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Sunday 26 February 2006
Rowan Pelling: The politics of pregnancy
A TV presenter is 'caught' smoking only a few weeks before she is due to give birth. Women who have Caesarians are derided as 'too posh to push'. But beyond the finger-wagging there is a real scandal that every expectant mother needs to know about
Pity any first-time mother-to-be who's currently wading through parenting literature trying desperately to decipher how best to give birth. The politics of pregnancy and childbirth have never been so entrenched and divisive. Media caricatures of celebrity motherhood make most choices look unpalatable, unwise or just plain barking.
In the natural childbirth corner there's Gwyneth Paltrow, giving birth privately, beautifully and macrobiotically in her very own birthing pool, in a way no mortal woman could ever quite envisage. In the too-posh-to-push corner we have Victoria Beckham, cruelly stereotyped as the kind of footballer's wife who would rather undergo the knife than risk indelicate stretching of her nether regions.
No celebrity mother is free from criticism. Her pregnancy is our pregnancy. Just look at the tabloid furore yesterday surrounding poor Kate Garraway, who was "caught" cowering in her car on Friday smoking a furtive fag or four. The poor woman immediately felt compelled to apologise to us, the public: "I feel like I've let myself and everyone down, but no one can be more angry at me than myself ... There are no excuses."
Really? How about, "I was working right up to the wire, I'm moving house and I'm about to squeeze a cannonball through my vagina. Of course I'm effing stressed and I need my ciggies."
But in their desire to persecute celebrity mothers, the media ignore the true scandal unfolding in front of their eyes. Last week the Royal College of Midwives (RCM) issued a statement, saying it believes that "a chronic shortage of midwives is putting the lives of women and their unborn children at risk." Not the lives of celebrities who can, and do, pay for top-quality care at private hospitals. (Though while we're on the topic, let's shower praise on Samantha Cameron, who at least had the decency to use her local NHS maternity unit, like a true blue woman of the people.)
We are talking about the less coddled life of your average British mum-to-be who, baffled by conflicting advice from the many childbirth gurus, rips up her birth plan and thinks, "To hell with it, I'll play it by ear", and books herself into the local hospital. She believes, naively, that decisions can be made while in labour. These floating voters, who are quite frankly most of us, find the bedazzling illusion of "choice" evaporates rapidly in most NHS trusts.
Beware the hospital that says its staffing levels are "up to establishment". This actually means, "We have enough midwives if you include all the ones on maternity leave, the ones on sick leave, the part-timers who for these purposes only we talk about as though they're full-time, and all the new ones who are waiting to have their job applications vetted by the police [which can take up to nine months]."
In reality there are rarely enough midwives for continuous dedicated care or to staff the birthing pool. Anaesthetists often rush between emergency Caesarean sections, without time to administer epidurals for such luxuries as mere pain relief. I know several women who had a natural birth when they fully intended to be knocked out by the strongest drugs available for the duration. Use of the ventouse, Syntocinon (an artificial birth hormone) and episiotomies may happen without much, or any, discussion. And then the RCM added insult to injury last week by suggesting that women who want epidurals for non-clinical reasons should be charged £500 for the service.
The reasoning behind this is that epidurals increase the chance of a woman needing medical intervention by 40 per cent, and this increases the manpower and cost involved in a labour. But I was amused to note that one of the RCM officials involved in the heated debate once told me that she herself had her child with the aid of a "walking epidural".
My own views on this subject were profoundly changed by the research I carried out for a documentary I presented for Channel 4 last year called The Truth About Childbirth. It became clear while making the programme that there was only one aspect of childbirth that all research and every expert agreed on as being absolutely key to a safe and happy birth experience. That was the importance of one-on-one continuous care from a midwife or similar trained individual for every woman in labour. But women aren't told this by the NHS, because this is precisely, terrifyingly, the one thing our hospitals cannot guarantee.
Unless you count Queen Charlotte's and Chelsea Hospitals, which have recently started a scheme where such dedicated care can be guaranteed to those willing to pay £4,000 for the service, prompting howls of outrage at a "two-tier system". The RCM believes that we are at least 10,000 practitioners short of acceptable staffing levels. More alarming still, the average age of midwives is currently 46, and half the existing members of the RCM are due to retire in the next 10 to 15 years.
I concluded my documentary by saying, "Choice has been rendered meaningless by midwife shortages ... There are beacons of hope, but I am convinced things will get worse before they get better. And that will be reflected not just in statistics, but in human tragedy."
At the time, an executive at Channel 4 asked me if I really felt I could justify saying something so doom-laden. But as the RCM's recent warning indicates, what else can anyone conclude? It's a plain fact that women who don't have continuous care from a midwife are more likely to suffer complications and interventions.
When I made the programme, I discovered that British research had linked 70 per cent of cases involving babies starved of oxygen at birth to staff shortages. Last week The Independent stated that a study in the British Journal of Obstetrics and Gynaecology "found that more than half of perinatal deaths in England involved cases where substandard care could have been to blame - the highest rate in Europe".
After decades of decline, the number of stillbirths and maternal deaths following childbirth recorded have shown slight but definite increases. And yet hospitals, bullied by the Government into performing for star ratings on which their funding depends, continue to deny that there are deep-rooted problems. One acting head of midwifery at a large hospital in East Anglia recently said to a meeting of the Maternity Services Liaison Committee: "We're not short-staffed, we're over-cliented." Sir Humphrey would have been proud of her.
Why isn't there more widespread outrage? The answer is simple. Childbirth is a Cinderella service in the NHS because it doesn't actually involve an illness. The majority of women will have a reasonably straightforward labour and a healthy baby whatever the pitfalls of an over-medicalised and understaffed maternity service. Most of us would walk away with a live infant if we gave birth in a hedgerow. British mums tend to praise the hospital for their womb functioning properly.
The truth is the sun shines out of the world's arse when you've got a healthy baby in your arms. It's only when your labour goes dangerously awry that you fully realise the frays and tears in the childbirth system. It's only through determined investigation that you realise how fiercely divided midwives and doctors are about natural vs medically managed births. This is usually because obstetricians see too many unnatural, crisis-ridden births to believe in alternatives.
Although every study I found showed convincingly that home births were statistically the safest form of labour (almost certainly because they involve the most experienced midwives, the best levels of one-to-one care and the best emotional experience for the mother), one of the country's leading female obstetricians said to me, off the record, "Personally, I would never consider anything other than an elective Caesarean." Medical scepticism influences pregnant women. We think, "Hell, if I can't believe the person with the stethoscope, who can I believe?"
I was typical of most pregnant women in that I drifted by default into having my son at the local hospital, Addenbrooke's in Cambridge, where he was born by Caesarean section. It was only through my subsequent research that I discovered that I was a textbook example of a birth that goes rapidly off the rails after Syntocinon is administered to "speed things up". And only then did I begin to ask the questions such as: who does this speed actually benefit?
But the arguments over childbirth will not be won by browbeating women with ideology. Nor by telling celebs - or their plebeian sisters - that they're bad mums because they smoked one ciggie, or had a glass of wine, or had a Caesarean or chose a home birth. (I honestly heard a woman apologise to another mother recently simply for the very fact that she had a C-section.)
What pregnant women need above all is support and constructive advice. NHS trusts need to provide quick and easy access to key information. Do they provide home births? What are the staffing levels of the local hospital in real terms? And what is the rate of medical intervention compared to the national average? (The latter is usually a good indication of the former.) And what is the likelihood of getting pain relief when you want it?
My own advice is that whatever kind of birth a woman is opting for, those with spare cash would be wise to consider hiring an independent midwife or doula (who provide dedicated support to labouring women - see doula.org.uk) to ensure that she receives dedicated one-on-one care throughout the labour. And, yes, I sympathise utterly with the RCM, which said last week that high-quality one-to-one care from a midwife "should never be rationed by a woman's ability to pay". Of course it bloody shouldn't - but it already is. Look at Queen Charlotte's.
Blame Blair's Britain, where "choice" invariably means a decision between paying, moving, or being forced to accept inadequate care or facilities. The Labour Party's 2005 manifesto made a mission statement - not a pledge - which said, "We want every woman to be supported by the same midwife throughout her pregnancy." Well, I want a palazzo in Venice and a winged horse. Fat chance.
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