All shook up in a midwife crisis

Natural vs medical birth - how does it feel to be caught in the crossfire?
The natural childbirth movement is in trouble again. Caroline Flint, the former president of the Royal College of Midwives and founder of Britain's first private birth centre, was found guilty of professional misconduct by a disciplinary committee this week, and cautioned in connection with a breech birth in 1995 that ended with the baby dying from lack of oxygen.

The parents now claim that they had no idea how risky breech births were. They believe they might have chosen a safer option had Flint given them more information.

The mother, Mrs Nyree Wright, went into labour on 7 November, 1995. Upon discovering that the baby was not in the best position for home delivery, Flint drove both Mr and Mrs Wright to Chelsea and Westminster Hospital. Upon arrival, she checked the baby's heartbeat. Satisfied that there was nothing to worry about, she told the couple that it was still going to be possible to have a natural birth. Mrs Wright recalls that she was glad to still "have that option open" to her.

Mrs Wright is herself a qualified midwife. The monitoring of labour was proceeding normally. But about halfway through the delivery, it became clear to her that all was not well. When the birth itself was met with silence, she became first apprehensive, and then hysterical. Then she collapsed. She had to be rushed into surgery for her placenta to be removed. She lost a large quantity of blood. Her daughter, Alicia, lived for only half an hour.

A post-mortem examination found that she had suffered a hypoxic episode (oxygen deprivation) between 12 and 24 hours before the onset of labour: this made her too weak to survive the difficult delivery.

It's this earlier episode that was the cause of death. The UK Central Council for Nurses, Midwives and Health Visiting confirmed that Flint was not responsible for the death and did not criticise her care during labour and birth. They found her guilty of taking inadequate notes, not taking temperature and pulse after delivery and failing to recognise maternal collapse an hour and a half after the birth.

Flint remained on intimate terms with the Wrights for a year after the death of their baby. Mrs Wright now claims that she did not immediately hold Flint responsible for her terrible experience. It was only when she was delivering her second child, who was also in breech, that she "was made aware of the information she should have been given" when deciding how to deliver Alicia.

But surely, as a midwife, she would have been aware of these risks already?

A few more questions: how important was it to her to have a "natural" birth? Why was it that important? How much did Mrs Wright's own views on natural childbirth as a midwife enter into the decision she made that day as a mother? Did she, like so many mothers I know, dread the thought of a Caesarean because it would be a win for the medical establishment, and so a personal defeat? Might she have been able to make a "more informed" decision had her understanding of the decision been less politicised?

This is a private tragedy, but it is cause for public concern, too, as it casts light on a turf war between midwives and the medical establishment that puts all mothers at risk, and therefore all babies.

A quick history lesson: this war has been going on for more than a century, and it has played itself out differently in different countries. In the US, for example, doctors are the big winners and midwives have little or no autonomy. Here, midwives have won enough ground so that it is normal for a woman to go through labour without once seeing a doctor.

But it's not just control that midwives in this country have campaigned for: it's a different way of giving birth. The word "natural" is perhaps misleading: the key idea is to put the mother as much as possible in charge of the process. Not just so that she'll have a positive experience on the day, but also so that she'll get off to a good start in that job for life.

If the medical establishment is slightly warmer to this humane and far- sighted approach than it used to be, this is as a direct result of 30 years of lobbying by organisations like the National Childbirth Trust and the Maternity Alliance, and high- profile campaigning by the likes of Sheila Kitzinger and Caroline Flint.

But there are no winners in this campaign. The midwives are constantly losing ground and then having to fight, and hard, to win it back. Many excellent midwife schemes have been chopped by the NHS Trust bottom-line men over the past few years; many more are under threat. So it is hardly surprising that some supporters of Caroline Flint feel this disciplinary hearing is itself part of a backlash against natural childbirth.

And as far as that big battle is concerned, I'm on her side. There is nothing better than a birth managed by a good, responsive midwife. If you have had a chance to get to know her beforehand, and if you are in a hospital where doctors and midwives work together harmoniously, you and your baby could not be in safer hands.

But compare that with the one I found myself in exactly 16 years ago, in El Paso, Texas. My daughter almost died because a proponent of natural childbirth (in this case, a doctor) was so keen to keep me out of the clutches of her "medical model" colleagues that she put off scheduling a Caesarean section for nine hours.

She waged her courageous battle with her political enemies over the telephone. Had she bothered to consult me - had anyone bothered to give me the facts - I could have told her that even though I had chosen her as a doctor because I wanted a natural birth, my ultimate goal was not to avoid surgery but to give birth to a healthy child.

In the end, I did - but only just. My daughter survived many unnecessary hours of foetal distress because she was strong. Had she suffered from an episode of hypoxia just prior to labour, it might have been a different story. I find I can no longer be dispassionate on the subject of bungled births.

In the case for which Caroline Flint was before a tribunal, it seems the politics of childbirth entered too much into the process. In their struggle to avoid the demon doctor by keeping things as natural as possible, both the mother and the midwife gave less importance to safety than they might have done in a hospital where the doctors were their friends.

This case awakens old worries about the ways in which the political battles over childbirth can impact on individual women and babies. Even the best midwife in the world cannot do her best if she is working in an environment that is hostile to her methods.

This is a great pity - there is no good medical reason why births can't be as natural as possible and, at the same time, as safe as possible. It's time for the medical establishment to stop marginalising midwives and instead work with them to create the sort of women-centred service we all deserve.

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