research in South Australia has shown that women like Sophie choose private obstetric care because they have no knowledge of midwifery. However, once such women are exposed to midwife-led care, they identify that they would choose it in subsequent pregnancies (Zadoroznyj 2000).

Had Michelle lived in New Zealand, she would have had considerably more chance of finding and getting to know a midwife who would be present during her labour. Legislative processes have enabled the majority of women in New Zealand to choose a publicly funded lead maternity carer to provide them with continuity of care.

This is an important consideration because midwives can play a crucial role in promoting psychosocial wellbeing. This was identified by Anne Oakley and colleagues (Oakley et al 1990, 1996) in a randomised controlled trial, which showed that the effect of midwives making themselves available, in a ‘listening ear’ capacity throughout pregnancy, had profound long-term consequences for the relationships and social lives of women, their children and their families.