Natural childbirth: whose birth plan is it anyway?

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With the trend for 'natural' childbirth growing and a government setting targets for home births, are British women really free to choose how they'd like to go through labour, or must they bow to a new earth-mother ideology? ...

Hannah Hancock was pregnant with her first child she was keen on the idea of a drug-free birth. But ... when labour pains kicked in, ideals were abandoned. 'It was a long labour. At first I was on an oxytocin drip, then on pethidine, and a few hours later when they asked me if I wanted an epidural I was shouting, "Give it to me now!"'

This is a common occurrence in hospitals where women do not have continuity of care and women don't have access to resources and preparation to help them through natural labour and birth.

Two years later Hancock gave birth at a London teaching hospital. There the experience was very different.

'I knew I wanted an epidural but the midwife ignored me, saying, "Why do you want pain relief? You're doing really well." I was crying, saying, "I don't want to do well!"' Hancock begged her to find the anaesthetist. 'But she just stood outside the door not going anywhere.'

Another scenario that doesn't generally happen with continuity of midwifery care and in particular private midwifery care. In these cases, the woman and midwife have formed a trusting and caring relationship so that the woman has been able - ahead of time - to let her midwife know her intentions for her birth and the midwife is then able to support her.

In the end Hancock gave birth to her daughter using just gas and air. 'It didn't help at all. I was panicking so much at the prospect of no pain relief I couldn't relax and tore really badly. I couldn't understand this patronising attitude ... It really coloured my view of the birth. When Ines was laid in my arms it was a special, dreamy moment. The second time I was in such shock, I'd been in so much pain without anybody helping, I could barely look at the baby.'

Birth trauma happens after natural birth as well as after birth with intervention.

As any woman with children knows, the politics of childbirth are so highly charged they make infighting between Labour and the Tories look like a teddy bears' picnic. On one side sit the medics, portrayed by their detractors as men in white coats intent on cutting women open so they can avoid litigation and clock off on the dot of six. On the other sit the midwives, scoffed at as strident feminists denying women modern analgesia in favour of whale-music CDs and back rubs. In the middle of these competing philosophies is a labouring mother, her wishes drowned out in the clamour of debate.

Maureen Treadwell of the Birth Trauma Association, which supports women who have had difficult births, says that far too often ideology takes precedence over individuals' needs. 'The consequences can be unbelievably cruel. The truth is that what suits some women can be distressing and wholly unacceptable to others. Some women are obsessed with a natural birth and are distraught if this doesn't happen. But for others - say, a 40-year-old woman who has had three miscarriages - the priority may be having the safest birth possible with naturalness very low on the list.'

At the heart of much of the argument are the philosophies of Grantly Dick-Read, a British obstetrician who was convinced that much of labour pain came from society conditioning women to expect it. His 1942 classic Childbirth Without Fear expounded his belief that women educated to be free of fear and tension would experience birth as a 'normal and natural defecation'. Pain relief, he said, was undesirable because it affected the baby and slowed down labour, frequently leading to interventions, such as the use of forceps or the ventouse vacuum pump, or emergency caesareans.

Dick-Read became the first president of the Natural Childbirth Trust, promoting better understanding of his system. This later became the National Childbirth Trust (NCT), whose antenatal classes are seen as a rite of passage for all middle-class couples ...

While acknowledging that pain is subjective, Belinda Phipps, the NCT's chief executive, defends such a stance. 'A lot of women who feel they are denied an epidural are on the verge of starting to push the baby out and don't actually need one any more ... an experienced midwife will know she's actually getting ready to push and persuade her to wait a few more minutes. She should reassure her that what she's feeling is normal and let her know it won't last much longer ...

Others, however, are furious their wishes were ignored. 'I talk to women who have been left screaming in agony because they were either not offered or were refused pain relief,' Treadwell says. 'Afterwards, they've needed psychological help, their relationships have been scarred, they've been afraid of getting pregnant again, they don't bond with their babies.' ...

Fashions in giving birth are as variable as hemlines. Tina Cassidy, the author of Birth: A History, asserts, 'The way we choose to give birth reflects the culture of the age. Whenever women feel their choices are being limited by political decisions, they push back and say, "We can do what we darn well want."'

In the early 20th century the church preached that suffering in childbirth was the curse of Eve and that to try to avoid pain was a sin. Outraged by such repression, the suffragette movement embraced the introduction of 'twilight sleep', a mixture of morphine and the amnesiac scopolamine injected during labour to made women forget the pain. Obstetricians initially expressed doubts about drugging women, but were rapidly shouted down. The result was that birth quickly became so medicalised that by the 1970s another generation of feminists were fighting for the right to experience childbirth awake.

'In the 1980s, when women were in thrall to "having it all", they embraced epidurals that rid them of pain while allowing them to be conscious,' Cassidy says. 'In the 1990s, when the focus was on technology and convenience, there was a vogue for elective caesareans.'

In today's eco-conscious society, the pendulum has swung back towards nature. On Manhattan's Upper East Side society women reputedly send out birth announcement cards embossed with the words natural childbirth in gold letters ...

In Britain the number of home births has risen from a low of one per cent in the 1980s to nearly three per cent today, a trend that the government seems eager to assist ...

The debate becomes even more heated when it comes to elective caesareans. The National Institute for Clinical Excellence (Nice), responsible for government guidelines, is pushing for a reduction in the caesarean rate from 23 per cent of all births to the World Health Organisation's recommended ten to 15 per cent. In fact, while acknowledging that a caesarean is major surgery, some women prefer the idea of a planned operation to the unpredictability of a vaginal birth. When pregnant for the first time, Leigh East, 37, from West Yorkshire, was terrified at the prospect of natural childbirth, not least because so many of her friends' attempts had ended in traumatic emergency caesareans.

'At my antenatal class they acted out a caesarean, showing you how there would be 12 people in the room,' she says. 'This was portrayed as a negative thing, but for me it seemed like a no-brainer. Why would I not want everyone I could possibly need around me?' Certain she wanted a caesarean, East had to battle to get one on the NHS. 'Midwives judged and lectured me,' she says. Eventually a consultant agreed to her request. 'It was the most amazing, calm experience, and I knew I had made the right choice.'

East has since had another caesarean and set up a website, csections.org, giving 'a balanced view of caesareans'. 'Some people are very negative about it, but the site's not saying planned C-sections are the best answer; it's just being pro-choice, letting women know about a route that organisations like the NCT keep quiet about. So much emotion surrounds the birth of the baby that rationality goes out of the window, which I find very frustrating. Birth is the most physically exhausting thing that is ever going to happen to you, and who is anyone else to tell you how to do it?'

East's sentiments are echoed by Julia Wilson, yet their attitudes could not be more opposed. Last year Wilson chose to give birth to her second child, Maddy, at home unassisted by even a midwife, a trend known as 'freebirthing'.

'Birth is a sacred process and nothing should interfere with it,' she tells me from her home in Worthing, East Sussex. 'I had a midwife for the home birth of my elder son, and her presence put me off. I believe that having a professional present poses more of a risk than being left alone, because they try to interfere when it's completely unnecessary.'

When Wilson first mentioned her plan to friends and family, most were horrified. 'At check-ups midwives were equally dismissive. They didn't even support a home birth, because my low iron levels meant I might haemorrhage. But that was just nonsense. It was so empowering just believing in myself, rather than relying on other people telling you how to manage your body.'

Such a view makes Pat O'Brien, a spokesman for the Royal College of Obstetricians and Gynaecologists, shake his head. 'In India and Africa thousands of women with potential complications give birth at home without support because they have no choice, and it ends in disaster. But in the West childbirth has become so safe that people have just about forgotten that there can be major problems. It's been written out of people's psyches.' After all, the risk of dying in childbirth is one in 28,000 at Queen Charlotte's hospital in west London, compared with one in seven in Niger.

It does seem extraordinary that an event that lasts at most a couple of days compared to the lifetime of actually bringing up a child can provoke so much controversy. Yet Belinda Phipps points out that nature probably has its reasons for this. 'If we just dropped babies like eggs without noticing, what would that say about the responsibilities we're taking on for the next 20 years? Birth marks you out as a mother and a carer for a very long time.'

Melissa Maimann, Essential Birth Consulting 0400 418 448